Subject: News from Dr. Kevin Fickenscher
From: "The Fickenscher Files" <[email-masked]>
To: <[email-masked]>
Date: Thu, 15 Feb 2018 16:51:19 -0500 (EST)

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The Fickenscher Files [http://r20.rs6.net/tn.jsp?f=001-8SwCJd7WrUVgZzUy4Tjj7VrJTyS_iua8MynA9R2TbWORyt7PQJiSaRZXEN2xklCTbWWaX8i8bTufT1E28QzIsMzR7__bKAxVHE4g8yXA8R9Uh5hqHaKMONVtGgE7Z-Gqbv4wHCRfh4ZhEg0RZlDpnDNmsWlbUbRL_qjdfBpiSz2KmDSXAQJtiQNsUQfSOz6&c=VNeTH_urGkpMYC37jnt-aohB60M-2_2JwJd8Na6KMlxMAun70D4Dew==&ch=3f4XusItksm9ED_uC_npVh1m-HT6KuByYhTMFNVkZJSUY10hV-Nd1Q==]
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The Fickenscher Files, Vol. 6, Issue 3
Kevin M. Fickenscher [http://r20.rs6.net/tn.jsp?f=001-8SwCJd7WrUVgZzUy4Tjj7VrJTyS_iua8MynA9R2TbWORyt7PQJiSdtXCuPGLnNHBb4tE9lsiM97pDAJMh4ZLVGsATsl4iAVyHIuXvJRjKDJbnuCWWIkV5CroqoiLoTMq3ZnczT0nC39pl2qTl3bb8iTHtmUEcp0PlBN28OaVp9imlj6AKGkjwZCL_Tc6jwRQ1chjSwIjiH9ys14FjXe5g==&c=VNeTH_urGkpMYC37jnt-aohB60M-2_2JwJd8Na6KMlxMAun70D4Dew==&ch=3f4XusItksm9ED_uC_npVh1m-HT6KuByYhTMFNVkZJSUY10hV-Nd1Q==],
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
"The ballooning costs of (health care) act as a hungry tapeworm on the American 
economy," said Buffett, the head of Berkshire Hathaway, in a prepared statement.
 "Our group does not come to this problem with answers. But we also do not accept
it as inevitable."
Warren Buffett, Founder of Berkshire Hathaway - one of the leading multi-national
conglomerates and, one of the richest persons in the world - in participating in
 the joint initiative by Amazon-Berkshire-JPMorgan on health care
"The three of our companies have extraordinary resources. Our goal is to create 
solutions that benefit our U.S. employees, their families and, potentially, all 
Americans."
Jaimie Dimon, Chairman and CEO of JPMorgan - a leading Wall Street banking firm 
- in same joint initiative announcement as Mr. Buffett
"Jesus himself is our flu shot. He redeemed us from the curse of the flu. We have
a duck season, a deer season, but we don't have a flu season, and don't receive 
it when someone threatens you with 'everybody is getting the flu'."
Gloria Copeland, a Texas minister who served as an advisor to President Donald Trump's
campaign voicing opposition to flu shots during one of the worst "flu seasons" the
USA has experienced in recent years.
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Consulo Indicium
Information for your Consideration...
How About An #Alt-Wall Movement? - In the last year, we've heard about the Alt-Right
which has been defined as the "alternative right" or, a loosely-connected and somewhat
ill-defined grouping of white supremacists, neo-Nazis, neo-fascists, and other far-right
fringe hate groups.  And, yes - full disclosure - I loath the Alt-Right! Now, I've
come to learn that there are Alt-Dating, Alt-Clothing, Alt-Comedy, Alt-pretty much
anything sites that have emerged in the last year. It seems that all things "Alt"
are in seemingly high fashion. So, I'm proposing that we consider establishing the
#Alt-Wall Movement. Our colors for the movement will be red, white and blue!
The notion of the #Alt-Wall Movement came to me the other day when I was reading
 about a couple of issues near and dear to my heart: public health, cybersecurity
and the opioid crisis. I mean, if we can have an Alt-Clothing Movement why not simply
call for an #Alt-Wall Movement. Let's start with a definition which I propose unilaterally
as a loosely-connected and somewhat ill-defined grouping of committed American citizens,
neo-moderate, multi-racial people who all originated from some other country and,
even some fringy neo-ChristoMusliBuddhaHindu types who believe all religions have
merit but, most importantly, uniformly feel that decisions inclusive of the vast
 majority of us generally stand the test of time. Wow, that's a mouth full of a 
definition. And, yes - full disclosure - I love the Alt-Wall idea!
