Subject: News from Dr. Kevin Fickenscher
From: "Dr. Kevin Fickenscher" <[email-masked]>
To: <[email-masked]>
Date: Thu, 7 Jan 2016 15:08:54 -0500 (EST)

The Fickenscher Files [http://r20.rs6.net/tn.jsp?f=0019EyS9OtPslqPQW2jLTpMi13-HA6pMtTq-Q6XbZMZInVQKVoxTO3TfAZUpdyd_4wesXTVe6kIi2YowWBv-wA0vR6CZS4fCfufsfgIuiUO8hIj9Lzl1LnU8KblDtdzd5pFU3iYBP6YmYo1fAGiMkjZDvMObp_5YAnNI5G0EQJC8_BRJKz_BjtzTg==&c=dOzIpgODHuHywVYhOgJKRFhLDi4sh69f1PPXn17V0tgQ_P9ZDQReKA==&ch=MuaHtVrAgt3hCA3e9r5XJpnMt4_NevbOBL4u0Ri5SV9iIM0r3hHMyA==]
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

The Fickenscher Files, Vol. 3, Issue 40
Kevin M. Fickenscher [http://r20.rs6.net/tn.jsp?f=0019EyS9OtPslqPQW2jLTpMi13-HA6pMtTq-Q6XbZMZInVQKVoxTO3TfPqgHzpphup0CxpMIGr256VlUjnKDzjyP6stBpoATBUHfxGkHvYG5F8gObuVmeOAoEAdyFYE2VhoYmlAetDlyW_V7erHtX0OVh3XkzRhuh2KQ0Zp9gth_JQPLbwWUOxzSwjKlGBKO1lFv-zVVna2A-b_YLSChlCK4wq_98IdJRI_kA4vcxmH0KOuL7cFAruGyLkvMzYNnDMGBIRf5GLD8BY=&c=dOzIpgODHuHywVYhOgJKRFhLDi4sh69f1PPXn17V0tgQ_P9ZDQReKA==&ch=MuaHtVrAgt3hCA3e9r5XJpnMt4_NevbOBL4u0Ri5SV9iIM0r3hHMyA==],
MD, CPE, FACPE, FAAFP
@MDKev

A compilation of information, thoughts, and perspectives on the issues of the day
related to healthcare, technology, and beyond - including the latest culinary explorations.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Quote(s) Of The Week
Thoughts we should listen to...
"What can we do to try and prevent it?  What can we do to treat it?   What would
 it take to invest in and find a cure?  ...I want to spend $2 billion dollars on
 treating and preventing Alzheimer's disease."
Hillary Clinton, Former USA Secretary of State, Senator (D-NY) and candidate for
 President of the USA in a campaign [http://r20.rs6.net/tn.jsp?f=0019EyS9OtPslqPQW2jLTpMi13-HA6pMtTq-Q6XbZMZInVQKVoxTO3TfH4YOJlEllV8P2NFtyOFTTgqvFo3RPfEPr5dbLhFPVEeO-KBDiz2fqmmFcLwS6xmD0AMx_GkpoykwhJVIU5VLxjCVcwshkyEk-6RwUYduec9GBO3pf6SHadRTTmYxUNJRg1AcBpN8_hBbOmbBvzzJNxfaHrrZFXq5PgrsKE7R9cGti661gbZtsfEl3Ke1juRM1Dto_hVsd4Y&c=dOzIpgODHuHywVYhOgJKRFhLDi4sh69f1PPXn17V0tgQ_P9ZDQReKA==&ch=MuaHtVrAgt3hCA3e9r5XJpnMt4_NevbOBL4u0Ri5SV9iIM0r3hHMyA==]
discussion in New Hampshire [http://r20.rs6.net/tn.jsp?f=0019EyS9OtPslqPQW2jLTpMi13-HA6pMtTq-Q6XbZMZInVQKVoxTO3TfH4YOJlEllV8P2NFtyOFTTgqvFo3RPfEPr5dbLhFPVEeO-KBDiz2fqmmFcLwS6xmD0AMx_GkpoykwhJVIU5VLxjCVcwshkyEk-6RwUYduec9GBO3pf6SHadRTTmYxUNJRg1AcBpN8_hBbOmbBvzzJNxfaHrrZFXq5PgrsKE7R9cGti661gbZtsfEl3Ke1juRM1Dto_hVsd4Y&c=dOzIpgODHuHywVYhOgJKRFhLDi4sh69f1PPXn17V0tgQ_P9ZDQReKA==&ch=MuaHtVrAgt3hCA3e9r5XJpnMt4_NevbOBL4u0Ri5SV9iIM0r3hHMyA==]on
the eve of the New Year.
"I probably would have raised the price higher... I think healthcare prices are 
inelastic. I could have raised it [Daraprim] higher and made more profit for our
 shareholders, which is my primary duty - and again - no one wants to say it, no
 one's proud of it - but you know this is a capitalist society, capitalist system
and capitalist rules, and my investors expect me to maximize profits."
