Subject: News from Dr. Kevin Fickenscher
From: "The Fickenscher Files" <[email-masked]>
To: <[email-masked]>
Date: Wed, 8 Feb 2017 13:08:37 -0500 (EST)

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The Fickenscher Files [http://r20.rs6.net/tn.jsp?f=001UfhOM8dZ3dw17DV9ja978Aq5jtcARsR58CYD5nTuAgO0EUjAWFFBKl1-LVmLhzN3F-e0Av3EtKIOs6QfDwOo4rSWvD22MHiyZLPFQM_srgJeASeJghu3h5Is5feP4IAx0mCQOwRRt0krYM3Aw3OFYB3UHjykZSSNBZj0lVffXKD4iX_FoAmvNB6v1Tr19fBX&c=RhgKuQ9WYnG2RkKCRaKuds8wq8wvfp2_A-_Q3M6Oy8qcL9SwnVEdmg==&ch=Juq0DRGVYDTGf7IBrNYvWr08pyqtjAnlrKbUN_4Fv2MFPYVTVjVhIQ==]
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The Fickenscher Files, Vol. 5, Issue 1
Kevin M. Fickenscher [http://r20.rs6.net/tn.jsp?f=001UfhOM8dZ3dw17DV9ja978Aq5jtcARsR58CYD5nTuAgO0EUjAWFFBKitS0CMcpNLU8KbH2CW3hV_C1PrelYW82DyryPavHbX48Rhm7xPUh2RRmi8F_hpabsGUQfzpnm1J6Bvhcpjcv_YpHVTLby18j4GdJRrRsfPpAyAqwReooODzx5TkCN4v0mG18ipjk4HVukRLvHmAUFCD4RrxR_dhiCkdMyBN1H_I1EoOm-7daG86kLVylHXFTRFN7KvHIVrjDgyRkXhcguc=&c=RhgKuQ9WYnG2RkKCRaKuds8wq8wvfp2_A-_Q3M6Oy8qcL9SwnVEdmg==&ch=Juq0DRGVYDTGf7IBrNYvWr08pyqtjAnlrKbUN_4Fv2MFPYVTVjVhIQ==],
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.
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Quote(s) Of The Week
"On the issue of cyber, this is not unique to the federal government. I have plenty
of CIO friends who work in banking, in retail, media and entertainment, automotive
and other industries and when I get together...with my CIO buddies, guess what the
number one topic is? I'll give you one guess. If you say, what are you spending 
more time on now than you spent last year? I'll give you one guess - it is cyber."
Tony Scott, Outgoing Chief Information Officer for the federal government, in comments
as part of an "exit" interview [http://r20.rs6.net/tn.jsp?f=001UfhOM8dZ3dw17DV9ja978Aq5jtcARsR58CYD5nTuAgO0EUjAWFFBKmFYfnXhZT7bddvW4gmN0swEultXkm8XekbK-O9rR5CLxTBDs8aihE4g-TCdwzO6fNs4awoL6AE4iwhTURHJ5BKJ9IezgiZ3vSQ3RHCt0a3Hokd0_Ir0qxlLcfT8YWCq5Apbc1EnemAtEIDJLDkxuFxWy9bIEKFnoG3RPIux2JSlhI7uMDbREcgOaJBAohlmMFB18rV6lNNJ&c=RhgKuQ9WYnG2RkKCRaKuds8wq8wvfp2_A-_Q3M6Oy8qcL9SwnVEdmg==&ch=Juq0DRGVYDTGf7IBrNYvWr08pyqtjAnlrKbUN_4Fv2MFPYVTVjVhIQ==]
prior to his departure from office on January 17, 2017
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Consulo Indicium
Information for your Consideration...
The Need For Continuous Focus On Cyber - It's been said that the need for cybersecurity
will "never go away" because bad guys tend to be lurking around every corner. Furthermore,
health care databases have been described as the trifecta of personalized data because
they include personal, financial and health care data - all from one pool. In addition,
cybercrime seems to be an ever-expanding market. Cybersecurity Ventures, a group
 which follows the industry, has projected that the overall costs of cybersecurity
problems will be in excess of $6 trillion [http://r20.rs6.net/tn.jsp?f=001UfhOM8dZ3dw17DV9ja978Aq5jtcARsR58CYD5nTuAgO0EUjAWFFBKmFYfnXhZT7bVKSWURZKvFCDCP3McobhWkB96sQkueSTk82N4UbJrHZYh98wS0BmSVynadWl8DhPwIliZXwZgqtBEsuO5dzOlOSoAWNPEEy7uxmRfkztCgxEsMP4fhxTPA==&c=RhgKuQ9WYnG2RkKCRaKuds8wq8wvfp2_A-_Q3M6Oy8qcL9SwnVEdmg==&ch=Juq0DRGVYDTGf7IBrNYvWr08pyqtjAnlrKbUN_4Fv2MFPYVTVjVhIQ==]
in annual costs by 2021 or, up from $3 trillion in 2016. And, finally, healthcare
is the most cyber-attacked industry [http://r20.rs6.net/tn.jsp?f=001UfhOM8dZ3dw17DV9ja978Aq5jtcARsR58CYD5nTuAgO0EUjAWFFBKmFYfnXhZT7blxHqybfeAEIa2yn_lu8-bgRMUJLsfLDZPDNC7r8oN1pLOedIJpWPt9KMahNdzixKKly1OC4OhRTtdigHnvkEEfsZuOjGJiFhLikLAq_WE5xh3YS0-IBFGU8c_CcOjXzP-hXoA-m3f_kqDshjxhWl5iKO5rZs3k58QAQbVeLvQvwViPh31tcseTDa-mKbwP78j3sQyLhthTmJDhsdxTLa4cbl6ZAGEaCqjfR_C6H-0L1hjj5i-LqjSw==&c=RhgKuQ9WYnG2RkKCRaKuds8wq8wvfp2_A-_Q3M6Oy8qcL9SwnVEdmg==&ch=Juq0DRGVYDTGf7IBrNYvWr08pyqtjAnlrKbUN_4Fv2MFPYVTVjVhIQ==].