Let me digress for a moment to explain the idea further. On the public health side,
we've seen in recent weeks an effort by the Trump Administration to decimate the
 investment we've been making in recent years to halt the spread of infectious disease
epidemics such as Ebola and Zika. In the last couple of weeks, the US Centers for
Disease Control and Prevention (CDC) announced a massive downsizing of epidemic 
control projects [http://r20.rs6.net/tn.jsp?f=001-8SwCJd7WrUVgZzUy4Tjj7VrJTyS_iua8MynA9R2TbWORyt7PQJiSRP3J9TBoLdWPtWinIdxNpMMOvKCEr7uZKeL0iraYn-KfZRxyejPISHHtREsChdmVLMTQ6GNPiPDv-Nxltoj4OgM_pXblV5GK0f8YmovT-3zifXSqO4uUqTAfKYOl66sZmmwwdTx2vnzlZgrcokmCyAy5QJNTpw-Xx9klqY5df9r63z34fv9AtuITLuh-pPYaBsa0d--Nt2HoNExXysu5Pp2Me0AzfEjBOlpM1soo2ldOlhmlT2hJjvoJwjLg6S2oORNiR3dxRECoFH87pRt2odPayk9vGklb907OK4J1-ozdvYT_N_gpQ34RvywBBu3qw==&c=VNeTH_urGkpMYC37jnt-aohB60M-2_2JwJd8Na6KMlxMAun70D4Dew==&ch=3f4XusItksm9ED_uC_npVh1m-HT6KuByYhTMFNVkZJSUY10hV-Nd1Q==]
in 39 out of 49 countries. Why? Because the funds to support these programs are 
running out! The only problem with the Wall of support for epidemiology programs
 is that they cannot be touched. They are not "big and beautiful". They don't gleam
and glisten in the sunshine. Rather, they are the hard work of people educating 
and treating people to prevent the spread of disease. And, it is through those efforts
that we stopped the Ebola virus from spreading across our borders and infecting 
our people. We caught those little viruses in the nick of time. And, it was because
of the virtual Epidemiological Wall we created through the largess and ongoing support
of the American taxpayer. So, now we issue proclamations and statements, but the
 Administration is not following through with funds.
The same could be said for the Cybersecurity Wall. Cybersecurity [http://r20.rs6.net/tn.jsp?f=001-8SwCJd7WrUVgZzUy4Tjj7VrJTyS_iua8MynA9R2TbWORyt7PQJiSRP3J9TBoLdWo4949XdxEk6qw_L-Jm9kT1EGSwETHVS_4ZdBg3WFiBMPf3zecDDUQJzDcjhEcgzR8FSgOa32R2IFu6SgnOMB7uKYad2SWtsC12-gTHJIvgmYIuckMcUt20-rMtbNgR4t&c=VNeTH_urGkpMYC37jnt-aohB60M-2_2JwJd8Na6KMlxMAun70D4Dew==&ch=3f4XusItksm9ED_uC_npVh1m-HT6KuByYhTMFNVkZJSUY10hV-Nd1Q==]
is a hidden, little understood problem that reaches across all industries in the
 USA. It's become abundantly clear in the last couple of months that our voter systems
were hijacked. And, if those can be hijacked - what about all the other vulnerable
systems that exist in our great nation. What about the electrical grid? What about
the transportation infrastructure? What about the very cars we seemingly control
 when we are driving down the highway?
And, then there's the Opioid Wall - yet another wall that gets rhetorical support
when the fire in the kitchen gets too hot. The opioid problem [http://r20.rs6.net/tn.jsp?f=001-8SwCJd7WrUVgZzUy4Tjj7VrJTyS_iua8MynA9R2TbWORyt7PQJiSRP3J9TBoLdW9GdHwskcGEdx0M7Hto6bSfaO-IiJLMmaXvcG87b64nWaZZWUeB8yxKGx5l86ikBgEiR-ElJixuDQcxqEW9AWWVdvw7CjQNiDU-FHO_3oAqx2B3W_4vhkK6OKQfapjhdfQlTQW010N2_lOnRyUhUNPJvVq5teInl5YnFrBDnzYIxHgujc-LovObm0FVzxhYBfuN3Wqv_kW7JyhoQvWh7_rDt9Vnp85uC-bwSJZf42LpH5xNZLufN1RIY0yBO57fCk7LrfCByk_8lqMT0Atxy7stBFiW2cDUYiXSwyp3eGlDE=&c=VNeTH_urGkpMYC37jnt-aohB60M-2_2JwJd8Na6KMlxMAun70D4Dew==&ch=3f4XusItksm9ED_uC_npVh1m-HT6KuByYhTMFNVkZJSUY10hV-Nd1Q==]
is a pernicious, unrelenting and growing problem that gets worse by the day. It 
is infecting families across the nation. But, when things die down a bit, funding
disappears.
So, my take is that we have an "Alt-Wall" problem!! There is an evolving Epidemiological
Wall problem by decimating funding for CDC work both domestically and internationally.