Martin Shkreli, CEO of Turing Pharmaceutical in comments at the 2015 Forbes Healthcare
Summit [http://r20.rs6.net/tn.jsp?f=0019EyS9OtPslqPQW2jLTpMi13-HA6pMtTq-Q6XbZMZInVQKVoxTO3TfH4YOJlEllV8Unj4BAAlP8fz7UAIpERaG-j_6PWhiXS94yG1u6zLz0ZPopDDdVa10tgrn8b6LUqjm0Id49zMwJDQLr1eNBhlUtVqzlNrlZyOB1n-osS7s3UEae-mSY6fGxbaNWd5XYZwXhbGmw7Hpdw=&c=dOzIpgODHuHywVYhOgJKRFhLDi4sh69f1PPXn17V0tgQ_P9ZDQReKA==&ch=MuaHtVrAgt3hCA3e9r5XJpnMt4_NevbOBL4u0Ri5SV9iIM0r3hHMyA==]
held in December on raising the price of the drug Daraprim by more than 5,000% earlier
in the year (See video 12/2015 [http://r20.rs6.net/tn.jsp?f=0019EyS9OtPslqPQW2jLTpMi13-HA6pMtTq-Q6XbZMZInVQKVoxTO3TfH4YOJlEllV8p9Ib_mNvs_X91krfgLykpnB5SNlKUPOj_PSrn8Sa-4ziObkbEbFAs3f7kpbVpsN-us7dTILO2YS5eSRfvEeXgt5j--uksPVVayXeioT_XNV5ut0kIMkzxUbdHsFkRB9OolIp7yTostU=&c=dOzIpgODHuHywVYhOgJKRFhLDi4sh69f1PPXn17V0tgQ_P9ZDQReKA==&ch=MuaHtVrAgt3hCA3e9r5XJpnMt4_NevbOBL4u0Ri5SV9iIM0r3hHMyA==])
"We have built-through the hard work of the private sector and states-an infrastructure
where every state has an information highway. In some communities, it's already 
connected across state lines. Our goal is to connect that highway, including the
 health information exchanges [and] the private sector exchanges, in the entire 
country within a year"
Karen DeSalvo, MD, National Director for the Office of the National Coordinator 
(ONC) in comments at a Bipartisan Policy Center event [http://r20.rs6.net/tn.jsp?f=0019EyS9OtPslqPQW2jLTpMi13-HA6pMtTq-Q6XbZMZInVQKVoxTO3TfH4YOJlEllV8-I9jY3PwAhocw8A-5HxmqlI2i-WW63ojPs1gtZdrPWH4FJ-dWjR57_OgMDb47uG4XHYQD4rOobNw2821By0Y1FhpjoLOYT9yf_4BUxRergbEm4NVcVcWoLiHaJNoS62_kpjOBPyi069NMmfzC32uIX4HjSoG3Vvaw6pJHbLu-9XA-bIan_C-moMq-hNTvW2-JcJ7ozkwZypFPdUJS_g8akNuijMOld9Dy4ZoWYAByYcAz_4V4t9fnQ_TYDAE0oIn8e0iASrq2246DXQWlizD-g==&c=dOzIpgODHuHywVYhOgJKRFhLDi4sh69f1PPXn17V0tgQ_P9ZDQReKA==&ch=MuaHtVrAgt3hCA3e9r5XJpnMt4_NevbOBL4u0Ri5SV9iIM0r3hHMyA==]
declaring her goal to support nationwide health information exchange connectivity
a reality.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Consulo Indicium
Information for your Consideration...
Meaningful Use Or Meaningful Abuse? - At home, I'm frequently reminded - by my clinically
active physician spouse - that some of the decisions by the Office of the National
Coordinator have resulted in "meaningful abuse" rather than "meaningful use" of 
electronic health record systems.  I recently took note of a blog by John Halamka,
MD - a friend and colleague who serves as the Chief Medical Information Officer 
for Beth Israel Deaconess - where he outlined a new path forward on meaningful use
[http://r20.rs6.net/tn.jsp?f=0019EyS9OtPslqPQW2jLTpMi13-HA6pMtTq-Q6XbZMZInVQKVoxTO3TfH4YOJlEllV8stmX9dV70PR10Y677_6O4P9qlUI9A3AkcQNIcmR542cQnhOe6hOVGGuU40AB_Hbudu6PXJ_K6dsFsMoNj-NhfN5dNMY-e6Df_UUWALY8I56_7510S5sH6FcJFAyesZFU-ZpK4gg9yWF7cVUSIBKsFsn7I3niw5JkxfX9OqTP3XZG9sIDpkMsT73gQQvOA3Fi&c=dOzIpgODHuHywVYhOgJKRFhLDi4sh69f1PPXn17V0tgQ_P9ZDQReKA==&ch=MuaHtVrAgt3hCA3e9r5XJpnMt4_NevbOBL4u0Ri5SV9iIM0r3hHMyA==].
 As he aptly points out in the blog among several other important points, one of
 the major flaws in the Meaningful Use Program is the lack of consistent standards.
 In addition the plethora of requirements to meet Stage 2 and Stage 3 actually serve
to impede good clinical practice by distracting the clinician from providing care
and engaging in a diagnostic discussion by requiring a focus on records, data and
information which are often extraneous to the overall care of the patient.  Somehow,
we need to improve on our approach...