 It has been and will continue to be a major target for hackers in 2017. It's an
 issue that requires further attention. There will be more to come in future editions
of The Fickenscher Files. Keep checking...
"Keep Calm And Carry On" - When I lived in London, I learned about a motivational
poster [http://r20.rs6.net/tn.jsp?f=001UfhOM8dZ3dw17DV9ja978Aq5jtcARsR58CYD5nTuAgO0EUjAWFFBKmFYfnXhZT7bV3oPzlwD3iNzIm_w27WAf25hwG5qegNs6PbM_w_KwWxpWdkLH_ZVeDFV1U5qC_SlsN3iOrsqc4acyzpxDhoPhDTNAdbY0vdKToIN2TsBzWMFlsR2Oo3StKP_-2_wy-2OB30n0882UpKlHzJw1GpAUg==&c=RhgKuQ9WYnG2RkKCRaKuds8wq8wvfp2_A-_Q3M6Oy8qcL9SwnVEdmg==&ch=Juq0DRGVYDTGf7IBrNYvWr08pyqtjAnlrKbUN_4Fv2MFPYVTVjVhIQ==]
that was produced at the behest of King George by the British government [http://r20.rs6.net/tn.jsp?f=001UfhOM8dZ3dw17DV9ja978Aq5jtcARsR58CYD5nTuAgO0EUjAWFFBKmFYfnXhZT7bM49AsfM8oyD0fnsCuFTnssJCsMNtYx0YE-_7vyD41NpFokt_ycwVCRSvOYVJipL2jOZKKpkMKuCYKYzsn3IxxQdFTE5EKmXbB6xiXi8hnBiy2y1x7XjlxjnPyUxhY-qVkivzQfMKsrWhtEY2eidaKea-XNdn62ka&c=RhgKuQ9WYnG2RkKCRaKuds8wq8wvfp2_A-_Q3M6Oy8qcL9SwnVEdmg==&ch=Juq0DRGVYDTGf7IBrNYvWr08pyqtjAnlrKbUN_4Fv2MFPYVTVjVhIQ==]
in 1939 at the outset of WWII. The poster was intended to raise morale among the
 citizenry due to the predicted air attacks which were anticipated on major cities.
The poster declared: "Keep Calm and Carry On".  However, of the original 2.5 million
copies that were printed only a handful were ever posted for the public with the
 bulk of them destroyed after the war as part of a paper salvage operation by the
Brits. A few copies were found when the poster was rediscovered in 2000 at Barter
Books [http://r20.rs6.net/tn.jsp?f=001UfhOM8dZ3dw17DV9ja978Aq5jtcARsR58CYD5nTuAgO0EUjAWFFBKmFYfnXhZT7b79an1h93cKjcgVNAqur3eXbQHCYQEAZclxq860Su1CNzRPmTzO_qHsN9qe3npv7JKwbwwkjBXmBQAXi9gY15JQbdmd1fw67fwXx9OCa09qQ54KT8Ucj_VPtb11NuwMEkbH2mPI0x5hQ=&c=RhgKuQ9WYnG2RkKCRaKuds8wq8wvfp2_A-_Q3M6Oy8qcL9SwnVEdmg==&ch=Juq0DRGVYDTGf7IBrNYvWr08pyqtjAnlrKbUN_4Fv2MFPYVTVjVhIQ==]
at a bookshop in Alnwick [http://r20.rs6.net/tn.jsp?f=001UfhOM8dZ3dw17DV9ja978Aq5jtcARsR58CYD5nTuAgO0EUjAWFFBKmFYfnXhZT7bBeDkTPqC6KhRshckyF5L8SDhpxkHOajSgseh8JD4Gql2x49QDNT738g0tw3CdaKrhUZj8c_XYHdbb1OYDXrt00ts5bkTUfM3K8C0qnVS7GTTYuFgwopA-xAzF44q8zej&c=RhgKuQ9WYnG2RkKCRaKuds8wq8wvfp2_A-_Q3M6Oy8qcL9SwnVEdmg==&ch=Juq0DRGVYDTGf7IBrNYvWr08pyqtjAnlrKbUN_4Fv2MFPYVTVjVhIQ==],
England. I actually give out copies to friends and colleagues who are facing problems
that require fortitude. So, why am I sharing this story?