There is a Cybersecurity Wall problem which we've only begun to scratch the surface
on. And, there's the Opioid Wall problem that So, the #Alt-Wall Movement needs funding.
And, I have an idea for that as well... How about taking all the funding proposed
for some of the other "walls" - like the one proposed on the Southern US-Northern
Mexico border - and use it for the #Alt-Wall Movement. If the movement gains momentum,
I predict there will be far more support for it than any of the other "wall" projects
proposed by the Trump Administration to date.
So, my request to all of you out there within listening range is write a letter 
to your Congressional representative, your Senator, your Governor and demand that
funding be earmarked for the #Alt-Wall Movement. Note in your letter that the trifecta
of Epidemiology, Cybersecurity and Opioids should get the bulk of the funding. You
should also note that funding for these three areas combined will be less that those
other walls. Now - that should get some support...
A Quick Diversion - If you've been following the Olympics, you may have noticed 
that one of the stars of the Women's USA Hockey team is Monique Lamoureux [http://r20.rs6.net/tn.jsp?f=001-8SwCJd7WrUVgZzUy4Tjj7VrJTyS_iua8MynA9R2TbWORyt7PQJiSRP3J9TBoLdWBuyGpVAmTWUkHAkCpbTI8rZqJcwYWuSpsLildT6J4uE300TrbPy9OenEgFztrM-2DaP8wTwczNWRJKTPmCJAigphPORf1YcrbStR-BFoaYBVzQyK3o46Y9tNRSB-nSJ451cd5s8gJEA=&c=VNeTH_urGkpMYC37jnt-aohB60M-2_2JwJd8Na6KMlxMAun70D4Dew==&ch=3f4XusItksm9ED_uC_npVh1m-HT6KuByYhTMFNVkZJSUY10hV-Nd1Q==].
  She is from Grand Forks, North Dakota - where I Iived for a decade and, where 
I watched her brothers play hockey for the UND Men's Hockey team. Monique and her
twin sister, Jocelyne, have been crucial in helping the Women's USA team attain 
silver medals in prior Olympics. The Lamoureux's are infamous in North Dakota!! 
Their father, Pierre, was a goalie on the UND team a bunch of years ago and Monique's
four older brothers all played as well. They got their start by playing outdoors
 - as all good hockey players do when they start out!! - on the English Coulee in
Grand Forks. Just wanted you to know since hockey is the main sport for those of
 us who grew up in North Dakota although I was never any good. But, I am a good 
fan...
A Trump Tax Bill Analysis - The Trump Administration released [http://r20.rs6.net/tn.jsp?f=001-8SwCJd7WrUVgZzUy4Tjj7VrJTyS_iua8MynA9R2TbWORyt7PQJiSRP3J9TBoLdWuZFxhSNUi9rgRohOXwwi5tE86GRC6VDofdeP8DWOPGDRrMf19JRoDG5lwgcPGYL2auJN1FB62wKUQzkk3buuw_UCfKpyOzMSc5c4KGiO3bjTBgwnbL5HoiLysLyK_caJkm2SsgLd7DblP6QXNw3StGvgWdhjNLryJG7hxowfyJADn59dSfSEjg==&c=VNeTH_urGkpMYC37jnt-aohB60M-2_2JwJd8Na6KMlxMAun70D4Dew==&ch=3f4XusItksm9ED_uC_npVh1m-HT6KuByYhTMFNVkZJSUY10hV-Nd1Q==]
the proposed FY19 $4.4 trillion budget - which while it was declared "dead on arrival"
like most Presidential budgets also contains some changes in how health care dollars
would be expended. The emphasis of the Efficient, Effective, Accountable: An American
Budget is on bolstering our defense spending while promoting austerity in nondefense
programs. It will be very interesting to see what the Republican legislators do 
with this budget because of the nearly $1 trillion in additions to the deficit for
FY19 and upwards of $7 trillion plus over the next decade. The Freedom Caucus and
the Tea Party members must be going nuts at this point. This is, in large measure,
why the budget is "dead on arrival" - from both sides of the aisle.
While there are lots of places to provide commentary, the health care portion of
 the budget deserves some attention because of what it portends from a directional
standpoint by the Trump Administration. Some of the notable health care changes 
include the following:

1. Reductions in federal obligations projected as part of a rescission of the Accountable
Care Act (ACA) including $675 billion in projected savings by 2028 from the "repeal
and replace" initiative - What the Administration could not get through Congress,
it is attempting to do through the budget process in a maneuver that is similar 
to the Graham-Cassidy bill. It would also repeal the Medicaid expansion program 
as it exists and instead promote a state block grant program. Also, those who are
on Medicaid, a per-capita cap program is proposed which is intended to create an
 incentive on the part of states to keep costs below a certain ceiling level. The
states with higher reimbursement rates will be the ones most adversely affected 
by this particular policy proposal. But, this is just the beginning, it appears.