Dr. Halamka also notes that one of the major issues we are facing at the present
 time is the "...lack of enabling infrastructure, data governance, uniform policies,
appropriately constrained standards, and economic incentives."  I couldn't agree
 more.  In fact, many of these issues would be resolved - in my estimation - if 
the focus of our efforts was on "interoperability" rather than all of the other 
areas of a more short term focus.
Finally, as alluded to in the blog, one of the major impediments toward fostering
true meaningful use are the inherent economic incentives of the healthcare system.
 Again, from my perspective, there is far too little attention focused on the debate
and dialogue required by the healthcare community on assuring that the economic 
incentives align with the needs in caring for the patient.  The Accountable Care
 Organization (ACO) movement is a step in the right direction but without a heavy
push by Medicare, Medicaid and the private insurers - progress will be slow and 
arduous.  We need to redouble our focus on the move toward a new payment model that
supports true "care management" - something I've been talking about for nearly over
20 years.  The opportunity is before us.  Will we take the leap?  It's an imperative
that is right before us.  Are you ready?
An Unrealisitic Goal Or Not? - Karen DeSalvo, MD, the National Coordinator for the
Office of the National Coordinator (ONC) for Health IT recently spoke at the Bipartisan
Policy Center in Washington, D.C. on the goal of ONC to connect private and public
health information exchanges (HIEs) across the nation over the next year (SEE "Quotes
of the Week").Making the nation's HIEs interoperable is among ONC's main 2016 priorities,
according to DeSalvo.  However, there are any number of detractors who believe that
the goal is unrealistic especially in light of the recently released Interoperability
Roadmap [http://r20.rs6.net/tn.jsp?f=0019EyS9OtPslqPQW2jLTpMi13-HA6pMtTq-Q6XbZMZInVQKVoxTO3TfH4YOJlEllV8XmMS0f9xGN5eiyTnRneIui6PvyHjCnRhQultFfCX6ADQzBNx-0QWVxceRo1hAQd4o2-ioXnvdQ4jSJNu9Yd1LqDZ2ipSMBQwBDWlTbnzLSYQmayrRsNI7BAo55iCX8qw8gyD67R6D5etL2dZke-rIy5U_UZuXbuWpCTJ3XgH-rfy0ldV4W-eXxM7ByiJV6qoQwP04RwyuC4=&c=dOzIpgODHuHywVYhOgJKRFhLDi4sh69f1PPXn17V0tgQ_P9ZDQReKA==&ch=MuaHtVrAgt3hCA3e9r5XJpnMt4_NevbOBL4u0Ri5SV9iIM0r3hHMyA==]
which contains over 100 short-term objectives with the intent of supporting the 
connectivity goal "by the end of 2017".  It is ONC's objective that the majority
 of health providers and consumers be able to send, receive, find and use a common
set of clinical information in order to improve healthcare quality and outcomes.
 In fact, our national efforts on interoperability are fundamentally failing.  Even
the Government Accountability Office (GAO) agrees that the current approach is not
working.  The GAO recently released a report [http://r20.rs6.net/tn.jsp?f=0019EyS9OtPslqPQW2jLTpMi13-HA6pMtTq-Q6XbZMZInVQKVoxTO3TfH4YOJlEllV8iBBDzDm5efbSPhNP5gZUuOjADPIqU8RcglzHOTVFLPIyKdaeBgmsq_p2FuJpLSKeiXfN6nFBrhFfmjELhb-QT5N6GU7uykHqrqN_GQk8rWyHc2d8SkiQQusJi-Np0mqSnBZFkcClvVhEVNbF7uGnQoNN7KH955WLtSCI45BX5RdMxK1A9X0x2PfeXp5hXhYrwHDgp7eM0nrZrQINDAhkkw==&c=dOzIpgODHuHywVYhOgJKRFhLDi4sh69f1PPXn17V0tgQ_P9ZDQReKA==&ch=MuaHtVrAgt3hCA3e9r5XJpnMt4_NevbOBL4u0Ri5SV9iIM0r3hHMyA==]
where representatives from 18 health information exchange initiatives described 
a variety of efforts toward supporting interoperability but which have been limited
in their effectiveness.  A renewed focus on the importance of interoperability is
crucial.
FBI Warns Of Ongoing Cyber Risk In Healthcare - With an abundance of personally 
identifiable and protected health information, there is clearly a trend among hackers
to go after the healthcare community.  In fact, in a recent interview, Donald Good,
Deputy Assistant Director of the Federal Bureau of Investigation's cyber division
indicated that the healthcare sector is a "Tier 1 highly targeted industry."  In
 the last 18 months, there has clearly been an acceleration of hacking across the
industry.  Examples include the hacking of Anthem where 78.8 million records were
exposed to cyber-intruders; Premera Blue Cross with 11 million individuals affected;
Excellus BlueCross BlueShield, with a cyber-attack on 10 million individual records;
and, Community Health Systems, with 4.5 million patients experiencing compromised
access to their medical records.  And, these are but a few of the more notable incidents
over the last couple of years.  Good warned that these reports are only the tip 
of the iceberg with many organizations simply not reporting their hacks due to the
desire to avoid negative publicity.  Clearly, there is a problem in the healthcare
community.  To help the community, the FBI has issued a report on medical devices
[http://r20.rs6.net/tn.jsp?f=0019EyS9OtPslqPQW2jLTpMi13-HA6pMtTq-Q6XbZMZInVQKVoxTO3TfH4YOJlEllV8R24Xgtq-VLIet47WykjCSzfiKDObnVRUgX7qc2qAI9DxFJpCJI1hASY7fHfAwOok9lroCdQcMQSwQWREmIsxjs79chKPKuNir5b3xqLy8aZ49X0QvIJFX1W--JXsP7FHy_hCyfTFWWWvLbM7zCStu8lpo13A_jd8GhZktwNmYWcT2s_lqLfVdmUcR0gYSep2PAej8_c-vjBxGTn5b9XYNw==&c=dOzIpgODHuHywVYhOgJKRFhLDi4sh69f1PPXn17V0tgQ_P9ZDQReKA==&ch=MuaHtVrAgt3hCA3e9r5XJpnMt4_NevbOBL4u0Ri5SV9iIM0r3hHMyA==]
which is intended to mitigate the growth of healthcare cyber-crime.