Well, I think Keep Calm and Carry On could be the new mantra for those of us in 
health care who are experiencing the avalanche of changes emanating from the new
 Trump Administration.  In particular, we've all heard about "Repeal and Replace"
- the theme of the Republicans over the course of the Obama Administration and into
last year's Presidential campaign. It seems; however, that the Republicans are wavering.
In fact, across the board, it seems that many of the Republicans in Congress are
 adopting a "Revise and Repair" perspective which is becoming a more common theme.
Repair, revise, rebuild, redo, re-whatever will no doubt become the new mantra. 
Why? First, there are 20+ million people that have health insurance today that did
not have it before the implementation of the Accountable Care Act (ACA). That's 
a lot of potential voters. Second, the "replace" options under consideration are
 capturing many of the options already contained in the ACA. Third, "revising" under
a reconciliation process is far easier than going after a totally new plan. And,
 fourth, it would allow the Republicans to spread the responsibility around a bit
and not be left holding the bag - if you will - with total responsibility for a 
new, yet-to-be-defined model to be digested for the American public.  Now, that 
may sound partisan. But, it's not. It's what's on the lips of politicians across
 the board in Washington, DC. I just attended a number of sessions over the last
 several days where Republican after Republican articulated these very positions.
So, Keep Calm and Carry On...
The Trump Executive Order On The ACA: The Inaction of Action - As promised on Inauguration
Day, President Trump issued an Executive Order (EO) calling for the de-implementation
of the Affordable Care Act (ACA). It directed federal agencies to take steps that
would minimize the burden of government's implementation of the ACA. It called for
those agencies to "waive, defer, grant exemptions from, or delay implementation 
of provisions" of the ACA which placed a "fiscal burden on any State" or that imposed
a "cost, fee, tax, penalty, or regulatory burden" on stakeholders such as providers,
insurers or patients. But, the order did not detail any next steps or specific provisions
which needed to be reexamined as part of the process.  Long story short - Trump 
kept his promise of issuing an order to dismiss "ObamaCare". But, the action really
did not contain any action and during the ensuing couple of weeks there have been
few substantive implications flowing forward as a result of the EO.
As I noted in the preceding piece, the Republicans need to come up with a longer
 term solution than simply abandoning the ACA. Until or unless they come up with
 an alternative, the issuance of Executive Orders will actually ring hollow. It's
clear that the action was not coordinated well with the Congressional Republicans,
who are still up in the air on which direction to take if efforts to undo the ACA
move forward. Specifically, the EO does not unwind any section of the ACA which 
cannot be accomplished through executive fiat. It has slowed the administrative 
processes in support of the ACA, however. For example, the public advertisements
 for signing on to the ACA were discontinued shortly after the proclamation and 
other similar administrative support functions were discontinued. But, the essence
of the law is still in place.
Over the last few weeks, Mr. Trump has been adamant in promising to replace the 
law with better, cheaper coverage "for everybody" until this past week when he offered
that it might take a bit longer. Meanwhile, Republicans in Congress are struggling
to articulate a plan. It's clear that the EO was primarily a symbolic gesture and,
is unlikely to have any real or long term impact. The real issue to watch will be
the coming days and months - and, most likely year(s) - in the House and Senate 
as alternative Republican proposals are more fully developed, vetted and put on 
the table. Senator Shelley Capito (R-WV), an incoming junior Senator from West Virginia
who previously served in the House recently said aloud what many Republicans are
 whispering: "A transition for perhaps three - I even heard four - years should 
be considered." Those ideas are signaling the direction in which the Republicans
 - if not the Administration - intend to take in promoting an alternative to the
 ACA. So, we await the next steps...
But Wait, There's More - It seems like every day there is a new Executive Order 
(EO) emanating from The White House - and, pretty much that's true. But, waaaait
 a minute!! Mr. Trump has actually issued only one more EO (45 as of this writing)
than his immediate predecessors, Mr. Obama (44), Mr. Bush (43) or Mr. Clinton (42).
So, in terms of pure numbers of EOs, there's not much difference than in the past.
However, the difference is in the scope and breadth of the Executive Orders. For
 example, a couple of days ago, Trump issued a new Executive Order (EO) requiring
that the costs of any new regulation proposed by the Executive Branch be offset 
by the elimination of existing costs associated with at least two prior regulations.