 Long story short - there will no doubt be another battle on the health care side
of equation. Other elements include:

* Deny benefits      to people who cannot prove their immigration status (= $2.2
 billion in      cuts over 10 years),
* Increase      beneficiaries' copayments for improper use of the emergency room
 ($1.3 billion      in cuts over 10 years); and,
* Allow asset      testing, which adds up all the value of a person's property and
     belongings, in addition to income as a test of Medicaid eligibility ($2    
  billion in cuts over 10 years).

2. HHS will receive a huge decrease in discretionary spending - these efforts would
focus on decreasing or diminishing considerably several federal programs, including:

* Responsibilities of the Agency for Healthcare Research and Quality (AHRQ) which
has been under attack for a number of years would be reallocated to other agencies
such as the National Institutes of Health (~$68 million net savings after merging
programs between AHRQ and NIH),

* The Community      Services Block Grant program which provides more than $700 
million in      annual grants for health care, food, and workforce programs is deemed
duplicative      of other existing programs - although which ones it is not clear;
and,
* The health care      workforce programs for supporting the training of medical
 and other health      sciences students in the form of programs to offset the cost
of their education      would be decreased (~ $451 million in savings). The White
House contends that these      programs do little to improve the workforce supply
around the nation.

3. Funding to combat the opioid epidemic is a major focus of the budget. President
Trump allots $5 billion in new resources for HHS over the next five years starting
with $1 billion in 2019 to address opioid abuse, treatment and prevention. The funds
will focus on a media campaign, improved access to opioid overdose reversal drugs,
surveillance and prevention efforts, drug courts, services for pregnant women addicted
to opioids, and supplemental funds for Native Americans and Alaska Natives, among
a series of other initiatives. But, long story short, this pales in comparison to
what is needed. It is estimated that the opioid crisis is now costing the USA north
of $80 billion per year. As Everett Dirksen (R-IL) the senior statesman from Illinois
once said, "A billion here, a billion there and pretty soon you're talking real 
money." In this case, we have a long ways to go. For example, the proposed budget
only allocates $123 million for the Substance Abuse and Mental Health Services Administration
and $126 million for the Centers for Disease Control and Prevention. All paltry 
at best.

4. Some notable exceptions to the health care cuts are proposed in the form of an
additional $70.7 billion for the Veterans Health Administration or, a 9.6% increase
from 2017 - The additional VA funds include $11.9 billion for a newly consolidated
veteran community care program, $381 million to address the opioid epidemic; and,
$8.6 billion for veteran-focused mental health services. The budget also calls for
Congress to set aside $75.6 billion in advance appropriations for VA care in 2020.

And, these changes are just for starters. There does not appear to be a coherent
 "plan" as part of an overarching strategy. Rather, the focus seems to be on cutting
programs. There is further analysis on the proposed impact related to Medicare and
we'll be following that in the coming week. Stay tuned...
Waitin' For Azar's Moves - A lot of us are waiting to see in which direction the
 new US Secretary of Health and Human Services - Alex M. Azar, II [http://r20.rs6.net/tn.jsp?f=001-8SwCJd7WrUVgZzUy4Tjj7VrJTyS_iua8MynA9R2TbWORyt7PQJiSRP3J9TBoLdWAc8UKhfjr9n8bQIMX0c6qilfJ3FPKBDoTg-LMacdJ--6azAMs6Ld98qvc7eOjHYqmIaSxALY23HakedCM7xoQFhXoYt9xawRvqJ0RxFS_1LRPr4yO2lBjvF7N33i-n5SXk8ZJ9iqzxDHq-UcPRwnMcl8FePDRDhNHvhi22vDo2r4404gL-WpYTU2-ezmc_hby2AER3pxYT5MOtrFobC0sVeO1JaSwKtmMAaov1qeiJrezwZ4ey336Q==&c=VNeTH_urGkpMYC37jnt-aohB60M-2_2JwJd8Na6KMlxMAun70D4Dew==&ch=3f4XusItksm9ED_uC_npVh1m-HT6KuByYhTMFNVkZJSUY10hV-Nd1Q==]-
moves after moving into his digs at the Hubert Humphrey Building in Washington, 
DC. As it relates to Obamacare, the question being asked is, will he "let it fail"
as announced by his Boss (i.e. Mr. Trump) earlier last year or use his significant
authority to "make it better"? One of the issues I keep raising is that the "problems"
with Obamacare will be addressed by coming to the middle from a policy perspective
rather than at either end of the extremes or, in other words, the far right or far
left. When you consider Medicare and Medicaid, as an example, it was not perfect
 when it was first passed. It was only after the tweaking that occurred over the
 following decade that the policy finally began to settle in as a worthwhile piece
of legislation that truly met the needs of the American public. The same will no
 doubt apply to Obamacare - assuming it continues to weather the policy storm.