Underage Tanning Verboten Under New FDA Rules -The Food and Drug Administration 
(FDA) recently announced a plan to ban minors from using tanning beds and require
adults to be informed about their risk of increased skin cancer from engaging in
 tanning.  I'm an "over-the-top" former smoker who assiduously advocates adherence
to no smoking requirements.  The effects of smoking and second hand smoke have been
clearly documented.  The same can be said for tanning beds.  The data show that 
there is a 59% increase in the likelihood of developing melanoma among tanning users.
The incidence of melanoma has doubled over the period of 1982 to 2011 according 
to data provided by the American Academy of Dermatology [http://r20.rs6.net/tn.jsp?f=0019EyS9OtPslqPQW2jLTpMi13-HA6pMtTq-Q6XbZMZInVQKVoxTO3TfH4YOJlEllV8dUcpwnMHFmKcAduPhs5ZHzAPAxxZeHg8oLdeX4XCH8-tR8CuFAx395Z416iq0mK9EpuWG1kOT7pp97EUyu8aheZYFMJHqnV6TzgB0N2sqFg=&c=dOzIpgODHuHywVYhOgJKRFhLDi4sh69f1PPXn17V0tgQ_P9ZDQReKA==&ch=MuaHtVrAgt3hCA3e9r5XJpnMt4_NevbOBL4u0Ri5SV9iIM0r3hHMyA==].
In fact, skin cancer is now the most common cancer in the USA and the incidence 
is growing.  Current estimates are that one in five Americans will develop skin 
cancer during their lifetime.  In several studies, the growth of basal cell cancer
among young people under 40 have been documented with growth especially predominant
among young women - the most frequent users of tanning salons.  The FDA should be
commended for taking the step of managing the use of tanning beds.
Be Forewarned! - The Centers for Disease Control and Prevention [http://r20.rs6.net/tn.jsp?f=0019EyS9OtPslqPQW2jLTpMi13-HA6pMtTq-Q6XbZMZInVQKVoxTO3TfH4YOJlEllV8_LOybbCfO5Y7znJsUwx5mmSlkBW41oP_Dse-XZfXf1VZns6sJNZ9ovsqS85_0g_KKvGzJ5IR1dtUSbn8lEekllvf7zbxydpI9NbbaPldwsskcKxwLtULJdzcuGHZ_zTx4PBtGd5Oir2zr6mwoYtzsZLttlklxVxZhwP7W641i-Tl53-j1HnaR-jSXeCD7Ya8RV9n7RcfEhCXIlpqio1fsMbeQ7F85EhkwcygBvCiqHr1lXlPg4rN2uZD_46VxBs5-CImGx2kUfshOMYaoHH2mo_PHJgLoTOaUmhB9EVvbAO4e3yGlFjJHeB4aJBtmOjyVYtldjn1KQQuECU7x6upwRWmnB8kX-J-v9E2aOhcfy7VUC1E8aHgxYpfEzAXjsGzmMrIAXImy342TXRrKYH-mBSqcymelf1YTqQaMhl56Ocs5T2-YB_2k57tsFLgT-R3BxBun3WYuy9WbsXtrED4pIbWQjdr-NUhRYLV3Lx_08MMLaw7Rw9RfvDzSCQhHLC-CbCkPyDJ9rYuMuWHhV9cvNxp3LLbeCkgtPLHvTLmLUKGwbFJA8KfANg4fM797UstuRLCqU0WbTEz7nw6gbbArw==&c=dOzIpgODHuHywVYhOgJKRFhLDi4sh69f1PPXn17V0tgQ_P9ZDQReKA==&ch=MuaHtVrAgt3hCA3e9r5XJpnMt4_NevbOBL4u0Ri5SV9iIM0r3hHMyA==]
(CDC) recently issued a report that was widely covered by the media noting that 
the USA has set a new record.  As of 2015, more Americans will die from a gunshot
than from a traffic accident in 21 states and the District of Columbia.  Why?  Well,
it seems that the efforts to get us to wear seat belts and the improvements in vehicular
capabilities during a crash have had a lot to do with the results.  It should be
 noted that the rate of homicides has also decreased.  So, why the changing trend?