The so-called Reducing Regulation and Controlling Regulatory Costs [http://r20.rs6.net/tn.jsp?f=001UfhOM8dZ3dw17DV9ja978Aq5jtcARsR58CYD5nTuAgO0EUjAWFFBKmFYfnXhZT7bD3wqO3iAwCP8O-7BMK3HYdOBMhV_bOYbCHn14RZk_lRTKOdj6GlYrpBn81OvsgsP6i7MsgDZSrv3IqVlwWUWBv8ihWVWTYvjQndO5I0DIvw48rj2c7yHchMHkacg9NNefxP6qC5f0XUdUXQZuJXF1_M54wa-HJUKjioC2P04xnQOunWHt4j26B5C0tgJ8JC8uAVGalDXD_W4g2d6jYawlI7LuItPYwcK&c=RhgKuQ9WYnG2RkKCRaKuds8wq8wvfp2_A-_Q3M6Oy8qcL9SwnVEdmg==&ch=Juq0DRGVYDTGf7IBrNYvWr08pyqtjAnlrKbUN_4Fv2MFPYVTVjVhIQ==]
EO even goes a step further and requires that the cost of all the FY17 regulations
must equal $0 in costs.  The guidance for these feats are left to the Office of 
Management and Budget (OMB) which is charged with the responsibility for issuing
 guidelines for agency heads to follow on implementation. No doubt there will be
 lots of blow back from all sides. The federal government is beset with regulatory
oversight. On the health care front, we are at the formative stages on the regulations
required for implementation of the Medicare Access and CHIP Reauthorization Act 
(MACRA) of 2015 [http://r20.rs6.net/tn.jsp?f=001UfhOM8dZ3dw17DV9ja978Aq5jtcARsR58CYD5nTuAgO0EUjAWFFBKmFYfnXhZT7bitKzCitvgkeKKJbiYtRwL1MYTLrjUabY8uAUPcKpcUqck3JzWDHwRI1cZTKgPUYkw22vrUootuF30X4coXU9noom-w-zFG6K88f-T_-8PyodFji-vVZwofO_2oaoyMLC6xFWxP_M6pECatzwUnE2MqBLvmaLDmsuMdhFso_yBz01zmgJGuIL-LccW52E-FAE&c=RhgKuQ9WYnG2RkKCRaKuds8wq8wvfp2_A-_Q3M6Oy8qcL9SwnVEdmg==&ch=Juq0DRGVYDTGf7IBrNYvWr08pyqtjAnlrKbUN_4Fv2MFPYVTVjVhIQ==]
as an example.  And, it's not just the implementation side that could be challenged.
The removal of a regulation could open the Administration to court challenges as
 well. So, it appears that the murky world may get murkier if efforts to follow-through
are forthcoming...
The Price Comments - Inquiring health care minds were all wondering this past week
what Representative Tom Price (R-GA) - an orthopedic surgeon - would have to say
 at his confirmation hearing [http://r20.rs6.net/tn.jsp?f=001UfhOM8dZ3dw17DV9ja978Aq5jtcARsR58CYD5nTuAgO0EUjAWFFBKmFYfnXhZT7bWGrnxeXEeA-JBj1NfLufK0P5_at5Z0Gn3otclOA87a_xhJJAY3R8RX8208ObJUq7ScKY4Epx7g91K0-5KqqrWUOEXYO6TFR8sbCIlX-SYLF1pYrVKk86ik5riTNbcgZfOjradTU_VQ-xGv-A35v-5djG1FdxkOO36HDuoE68ttF1L_2ohNf3zPs1Npq9jY9RIAmmb6oRTRCijcej-hXL_LOhYLU2oa94q5PPgh2FRIA9qiHCx3uhHQhtOsl7eTk1l21rGkyIHEnqAm3TcpcOFw==&c=RhgKuQ9WYnG2RkKCRaKuds8wq8wvfp2_A-_Q3M6Oy8qcL9SwnVEdmg==&ch=Juq0DRGVYDTGf7IBrNYvWr08pyqtjAnlrKbUN_4Fv2MFPYVTVjVhIQ==]s
before the Senate Finance Committee and the Senate Health, Education, Labor, and
 Pensions (HELP) Committee hearings [http://r20.rs6.net/tn.jsp?f=001UfhOM8dZ3dw17DV9ja978Aq5jtcARsR58CYD5nTuAgO0EUjAWFFBKmFYfnXhZT7bpvktBEli8m-5uBzkWEWX2o5T_S0AB8Q-o2BB0h9s1Sxr27txW4Nclr36wUo8xN3LAemASzaVJMPU1aGU3hVQ3HdqNIBXvjcHyMMweTE0BafjTFjk0wXAL0-FaH29zMNWMazoQV9ArvGA8lERhD9qyQ9TeJIw7uK7ppV0nriZQmcSGS7XeBo7hQ==&c=RhgKuQ9WYnG2RkKCRaKuds8wq8wvfp2_A-_Q3M6Oy8qcL9SwnVEdmg==&ch=Juq0DRGVYDTGf7IBrNYvWr08pyqtjAnlrKbUN_4Fv2MFPYVTVjVhIQ==]
last week. Some highlights include:

* On the ACA - President Trump has been absolutely clear that his "plan [http://r20.rs6.net/tn.jsp?f=001UfhOM8dZ3dw17DV9ja978Aq5jtcARsR58CYD5nTuAgO0EUjAWFFBKmFYfnXhZT7bnQvAw8f7l-1OFBoSRUdosVdrdqwm9YAwrr04qNftJvHV_97cHr1SmFyet3Sd60-L-Ade9h-pENtJnAX-M6mD9q9p8HwS9StNxKrVgSMoFt_x0WbRD-QAjlPghD_OVS6W0fUC2NBkArm6OJhDvhyT1ed_8dE9MOj8g7eUvLTPlhLUMoRkt_aROH8psjFxUH2Y&c=RhgKuQ9WYnG2RkKCRaKuds8wq8wvfp2_A-_Q3M6Oy8qcL9SwnVEdmg==&ch=Juq0DRGVYDTGf7IBrNYvWr08pyqtjAnlrKbUN_4Fv2MFPYVTVjVhIQ==]"
has been to replace the ACA with a program that provides health insurance for "everybody."