If you review the hyperlink on votes taken by the US House of Representatives over
the period 1949 - 2011 [http://r20.rs6.net/tn.jsp?f=001-8SwCJd7WrUVgZzUy4Tjj7VrJTyS_iua8MynA9R2TbWORyt7PQJiSRP3J9TBoLdWTDYEv_dacay8cApikP135QT1vGpEx7183E8FFMEC584iYzSu3XIOHixJQGTW2n3LoDlWGSILHOEbSXsGzA-CvWtCO4F1ndHQKUXj1buS25MELEXkee1DI3-kibwKftwrs_WYBh_H1Mvs86LQeREqKzb5g7M4pWmzHl45Mnp8wFHUk1aNM91fCA==&c=VNeTH_urGkpMYC37jnt-aohB60M-2_2JwJd8Na6KMlxMAun70D4Dew==&ch=3f4XusItksm9ED_uC_npVh1m-HT6KuByYhTMFNVkZJSUY10hV-Nd1Q==]
in the attached graphic, you can see how the legislative body has become increasingly
polarized. This makes solving the Obamacare problems - let alone the rest of the
 nation's problems - increasingly difficult. So, how does this happen? Gerrymandering
is the answer. Over the last two decades the number of "safe districts" has expanded
considerably to the point where there are virtually no contested elections in certain
districts. The end result is that we as "the people" are getting the results we 
have allowed to occur.   The Democrats for their part have not exactly been at the
forefront of proposals for improving the Obamacare legislation. In fact, the changes
they would enact - if given the chance - are relatively unclear. But, lawmakers 
on both sides have floated a range of options extending from the need to control
 prescription drug costs, to shoring up the Obamacare exchange program, to revival
of the perennial "public option" idea to compete with private carriers on the notion
that such an approach would drive down prices. Regardless, many of us hope that 
Mr. Azar is open to some suggestions on "changes" that would improve Obamacare rather
than simply disrupting it in an effort to destroy it. We shall see...
Accountable Care Organizations (ACOs) Growth Continues - The adoption of the ACO
 model for reimbursement of health care services has more than doubled since 2013
going from 34% to 71% according to a recent report by the Healthcare Intelligence
Network. In addition, over the same period, the use of shared savings models for
 provider reimbursement increased from 22% to 33%. The other major finding of the
report was the shift from managerial leadership derived from Physician-Hospital 
Organizations (PHOs) to Integrated Delivery Networks (IDNs) which now represent 
more than one quarter of all ACO initiatives.
At the same time, another survey was released by Leavitt Partners [http://r20.rs6.net/tn.jsp?f=001-8SwCJd7WrUVgZzUy4Tjj7VrJTyS_iua8MynA9R2TbWORyt7PQJiSRP3J9TBoLdW7Q0kedQAKIbzkrEMu4DYKztmDbMoasfaIR8VUNOSrVgvjjkz-J_HQ2mWiRpG-paDx8GnHwjVSV9_HrhhBKmyrF_uz8793xbLBGHunnFhTP0H3Ak5XfB2s3xVHmSxgKKaREZnffi_MzVUA63EESPEfkTi0LJuhT_xQ4_XMyIkhAoeRkHvBl5gH5esiE-ZC0Ft_evz0r4cmb9pvrlF4_an3nxDSr1Kz_am6aF55XIIfCALrl46m1BRB7w_MEAjqT-jcAmgQSjj6hk=&c=VNeTH_urGkpMYC37jnt-aohB60M-2_2JwJd8Na6KMlxMAun70D4Dew==&ch=3f4XusItksm9ED_uC_npVh1m-HT6KuByYhTMFNVkZJSUY10hV-Nd1Q==]
showing that physicians are not nearly so excited about the use of value-based payment
models for either controlling costs or improving health outcomes. In each case, 
about one-fifth to one-third of the physicians felt that bundled payments or ACO
 initiatives would manage costs more effectively. So, it seems that there is a disconnect
between the frontline physicians and the health system executives. It seems; however,
that the attitude of the physicians is primarily related to a lack of information
or experience with the new, evolving payment methodologies. Clearly, more work needs
to be done. According to the Leavitt Partners report, the fact that frontline physicians
are uninformed on the effects of payment methodologies relates directly to the investment
level of the organizations the physicians work within. It seems to be a simple dictum:
Little investment in educating physicians results in little understanding of the
 evolving change.