 It seems that the decrease in homicides has been offset by an increase in the incidence
of suicides, which again points to the inadequacies of our mental health programs
in the USA.And, Speaking Of Mental Health Program Inadequacies - In another report,
the CDC released a report [http://r20.rs6.net/tn.jsp?f=0019EyS9OtPslqPQW2jLTpMi13-HA6pMtTq-Q6XbZMZInVQKVoxTO3TfH4YOJlEllV8rbeVOJskUe1z86oQ8VQQeoAk7bpNyvb25q3on8gh2rJ94FmGHITparN8oi4B1dTS-FwmT5eMfHPg5MRIE29fr77gKQchV-vbSLQlUz4LZzDdi06q9YbarZKbF4BSH0MsZmmcjiRfYgRHPpFDqXngNcpRu9aLX5VphmKaTyZfpDP23slRWz_-eo5nM2T3t4pJm_cxSsMX2_tSxdPKWVjsI9XW077RLhJ9o49CNO-LjgaDtAb2CpxcgcOfIT9aZcNYTpd2Vu4rUI6sRddw9CIkNg2SqvD2GJ4DCuHIfzELVAzQyYOxpE2jwenImNZT2HPxvGLiWgkG7K90R6U_JcA5coZfjQJH6bhwbDtqRduHXPJSKQcoRl08trVjgR9jdEpeKx7IpEX1PmLofd1XDfToi1GUA9WdERnbpwhUtlP4gCAPDkTPsL4wEUtuVEk_iuw502Ln-GDIu6-edbhPM39qg6rxXatgAQY2i7ocTGy0y7I5fIYb6Km0UFgkbg_c34xEf6ow83GYuC-RK12HOOyr2DAOtLe19FPwwYNlnE77uPV3LUIn6UDCGG1C3Xqgas5jEeen8wHPrvBmvIJIJRyV_A==&c=dOzIpgODHuHywVYhOgJKRFhLDi4sh69f1PPXn17V0tgQ_P9ZDQReKA==&ch=MuaHtVrAgt3hCA3e9r5XJpnMt4_NevbOBL4u0Ri5SV9iIM0r3hHMyA==]noting
that fatal drug overdoses from prescription opioids and heroin "surged" in 14 states
last year.  In fact, the surge resulted in a record number of overdose events across
the country with more than 47,000 deaths reported in 2014, a 7% increase over the
prior year. The troubling part was that fatal overdoses due to heroin and prescription
pain medications were up 28% and 16.3% in 2014, respectively. There have been a 
flood of legislative initiatives passed by various state legislatures in an effort
to stem the problem.  The problem with all of the initiatives, however, has been
 that there is insufficient evidence on which of the initiatives work the best. 
 Finding the right solutions would be a better way.
The Uninsured Problem Continues - For too many Americans who provide service in 
fast-food restaurants, call centers and retail stores, the ObamaCare initiatives
 have not yet dented the problem of being under- or un-insured.  It is estimated
 that more than five million such American workers are not only poor but also continue
in the uninsured category.  Why? It's primarily because many of these individuals
are part-time workers or independent contractors. Because of their status, companies
who hire them are able to avoid an obligation to provide health care insurance. 
In other instances, the state governments have not expanded their Medicaid.  The
 decision to create states opting out was supported by the 2012 Supreme Court decision
allowing states the authority to determine if they would expand their programs. 
Declining to participate in the Medicaid expansion initiatives was a statement of
opposition to the ObamaCare program led by the Republican Governors in 20 such states.
 Implementation of the federal Medicaid enhancements would have captured these low-wage
earners. In addition to these points, a recent USA Today report examined the problem
and found:

* The use of contract workers by companies is increasingly used as a mechanism for
avoiding increased healthcare costs for workers.  In addition, state and local governments
are also contracting out more jobs to small businesses but do not require these 
companies to provide health insurance coverage for their workers.
* Upwards of 20% of businesses have cut or plan to cut workers' hours to avoid paying
for health benefits usually at or just below the 30 hour minimum required to qualify
for health insurance.
* Despite the size of some large corporations - such as fast food restaurants - 
their franchisees often fall under the 100 employee limit which was set for companies
to provide health insurance.  We will have to wait and see what the impact of the
new 50 employee limit will be that just went into effect on January 1st.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Future Health
Delivering care in the new virtual world...
You Can Weigh In - My friend and colleague, Art Papier, MD recently sent out a notice
on his projections for the most significant market trends in healthcare for 2016.
He's asking for feedback.  You can weigh in by checking his website [http://r20.rs6.net/tn.jsp?f=0019EyS9OtPslqPQW2jLTpMi13-HA6pMtTq-Q6XbZMZInVQKVoxTO3TfH4YOJlEllV8AfkdeGm_HtNK9tr_5w_Koywlu7J7GSyd_VvkDqym7DxKquM9K9JH4RZrbX-FNpgYixTwaMsW9IQslKgYj7EvYizeM65YKSMrmn5yvbIDbCr0_nedhJtPKGTcMxrMi1MnFe4ZdPipIRmX3nDOtOGhmjeLEacXlOu-Thlg7KK0wLzBRDSAcxrChw==&c=dOzIpgODHuHywVYhOgJKRFhLDi4sh69f1PPXn17V0tgQ_P9ZDQReKA==&ch=MuaHtVrAgt3hCA3e9r5XJpnMt4_NevbOBL4u0Ri5SV9iIM0r3hHMyA==].