Congressman Price demurred noting that he favored having the "option" or "opportunity"
to access affordable health coverage. He went further and noted that those with 
pre-existing conditions would not be abandoned and he expressed support for high-risk
pools. Just a couple of days before, Trump had issued his mandate stipulating that
federal agencies needed to "ease" the burden of the ACA. Price was able to slip 
by answering those questions.  He also did not promise that those residents who 
currently have coverage would not lose it. Instead, he remarked that "every single
American" should have access to affordable coverage - a slightly different promise.
 It should be noted that the parsing of words is part of the process for achieving
confirmation :-)

* On Medicare and Medicaid - Price was clear that while in the past he may have 
considered privatization of Medicare - he no longer supports the idea. Rather, he
testified that he would "save and strengthen" the program. On the Medicaid side,
 he was less direct and deflected questions from the Senators on his perspective.
It is anticipated on most fronts that there will be a strong move to allow the States
"options" for going down their own path.

* On the Center for Medicare and Medicaid Innovation (CMMI) - Again, while he was
not specific, Price did indicate that he felt CMMI has gotten "off track" in its
 efforts to drive innovation in value-based health care. Again, specifics were missing
except for the notation that the Center should be retooled to improve programs for
patients. Retooled would imply that abandoning is not part of his strategy.

* On health IT - He seemed to be stepping forward in support of further investments
in the health information technology space when he commented, "I think there are
 areas from a technological standpoint where we are missing the boat, especially
 for our rural areas and critical access hospitals [adding that] In health care,
 we put roadblocks up to the expansion of technology, especially in rural areas.
 We ought to be incentivizing that so that patients are able to receive the highest-quality
care." From my perspective, health IT is a tsunami wave that the politicians need
to be in front of and surfing. We should anticipate an embrace of further investments
in this space.
There were other topics specifically directed at Congressman Price such as the ethics
questions surrounding his stock trades in dozens of companies, his position on vaccines
and other areas. On the whole, he seemed to avoid any major potholes and appears
 to be headed for confirmation (probably completed by this time this comes out).
 The final Senate confirmation vote is anticipated later this week.
ECRI Institute Releases 2017 Top 10 Health Tech Advances - Determining which technologies
will have the biggest positive impact on health and health care is one of the biggest
headaches for leaders in the industry. It seems like every day, a new widget, capability
or solution is coming to market. Which ones to support?  That's the question that
causes the C-suite to pause. The ECRI Institute assessment [http://r20.rs6.net/tn.jsp?f=001UfhOM8dZ3dw17DV9ja978Aq5jtcARsR58CYD5nTuAgO0EUjAWFFBKmFYfnXhZT7bJTen5dgOqQkrKJxdcvu7-qBwVAu5QpmIFfIwIquo-59YiMx9OkAolYgLEIRVIdtx8qmzX4Ds-i_9PnaypfIreFcLIkiYY9blJsNUAXZnwkcitZof753zvCQLnTxaI5iYrGkMxtqVe-Sb8OijwaYVfX-MGe65h3iVbOgtrtqXHagqBc9go8wXf23vqCLX1gHCizGcXJ_VzuE=&c=RhgKuQ9WYnG2RkKCRaKuds8wq8wvfp2_A-_Q3M6Oy8qcL9SwnVEdmg==&ch=Juq0DRGVYDTGf7IBrNYvWr08pyqtjAnlrKbUN_4Fv2MFPYVTVjVhIQ==]
was recently released and the results are in! The tech areas they believe will be
the most influential in the coming year - according to the proper David Letterman
way of presenting - are:
#10: Type 1 Diabetes Vaccines - There are two types of vaccines coming to market:
a) a therapeutic vaccine which slows or stops the autoimmune attack on insulin-producing
islet cells of the pancreas for those patients who possess some residual function;
and, b) a preventative vaccine to create islet cell immune tolerance in children
 who are predisposed to developing diabetes because of genetics.
#9: Stem Cell Therapy for Crohn's disease - There are two mesenchymal stem cell 
treatments in the development queue. One uses umbilical cord blood stem cells and
the other uses stems cells cultured outside of the body. Trials are ongoing and 
at the formative stages.