Where Do We Spend Our Time? If you haven't signed up for the blog of Peter Ubel,
 MD you should check him out at Peter Ubel [http://r20.rs6.net/tn.jsp?f=001-8SwCJd7WrUVgZzUy4Tjj7VrJTyS_iua8MynA9R2TbWORyt7PQJiSRP3J9TBoLdW1dkUMLRB4EavQMmrbaRkFds00Hy9sBw7J7yu8K8z1cHqpE0sxgFyRFJ6LQGVmy6dAUkJcVybldkruX2tIeqkrBpsgkwis9CFNWXxGzyCbJ8=&c=VNeTH_urGkpMYC37jnt-aohB60M-2_2JwJd8Na6KMlxMAun70D4Dew==&ch=3f4XusItksm9ED_uC_npVh1m-HT6KuByYhTMFNVkZJSUY10hV-Nd1Q==]
or, on Twitter @PeterUbel [http://r20.rs6.net/tn.jsp?f=001-8SwCJd7WrUVgZzUy4Tjj7VrJTyS_iua8MynA9R2TbWORyt7PQJiSRP3J9TBoLdWyW08NvCOm4lM5EkteP5Ah3PgF0gBnVYVVQFMf0K1Azk2YLNIt9W7L9dyv7IoAnGXwCn4Io3pUXK9Wj5jChsDY6AVL9snW-ertTQ3BqEtR-clSQpNL15Twg==&c=VNeTH_urGkpMYC37jnt-aohB60M-2_2JwJd8Na6KMlxMAun70D4Dew==&ch=3f4XusItksm9ED_uC_npVh1m-HT6KuByYhTMFNVkZJSUY10hV-Nd1Q==].
He recently had a rant on the use of the electronic health record (EHR) and the 
amount of time it takes from physicians interacting with patients. He noted one 
study from The Annals of Internal Medicine [http://r20.rs6.net/tn.jsp?f=001-8SwCJd7WrUVgZzUy4Tjj7VrJTyS_iua8MynA9R2TbWORyt7PQJiSRP3J9TBoLdW1ifDUFwgwFChCn6bfNyNqmRPuyyu6IB4LF45aZeIbknPR-G3hIHfpnGVM0gkAo6KG8tl7SFcvx3xTTqlYW7Z3SMbuDNIsvXFIdSca6KrmMVXhjCWbO8scqkX4pjX_k8PewPg2lGLpNIZDKKQPkOGIgoOcej4en5CWnW-2mOCOTRnAxCc21fFL16FbCpyZJ4JDYZgo_WHrEgHfEsYQBJE40bYqXHfu-LopHcH6aJXdgHHoyB1pGiRUCslKTwXgOVI&c=VNeTH_urGkpMYC37jnt-aohB60M-2_2JwJd8Na6KMlxMAun70D4Dew==&ch=3f4XusItksm9ED_uC_npVh1m-HT6KuByYhTMFNVkZJSUY10hV-Nd1Q==]where
the research teams directly observed the activities of physicians in outpatient 
clinics. They reviewed four specialties: family medicine, internal medicine, cardiology,
and orthopedics. The study revealed that the physicians spent about one-half their
work time on interacting with the EHR. One-half!!! In another study from Health 
Affairs [http://r20.rs6.net/tn.jsp?f=001-8SwCJd7WrUVgZzUy4Tjj7VrJTyS_iua8MynA9R2TbWORyt7PQJiSRP3J9TBoLdWFvBtc2kjdOABOi9_AhxCgWQWdbKmmrJTbZrV011lE_ZS7U7SeZKudr52ckmf8H3UjamsoKtvUPOZdMm14j31AwmWuT_q6pWxpWlTuxGjfZ601ANychDhayJu7fgshtwUg6frj1noI7CefZEwcE_f4Q==&c=VNeTH_urGkpMYC37jnt-aohB60M-2_2JwJd8Na6KMlxMAun70D4Dew==&ch=3f4XusItksm9ED_uC_npVh1m-HT6KuByYhTMFNVkZJSUY10hV-Nd1Q==]
the work of primary care physicians on inputting information into their EHRs was
 studies. The results were similar. These results confirm my own personal "at home"
results where my 88-year-old father-in-law complained to me several months ago that
traveling for more than an hour to get to the doctor's office then, waiting in the
waiting room for at least another hour, having some tests done by technicians and
then, "only talking with the doctor for 10 minutes or less" made no sense to him.
I couldn't agree with him more.  Not all systems are bad. But, just like we need
 to not become captive to our iPhones - so, we must not become captive to the EHRs
we use to support our care delivery.
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Future Health
Delivering care in the new virtual world...
Considering Automation of Health Care Delivery - In the last several months there
have been a number of articles appearing in various journals and newspapers on "the
future of work". These articles focus on the impact of robotics, machine learning,
automated delivery, artificial intelligence and the like. The advocates for these
technologies point toward "transformative changes" that will be derived from the
 deployment and implementation of these new tools. I'm one of those advocates. But,
what gets lost in the debate is not "what" but "how soon?" Some of these technologies
will be disruptive over the next several years. Others will not come to fruition
 for a couple of decades.