His top 5 included the following:
#1: Death to Meaningful Use (SEE above posting) - He points out that Larry Weed,
 MD in a lecture [http://r20.rs6.net/tn.jsp?f=0019EyS9OtPslqPQW2jLTpMi13-HA6pMtTq-Q6XbZMZInVQKVoxTO3TfH4YOJlEllV8wfEkget5eeWMhC0MufbWsnMw1dMqELFo4D_NIFBigAyiLZdKXwNj08wYLvnj4qj8WC5yb1Al3gblL7WsSKtaveD25bvztyhBFtBHrw2EVVRqKXqt8TrKq6yrRpovyDt7ug_M6wq6HZkkLlVjdpa-U02R8eTmaydXVE_Iv_lYr3uXd2LDt1mH0g==&c=dOzIpgODHuHywVYhOgJKRFhLDi4sh69f1PPXn17V0tgQ_P9ZDQReKA==&ch=MuaHtVrAgt3hCA3e9r5XJpnMt4_NevbOBL4u0Ri5SV9iIM0r3hHMyA==]
at Emory University in 1971 started his talk by saying: "We are not taking care 
of records, we are taking care of people." As Art points out, "too many physicians
today feel like they are taking care of records."
#2: Overhyped Precision Medicine - Art's contention is that the focus on Precision
Medicine is essentially the wrong focus.  If we want to improve the health of the
population, he argues that focusing on the "waste" of healthcare would yield far
 more results (i.e. inappropriate testing, unnecessary radiology studies, unneeded
surgeries and procedures, ineffective and overpriced medications, diagnostic error,
etc.)
#3: Diagnostic Error - As he points out, the issue of diagnostic error has been 
"under the waterline" for a long time.  The problem is summarized by two infographics
[http://r20.rs6.net/tn.jsp?f=0019EyS9OtPslqPQW2jLTpMi13-HA6pMtTq-Q6XbZMZInVQKVoxTO3TfH4YOJlEllV8irdcGkeeGGPw3BALAQ8yalb_NwvqMlgy0IF064IZlYwpxpVh3VgKSZs99IckbWosyWUwK1NO-A1Mr_H29rlRceOFE8M4GqdzCkhSDJECc-C8fhwvpdU1bQfdmwE4e0-GMHi05T0pkwKav40kHkoQ-k55Xiwzu129&c=dOzIpgODHuHywVYhOgJKRFhLDi4sh69f1PPXn17V0tgQ_P9ZDQReKA==&ch=MuaHtVrAgt3hCA3e9r5XJpnMt4_NevbOBL4u0Ri5SV9iIM0r3hHMyA==]
that are part of his narrative on the problem.
#4: Direct-to-Patient Lab Tests - Is this a positive or a negative?  Will it result
in better care?  Or, in more unnecessary care as a result of false positives and
 the inevitable questions that patients will have a result of their lab results?
  Art likens the use of D2P lab tests to "self-directed full body CT scans at the
local mall."  I agree.  What are your thoughts?  And, round out the list at...
#5: Healthcare Analytics Gold Rush - There is a massive amount of money being thrown
at healthcare data analytics. [http://r20.rs6.net/tn.jsp?f=0019EyS9OtPslqPQW2jLTpMi13-HA6pMtTq-Q6XbZMZInVQKVoxTO3TfH4YOJlEllV8vbUwysEKcntAT5R2zgXr5NCQUv6eLxgC9869i0DehwGQGfD5jA9HMg27oCrVs0_MrMDLZ1pNYVwqYGVgpgvTDJl40Wj0if783hCqVh5gCVyPXN98T1RrApOiNQQ4jKlpdP339a8CcI7HA22F2TR8hx3N7VKSlFcDTRiYOeZDHrxHjklneuvChAc4lszCvwaMxol87l0SCiiX9A7kditI44Jp4jYCdwgI_y7kArUuXByqCxSPRclV1xlciaFK1e_Q&c=dOzIpgODHuHywVYhOgJKRFhLDi4sh69f1PPXn17V0tgQ_P9ZDQReKA==&ch=MuaHtVrAgt3hCA3e9r5XJpnMt4_NevbOBL4u0Ri5SV9iIM0r3hHMyA==]
The question is: Will it change the character, process, and outcomes of care delivery?
As I noted at the outset, I encourage everyone to weigh at Art's website [http://r20.rs6.net/tn.jsp?f=0019EyS9OtPslqPQW2jLTpMi13-HA6pMtTq-Q6XbZMZInVQKVoxTO3TfH4YOJlEllV8AfkdeGm_HtNK9tr_5w_Koywlu7J7GSyd_VvkDqym7DxKquM9K9JH4RZrbX-FNpgYixTwaMsW9IQslKgYj7EvYizeM65YKSMrmn5yvbIDbCr0_nedhJtPKGTcMxrMi1MnFe4ZdPipIRmX3nDOtOGhmjeLEacXlOu-Thlg7KK0wLzBRDSAcxrChw==&c=dOzIpgODHuHywVYhOgJKRFhLDi4sh69f1PPXn17V0tgQ_P9ZDQReKA==&ch=MuaHtVrAgt3hCA3e9r5XJpnMt4_NevbOBL4u0Ri5SV9iIM0r3hHMyA==].