#8: Florescent Endoscopic Imaging - What if your physician could "see" cancer cells
when she/he did an endoscopic procedure? It's on the horizon with the use of indocyanine
green imaging which targets malignant tissue not seen with regular light. It's amazing
technology!
#7: Robotic Surgery - I thought we were already there but no! The latest surgical
robot models are much more complex than the ones now used for common surgeries like
prostate or bariatric surgery. The newer versions have multiple robotic arms that
are connected to a new type of operating table, which allows for automatic repositioning
of the patient as needed during surgery. We are clearly moving in the direction 
of totally robotic surgery for some procedures in the not-too-distant future.
#6: Artificial Intelligence - The invasion of the robots with intelligence is not
limited to the factory floor. A new such device affectionately known as "Pepper"
 can interpret human body language and read emotion. There are other models afoot
as well. In fact, I refer to this type of capability as "clinically augmented intelligence".
I liken it to the stethoscope which augments the ability of the clinician to hear
body sounds and make diagnosis. In a similar manner, robotic devices in the not-too-distant
future will "hear" our discussions with patients and "augment" our intelligence 
with suggestions on what might be occurring with a patient. For example, can such
tools help us pick out PTSD? Already in the works! Depression from the matrix of
 possibilities? At the formative stages. How about early stage Parkinson's Disease?
I think so. It's right around the corner.
#5: Ultraviolet-C LEDs for Disinfection - New LED options are coming online that
 emit UV-C light that holds the greatest germicidal effect. These new devices use
little power, are stable, have a relatively long lifespan and can get into hard 
to reach areas. Sounds like "Mr. Clean" doesn't it?  Coming soon to your hospital
or clinic...
The ECRI team then jumped into three "process" recommendations, including:
#4: Horizon Scanners - the need for designating a "leader" who is responsible for
conducting tests and managing planning related to these technology developments 
is becoming increasingly clear. The evolving technologies will clearly disrupt the
standard way of providing care. Planning ahead will help reduce the unintended consequences
of technology deployment.
#3: Abdominal Surgery Initiative - There are new web-based, risk-assessment algorithm
and patient coaching tools available that can mitigate poor outcomes and reduce 
costs of patients facing major abdominal surgery. Regular use would have a big impact...
#2: Genetic Testing and Biosensors for Opioid Addiction - Genetic tests are now 
on the horizon that can be used to identify individuals at the greatest risk for
 opioid addiction. In addition, biosensors - like your Fitbit - can be worn which
detect relapse episodes for opioid addicts using skin temperature, electrodermal
 activity and movement. Whoa!! Will they have one for road rage? Perhaps not too
 far down the road...
And, the #1 technology trend that will impact health and health care in 2017? According
to the ECRI Institute it is...
#1: Liquid Biopsies - There are more than 40 companies who are driving the use of
liquid biopsies, which includes the use of urine, serum, plasma and blood instead
of tissue biopsies for identification of problems. In fact, the FDA approved the
 first liquid biopsy for cancer in June 2016. More are on the way.
There you have it. It's a different world every day...
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

The Weekly Whisk
Musings from a foodie...
Considering Old San Francisco - I had the opportunity to travel through San Francisco
last week as part of my annual (now 36 years running) pilgrimage to Hawaii. We visited
just a couple of days after the annual JP Morgan Conference on up and coming technology.
Naturally, I wanted to check out some of my old haunts since I lived in the Bay 
Area for over a decade. So, we met some close friends at Sears Fine Dining [* * 
* *], an iconic place near Union Square with an all-day breakfast menu in addition