In the last several months, I have advocated that we need to seriously reconsider
the scope of training we provide our future health care providers. For example, 
we are clearly moving in a very rapid way toward the use of "virtual" technologies
for the delivery of care. In the same breath, I will argue that the skills, talents
and knowledge required for providing virtual care is different than that provided
in in-person environments. What do I mean? The nuance of communication, the detection
of subtle signs, the inflection of voice, the comparative data analysis to other
 patients with similar problems are but a few of the markers where in today's world
health care students get very little, if any, training. These types of skills will
become essential - even at a rudimentary level - in the not too distant future. 
So, do we need to reconsider how we train our future work force? I think so...  
More on this topic in the future.
More On CRISPR - The advances in health care derived from the use of CRISPR are 
occurring at an incredibly rapid pace. New companies seem to spring up on almost
 a daily basis using CRISPR-based therapeutic approaches. The intent is to "solve"
problems by "fixing" the genetic errors in our DNA. One example that I've been following
is from CRISPR Therapeutics, Inc. based in Cambridge, Massachusetts. The company
 recently submitted a request to the European Union oversight body for permission
to start a new trial on beta thalassemia [http://r20.rs6.net/tn.jsp?f=001-8SwCJd7WrUVgZzUy4Tjj7VrJTyS_iua8MynA9R2TbWORyt7PQJiSRP3J9TBoLdWnoxysCAqBJNLdc50S7x3JkG1CsZkzf-AmBxaEE-vvsyzqQuWPMiduLoyDsnBImkUq-D5iH_VB8GMvbuAijU_i3y4sV3O-yPYR1ZndcXOEe7ac-uRjUK1GJ--wKBrgr_cElW-d_g8eqabxPS0ywDJNQBdzFjMQ4mg8-QAOnmWbg2ZoJVaDVpjz5ffWGs4u6Gjh5r3wbnqCsBBVXar1o9LKa06YP-YJU5v9NsFexMTc9yQNHxbIRvV8A==&c=VNeTH_urGkpMYC37jnt-aohB60M-2_2JwJd8Na6KMlxMAun70D4Dew==&ch=3f4XusItksm9ED_uC_npVh1m-HT6KuByYhTMFNVkZJSUY10hV-Nd1Q==]
(an inherited blood disorder) The company uses CRISPR technology to edit the thalassemia
gene and fix the defect...permanently. Assuming the technology works - and, all 
the indicators are that it will - they can initiate a trial using the same methodologies
for treating sickle-cell disease, a far more prevalent blood disorder. Some would
say we are in the "hype cycle" for this technology. It will not be the panacea, 
but it will have a massive impact on certain diseases. This technology is going 
to totally reshape our approach to care delivery over the next decade. Mark my word...
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
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The Weekly Whisk
Musings from a foodie...
One of the food elements that I dearly love is breakfast - especially the kind of
breakfast that borders on over the top or near greasy status. My usual in Kittery,
Maine is the FireFly [http://r20.rs6.net/tn.jsp?f=001-8SwCJd7WrUVgZzUy4Tjj7VrJTyS_iua8MynA9R2TbWORyt7PQJiSRP3J9TBoLdWsBkFvjJAj-lWB4otJB9UJ_q1DVsSDsk0SiVaC3ioNf9QYyXEuSsJ6fnlngAXBukWJ58heqygYP-UL4nwWziaEwvtRLSxxr4hzLE5NioRVZ-TUBaxmvFk2w==&c=VNeTH_urGkpMYC37jnt-aohB60M-2_2JwJd8Na6KMlxMAun70D4Dew==&ch=3f4XusItksm9ED_uC_npVh1m-HT6KuByYhTMFNVkZJSUY10hV-Nd1Q==],
a local where the citizens gather, debate the major issues of the day (e.g. how 
quickly the tide will rise on the Blue Moon), play cards and engage in simple neighborly
discussions. Stephanie is the lead waitress and keeps us all on our toes. However,
over the weekend I was out and about in Portsmouth, New Hampshire - a stone's throw
from Kittery (although the Portsmouth types would suggest that Kittery is a stone's
throw from Portsmouth). Nonetheless, we are kindred communities on the banks of 
the Piscataqua River.
I noticed several weeks ago that a new place, The Goat [http://r20.rs6.net/tn.jsp?f=001-8SwCJd7WrUVgZzUy4Tjj7VrJTyS_iua8MynA9R2TbWORyt7PQJiSRP3J9TBoLdW-uOB5KgnUy-d1aMERODGMiTAFNwevcsvWff7QLncSgTGu7QoaRCfpaWHMTGlo73VXQGVbg4n9cYRjrWdwaCQ4u3q4F7Ep-dwsWNftjDebKQ=&c=VNeTH_urGkpMYC37jnt-aohB60M-2_2JwJd8Na6KMlxMAun70D4Dew==&ch=3f4XusItksm9ED_uC_npVh1m-HT6KuByYhTMFNVkZJSUY10hV-Nd1Q==]
[* * * *] had just opened. It fancies itself as a sports pub but on the weekend,
 they serve breakfast which was why we stopped. The wait staff were very genial,
 and the food options were unstoppable. For a greasy spoon advocate, it was heaven.