 I'm sure he would appreciate hearing from you and gaining your thoughts on the 
top 5 for 2016.
Speaking Of Precision Medicine And Predictive Analytics - One of the issues that
 has plagued the military in the last decade has been the high rates of post-traumatic
stress disorder (PTSD), substance abuse, and depression among our returning military
service members following service in Iraq, Afghanistan and other locations.  In 
an effort to find better solutions, the military has linked up with Geisinger Health
in an effort to identify, predict and use mental and behavioral health risks among
the veterans. The Geisinger study [http://r20.rs6.net/tn.jsp?f=0019EyS9OtPslqPQW2jLTpMi13-HA6pMtTq-Q6XbZMZInVQKVoxTO3TfH4YOJlEllV8EVbJmArMw9DiWOPmNTFOm1gYkjhokpO59EdWWIfcIb-F10l9KxLDZ9GSdT9UzeXYzpWAh2f-aMJWbz5iZWFo0efDspsDCZpXBxwczWFyS8Q2MpggpHyFi6z09XIcI_G4Hmig03Hq4VaDRajLQ8QYhoyqzckqbaRwJbtg1lHabghtsIG3kvTNRgjz5ar_1wNNEepl8y0Qa-4qO8LA9sSn65Gqim8ditvCsycTaymVq9v1RES3h05vWlvIZecpoVfl6EHjOIL7-wfe3SAHXyw6DepVGQ-NuXQMTHUVlxXpLO4=&c=dOzIpgODHuHywVYhOgJKRFhLDi4sh69f1PPXn17V0tgQ_P9ZDQReKA==&ch=MuaHtVrAgt3hCA3e9r5XJpnMt4_NevbOBL4u0Ri5SV9iIM0r3hHMyA==]
will attempt to identify genetic risk factors that may potentially predispose these
patients to developing these serious conditions, which in today's world cannot be
accurately predicted.  Why do some individuals who have the same experiences come
away without evidence of PTSD and others exhibit the worst aspects of the problem?
 That's the question that the Geisinger study is intended to address.  But, the 
effort is not only about genetic markers.  The study is also intended to assess 
the impact of telehealth [http://r20.rs6.net/tn.jsp?f=0019EyS9OtPslqPQW2jLTpMi13-HA6pMtTq-Q6XbZMZInVQKVoxTO3TfH4YOJlEllV8SplSbNwNPDCLDyLhhnjKToGpDoQHOJAWsC65RF_aFqi-ushwgPjVviVoNyxo-F0Wiv1kELt8-s-gWjMSUxMCSfszHHk20Qh7GtWoDCvCde__1qs6fzxxP2B-O1Ko3VaosUtY4XD9XNjo-n_FH0ikAYeMo5tKcU4rDgmEsU6R94sEzxRXEmx6S-BkspS90XCGb2eP1faOkfI=&c=dOzIpgODHuHywVYhOgJKRFhLDi4sh69f1PPXn17V0tgQ_P9ZDQReKA==&ch=MuaHtVrAgt3hCA3e9r5XJpnMt4_NevbOBL4u0Ri5SV9iIM0r3hHMyA==]
initiatives and mHealth apps by veterans and their caregivers to determine the best
approach toward using these new technologies in providing services to a population
that is literally spread across the USA.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

The Weekly Whisk
- A Minor Israeli Culinary Tour
Musings from a foodie...
I recently had my first trip to Israel and what better way to explore a new country
than to try out the variety of culinary offerings.  First, my expectations were 
clouded by my experiences with Israeli-like restaurant offerings in Manhattan and
Brooklyn.  But, then I quickly remembered that one should never let one's international
culinary experiences be flavored by anything that goes on in the USA.  The end result
is that my Israeli tour ended with some surprisingly wonderful experiences.
Ari's Restaurant [* * *] in Tiberias was the first experience.  Probably the most
expansive part of the menu was Ari himself.  He welcomed everyone with robust conversation
as well as some wonderful food.  We took the appetizers as a group and delighted
 in the fresh corn with red peppers sprinkled with dill.  The olives - a regular
 offering in Israel - came in a light vinegar marinade and, were real, fresh olives!
 The eggplant tahini was quite good with a smattering of parsley and lemon.  I've
been chastised of late to have at least six cups of fruit and vegetables per day
 so I've been making more a diligent effort to meet the mark.  To that end, I found
the cabbage with sweet vinegar and sesame seed, carrots with red pepper marinade
 and the red beets quite a wonderful start for meeting my objective.  It was then
off to the main course with the obligatory lamb kebabs (quite good) and the St. 
Peter's fish, a tilapia-like white fish from the Sea of Galilee (OK...but, not great).
 All of the above was accompanied by an overabundance of flatbread and olive oil.
 So, needless to say, we were stuffed and enjoyed the meal after a long day of seeing
the sites around the Sea of Galilee.