to the other comfort fare. The place was originally started by Ben Sears [http://r20.rs6.net/tn.jsp?f=001UfhOM8dZ3dw17DV9ja978Aq5jtcARsR58CYD5nTuAgO0EUjAWFFBKmFYfnXhZT7br8oO5t4NkdB2eaMAUiPbf1MbQWY8p50pc7p4wcSWeIqPEAy8kttyeSAbALDlnGqbZd4mBp6IWjQMVdlnC20ZlKuRi2GklY2OFZZ79qB478U2V56KB_QipZQFLW-tZVpz&c=RhgKuQ9WYnG2RkKCRaKuds8wq8wvfp2_A-_Q3M6Oy8qcL9SwnVEdmg==&ch=Juq0DRGVYDTGf7IBrNYvWr08pyqtjAnlrKbUN_4Fv2MFPYVTVjVhIQ==],
a former clown who became famous in San Francisco for his Swedish pancakes which
 are still served to this day. Sears serves the complement of your favorite classic
cravings ranging from pancakes to corned beef hash to Reuben sandwiches and the 
like. You can't go wrong if you're in the mood for something that is not good for
the waistband but brings back the memories of a time gone by... San Francisco comfort
food at its best - Sears Fine Food [http://r20.rs6.net/tn.jsp?f=001UfhOM8dZ3dw17DV9ja978Aq5jtcARsR58CYD5nTuAgO0EUjAWFFBKmFYfnXhZT7bNl7GISfaQqZb5_9goPM7rhitPIJUyhz5su_TryNDCpimWGrM3tTv57iqlPM5Yh_exUck44-ILUmDJXV_Z-gALSHe0L-YoI6KBkm4is-Z_6D5SX9PCz4Hcg==&c=RhgKuQ9WYnG2RkKCRaKuds8wq8wvfp2_A-_Q3M6Oy8qcL9SwnVEdmg==&ch=Juq0DRGVYDTGf7IBrNYvWr08pyqtjAnlrKbUN_4Fv2MFPYVTVjVhIQ==]
- 439 Powell St, San Francisco, CA 94102 [http://r20.rs6.net/tn.jsp?f=001UfhOM8dZ3dw17DV9ja978Aq5jtcARsR58CYD5nTuAgO0EUjAWFFBKmFYfnXhZT7b2fduFq4knaPPX614N1C_BHDYaine2TvmEP-aG3BjFjLtB5m7a1BLk2IdloLZMIPkZUAlKvFbe8FK-k7sST8Tk2AV1FLFDsbxzvlaPHDQKXTL-FsIf7ZnZg53bTYMR9fGqQrMET9xTl8jGfcOObQH8BsCg3mznnMTmEh6BrQZ9qFygEVfcYZxrFumMIpN0MLelNeBbkaeLic4n0BO7jtoL_WifIPkg_VkVntkF74f948BcQqa63H0BS87D9Zc1u_Pml_qVI_1f_dj6alVZFyU3bm3HcGFUz4l8k3jIrmUiVuBT1CAhg4Q8IC02wgH_VIt9pWYQlv_NuyUWxYLXV3-vLeWlUWPlcgFor9H1RuIsz_enVXYVmF2-DqaKARUUVWzFhrjGA1tcUY=&c=RhgKuQ9WYnG2RkKCRaKuds8wq8wvfp2_A-_Q3M6Oy8qcL9SwnVEdmg==&ch=Juq0DRGVYDTGf7IBrNYvWr08pyqtjAnlrKbUN_4Fv2MFPYVTVjVhIQ==]
- (415) 986-0700 -www.searsfinefood.com [http://r20.rs6.net/tn.jsp?f=001UfhOM8dZ3dw17DV9ja978Aq5jtcARsR58CYD5nTuAgO0EUjAWFFBKmFYfnXhZT7bNl7GISfaQqZb5_9goPM7rhitPIJUyhz5su_TryNDCpimWGrM3tTv57iqlPM5Yh_exUck44-ILUmDJXV_Z-gALSHe0L-YoI6KBkm4is-Z_6D5SX9PCz4Hcg==&c=RhgKuQ9WYnG2RkKCRaKuds8wq8wvfp2_A-_Q3M6Oy8qcL9SwnVEdmg==&ch=Juq0DRGVYDTGf7IBrNYvWr08pyqtjAnlrKbUN_4Fv2MFPYVTVjVhIQ==].
But, Embracing New San Francisco - With all of the dot.com activity in the Bay Area
- some of the parts with which I had lots of familiarity have changed remarkably.
In particular, the Mission District has undergone a dramatic gentrification similar
to what Brooklyn did over the last decade in New York City. When I traveled to the
warehouse area - which once sat vacant - I was amazed at the number of shops, restaurants,
boutique places - and, most importantly, places where people were living. Tartine
- an iconic bakery that is widely known for its bread - recently opened a new restaurant
in November 2016. Dubbed Tartine Manufactory [* * * *], it is an eclectic little
 place that first and foremost, serves up the bread! In fact, the mantra of the 
new restaurant could be declared "It's better with bread". The menu is divided into
four parts: the breads and table top munchies (the warm olives are great), appetizers,
salads and grains; and, proteins. I would describe the menu as eclectic American
 cuisine. For example, the "grain" was risotto with mushrooms, farro and parmesan
shavings. It's the kind of place that should definitely be on your "to do" list 
if you are in San Francisco for any reason. I know there are tons of places to visit
in the city but the Mission District deserves a walk around. Go to: Tartine Manufactory
- 595 Alabama St, San Francisco, CA 94110 - (415) 757-0007 - www.tartinemanufactory.com
[http://r20.rs6.net/tn.jsp?f=001UfhOM8dZ3dw17DV9ja978Aq5jtcARsR58CYD5nTuAgO0EUjAWFFBKmFYfnXhZT7bYr47dAmn5rsVifUHlPokS63raIll5m63MUe7hofi1bGYSeFDSQ_jpik4el6up8dFlWSXrNtZPz535ezffitAFkKXPmrMsDVXyIjWrn4jcJmbQo00R2HuFZZNH_COw-sm&c=RhgKuQ9WYnG2RkKCRaKuds8wq8wvfp2_A-_Q3M6Oy8qcL9SwnVEdmg==&ch=Juq0DRGVYDTGf7IBrNYvWr08pyqtjAnlrKbUN_4Fv2MFPYVTVjVhIQ==]
- Reservations: opentable.com [http://r20.rs6.net/tn.jsp?f=001UfhOM8dZ3dw17DV9ja978Aq5jtcARsR58CYD5nTuAgO0EUjAWFFBKmFYfnXhZT7bpTjqT68greHoK4yAuELgPTJNOTtq6qJwbQ-Ao81f5C31HkdUH_wPswC818ASrera7DNjbWbHw0_Aoc4k48nklnQAyQJOUw3ciriu-DRhwvKu0zHQzwVolDInc80dBpqQACHbTiRbjbrX4n78nYYIjF3VGTdhrGEvbDNUdTHs03I=&c=RhgKuQ9WYnG2RkKCRaKuds8wq8wvfp2_A-_Q3M6Oy8qcL9SwnVEdmg==&ch=Juq0DRGVYDTGf7IBrNYvWr08pyqtjAnlrKbUN_4Fv2MFPYVTVjVhIQ==].