In the pure "comfort food" category was the next find, which was exceptional.  Look
for Ronen's Place [* * * * *] in Central Tzfat (some spell it "Zafat") - a town 
up the mountain from the Sea of Galilee which holds a central spot in the heart 
of Jewish history.  The owner of Ronen's is "Ronen" - naturally - who is originally
from Yemen.  During our visit he was one busy guy given all of the people that stopped
by his small little stand!  His menu is very limited but exceptionally good.  And,
given the number of people, you can tell that it's a very, very popular crepe stand.
 His mainstay on the menu is a crepe with a variety of cheeses and thinly sliced
 veggies (e.g. I was sticking with that six cups regime, including red peppers, 
onions, etc.).  But, the magic in his cheese crepe was the spicy addition of "za'tar".
 There is no phone number and no address - but, he's in Central Tzfat every day.
  If you get any place close to the top of the mountain near Tzfat - I would definitely
recommend Ronen's Place.  Just ask around.  Anyone who knows Tzfat will know about
Ronen's.  In fact, on my next trip to Israel, I'm planning my visit around a revisit
to his stand...
Another fabulous find was Restaurant Cherkessia [* * * *], located in Kfar Kama,
 Israel at the Village Entrance on the left side - +972 (50) 261-9996.  Now, if 
you are not careful you'll miss this place.  It's on a frontage road near the highway
on the first floor of a home.  Parking is a premium but the owners will come out
 and help you find a parking spot.  Unless you speak Hebrew all communication is
 done with hand signals and very limited English.  The owner/waitress is delightful
and clearly enjoyed having us although a bit exasperated with English.  We started
with a freshen-upper of house made lemonade.  She then (via hand signals) got us
 to accept the "house offering" which we took.  We started with lentil soup in a
 bouillon base.  She then offered up a smoked Gouda and a fresh feta cheese along
with cabbage that had been soaked in a white vinegar (better than Ari's as noted
 above), diced tomato and cucumber with mint and pita bread and sour cream.  We 
couldn't quite figure out the spice but it was a salt and sesame mixture combined
with some type of red spice - perhaps sumac, but, we were not sure.  Following the
introductory appetizers, the main course consisted of ravioli stuffed with Cherkessian
cheese and green onion or "Mat'za".  Quite good!  This was accompanied with a fried
bread stuffed with Cherkessian cheese or, "Hal'vaz".  Again, quite good - but, probably
not as healthy J.  Following the meal, she brought us small coffees flavored with
cardamom - a Middle Eastern approach that starts to grow on you over time.
For a more upscale dinner, we tried Cielo [* * *] - Ben Sira 18 - Jerusalem, Israel
- +972 (2) 625-1132, an Italian restaurant near Old Jerusalem.  After a week of 
shawarma and falafel, it was an effort to move toward more of a mainstream meal.
  While the anti-pasta was quite good, it's difficult to mess up on sliced vegetables
and salamis.  We were impressed with the sautéed chicken livers and onions primarily
because the sauce was a balsamic vinegar type sauce which provided a different taste
than the usual preparations.  My favorite was the lasagna.  It was different than
the usual Italian restaurant fare because the noodles were clearly made at the restaurant
and were paper thin.  The sauce was great.  The main courses of veal with lemon 
and mushrooms and the lamb osso bucco were both good but not stellar.  On the whole
this restaurant was "average" and a disappointment given the cost.  Topping it off,
the music was far too loud, making it difficult for older rockers like myself to
 have a conversation...  If you're desperate after a week of shawarma, it's worth
a stop but, be prepared to pay top dollar for average food.
The best part of the culinary tour of Israel; however, is that we found a fabulous
shawarma and falafel place in the Muslim Quarter of the Old City. Abu Shukri [* 
* * * *] is a must on your luncheon list when you visit the Old City.  It's relatively
easy to find.  Not only is the food great but the price is right!!  We tried lots
of places during our visit throughout Israel - most of which I decided to not review.
Abu Shukri was ranked by all of us as the definite place to stop for the hungry 
tourist.  There is no phone number nor an email address.  It is located in the Muslim
Quarter across from Station V on the way of the Cross in the Old City of Jerusalem
at the corner of Al Wad and Via Delarosa.  You can't miss it.  Check it out...
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

The Good, The Bad, And The Ugly
The ongoing saga...
The Unbelievable - My faith in polls vanished when the validity of the "Man of the
Year" poll came out with Pope Francis and Donald Trump tied in second place behind
Barack Obama and Hillary Clinton.  Since people are simply asked to name those the
person they most admire, perhaps it is really a poll of the name most remembered
 by those who are polled.
The Good - While Christmas is good, it's also over...
The Bad - The continuing and evolving internecine warfare between the Shia and Sunni
factions in the Muslim world is a centuries' old problem.  The tensions between 
the nations - like Saudi Arabia and Iran - do not help the situation.  From my recent
trip, I learned more directly that this is a centuries' old conflict; however, with
no quick solution.  And, it will need the reasoned minds of leaders...
The Ugly - The continuing increase in the number of under- or un-insured in the 
USA despite efforts to be more inclusive in health insurance coverage.  We should
be embarrassed as a nation...
The statements in The Fickenscher Files are the personal views of Kevin Fickenscher,
MD and do not reflect the views or policies of any organization with which he is
 affiliated.
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