Finally - and, ironically - as I was preparing my review of Tartine Manufactory,
 the San Francisco Chronicle came out with their review [http://r20.rs6.net/tn.jsp?f=001UfhOM8dZ3dw17DV9ja978Aq5jtcARsR58CYD5nTuAgO0EUjAWFFBKmFYfnXhZT7bw5Z4nQgDqhh9iG_unBkEeVcO0Z0RfNpCRDU8K0Fkfup1F-w5WKKL0UnemFzFajO5aFQfln1KTKBvlWFtlrBXwKtv5oQkufXMMrCXdOshXOHndMt7-AvEoWKjJIz--9yrs31JiCS5d9neDiIBfg0lwtmP6tYbqPR9jjldxFKsmrKw9bJKAE6VSLvPHkAZXFBS8swqktdSPIqkZxvZ8XjzhAKujYgpiu3SJscZEM8nJkN_dOvl8Q-k7eWE1mjAREy9&c=RhgKuQ9WYnG2RkKCRaKuds8wq8wvfp2_A-_Q3M6Oy8qcL9SwnVEdmg==&ch=Juq0DRGVYDTGf7IBrNYvWr08pyqtjAnlrKbUN_4Fv2MFPYVTVjVhIQ==]
of the restaurant which was just as laudatory as mine. So, if you happen to be near
San Francisco, I highly recommend a stop in the Mission District and a diversion
 to Tartine Manufactory. It'll be worth it...
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

The Good, The Bad, And The Ugly
The ongoing saga...
The Great - The first 100 days were compressed into the first 10 so now we can get
back to business...
The Good - A more reasoned approach towards the Accountable Care Act (ACA) is apparent
among the Republican leadership with the recognition that rather than "replace" 
a more prudent course might be to "revise". Many of us would agree and, will support
the effort!! But, wholesale "rejection", I don't think so...
The Bad - The uncertainty on the direction of policy in American health care. But,
the uncertainty seems to cut across a lot of other sectors as well. It's the tenor
of the times as the Trump Administration gets its sea legs...
The Sad - The demise of the Ringling Brothers Circus. Having attended the circus
 any number of times as a kid, it's sad to see "the circus of Circuses" close up
 shop. Besides, where can we run off to now if the circus is closed?
The statements in The Fickenscher Files [http://r20.rs6.net/tn.jsp?f=001UfhOM8dZ3dw17DV9ja978Aq5jtcARsR58CYD5nTuAgO0EUjAWFFBKl1-LVmLhzN3F-e0Av3EtKIOs6QfDwOo4rSWvD22MHiyZLPFQM_srgJeASeJghu3h5Is5feP4IAx0mCQOwRRt0krYM3Aw3OFYB3UHjykZSSNBZj0lVffXKD4iX_FoAmvNB6v1Tr19fBX&c=RhgKuQ9WYnG2RkKCRaKuds8wq8wvfp2_A-_Q3M6Oy8qcL9SwnVEdmg==&ch=Juq0DRGVYDTGf7IBrNYvWr08pyqtjAnlrKbUN_4Fv2MFPYVTVjVhIQ==]
are the personal views of Kevin Fickenscher, MD and do not reflect the views or 
policies of any organization with which he is affiliated.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Name | Company | Phone | Email [mailto:[email-masked]] | Website
[http://r20.rs6.net/tn.jsp?f=001UfhOM8dZ3dw17DV9ja978Aq5jtcARsR58CYD5nTuAgO0EUjAWFFBKl1-LVmLhzN3F-e0Av3EtKIOs6QfDwOo4rSWvD22MHiyZLPFQM_srgJeASeJghu3h5Is5feP4IAx0mCQOwRRt0krYM3Aw3OFYB3UHjykZSSNBZj0lVffXKD4iX_FoAmvNB6v1Tr19fBX&c=RhgKuQ9WYnG2RkKCRaKuds8wq8wvfp2_A-_Q3M6Oy8qcL9SwnVEdmg==&ch=Juq0DRGVYDTGf7IBrNYvWr08pyqtjAnlrKbUN_4Fv2MFPYVTVjVhIQ==]
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The Fickenscher Files | PO Box 840 | Kittery | ME | 039