I had the Meat Lover's Omelet with the addition of Home Made Corned Beef Hash, Goat
Cheese and some additional American Cheese. It was a cardiac overload but a wonderful
struggle to complete. It was topped off with tater tots covered in melted American
cheese and bacon bits on the side. Now, what American boy wouldn't love that kind
of breakfast? While it will be a few weeks before I go back (I need to recover),
 I heartily recommend it especially if you have not eaten in the last three or four
days. Enjoy if you get there. For lunch you can head over to The Lobster Pound or,
Maine's Best; or, Bob's Clam Hut, again one of the best in Maine. Stay well. Exercise
to keep your cardiac vasculature open and only do The Goat thing once a year!! Check
'em out at: The Goat - 143 Congress Street, Portsmouth, NH 03801 - 603-590-GOAT 
(4628) - https://goatnh.com/portsmouth/ [http://r20.rs6.net/tn.jsp?f=001-8SwCJd7WrUVgZzUy4Tjj7VrJTyS_iua8MynA9R2TbWORyt7PQJiSRP3J9TBoLdWKR12fTCLCm4F0fPrATNoSGPk1vjAy32hPUDArCCelZk3sxFhvuz3EuTnxWTPazb1xGf8eoRPiqty3BG7qXTdakq8BuRBucPwwJRuQLv3CWyDbrkt-U-BPQ==&c=VNeTH_urGkpMYC37jnt-aohB60M-2_2JwJd8Na6KMlxMAun70D4Dew==&ch=3f4XusItksm9ED_uC_npVh1m-HT6KuByYhTMFNVkZJSUY10hV-Nd1Q==]
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
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The Good, The Bad, And The Ugly
The ongoing saga...
The Great - Carnival has started in Brazil which means that warmer days are ahead
in Maine!!
The Good - The stimulus provided by the Amazon-Berkshire-JPMorgan initiative will
no doubt do a lot to shake up health care and move it from seeming lethargy to hopeful
action.  We shall see and, we shall monitor the results.
The Bad - Four years after the United States pledged to help the world fight infectious-disease
epidemics [http://r20.rs6.net/tn.jsp?f=001-8SwCJd7WrUVgZzUy4Tjj7VrJTyS_iua8MynA9R2TbWORyt7PQJiSRP3J9TBoLdWkp5zasyjHToAo0QXJ9QaHmvhG24fv6Qn8TwlNcMXbnXcL68FWe1kvmgDOE8WnG14QIJcr0uCruTwNWRmkZfwA3vDYTWmU4dPA5VjJVMmv2bVy27yzfNvEqPgqKx--NEO8qq_PrzrVNZLUAsSL97A1Tw5y4rB026vBa-oxVYKQgGF_001ZiaXNTq-hEScjxcIttBwB3zUyhwH5HuGo2CGCtaHtobQQqgLHTjeEIzeax_LhRv41DhodqSdc6LPxGmiqQS3DQfQdHSWLI5hxHfk-xhTB1uyTpcE&c=VNeTH_urGkpMYC37jnt-aohB60M-2_2JwJd8Na6KMlxMAun70D4Dew==&ch=3f4XusItksm9ED_uC_npVh1m-HT6KuByYhTMFNVkZJSUY10hV-Nd1Q==]
such as Ebola, the US Centers for Disease Control and Prevention (CDC) is making
 huge cuts in its epidemic prevention programs for 39 out of 49 countries.  Why?
  Because the money is running out.  But, hey, we need money to build a wall (SEE
commentary above)...
The Ugly - Every day I seem to wake up to yet another effort - whether intentional
or not - at piercing our democracy in an effort to rupture out state of affairs,
 sow mistrust among the people or sway in untoward directions with dystopian information.
 The last time we had a similar level of crisis was during the Watergate Hearings,
which I remember as if they were yesterday.  I was glued to the television when 
I wasn't studying.  But, those days pale in comparison.  While we are attacked from
the outside, we seem to be simultaneously rotting from the inside.  The majority
 are in the middle.  We need to reclaim our rightful role in maintaining balance
 in society...
The Intolerable - As I'm preparing this blog, the news of the mass shooting at a
 Florida high school is crossing the news wire and consuming all of us.  When is
 enough, enough?  It is absurd that we allow this type of situation to occur in 
our nation's schools.  Is the NRA going to suggest that we should arm our children
so that they are protected?  WE, THE PEOPLE - from all political persuasions - need
to say we're done with this type of absurdity.  How many more must die before we
 declare enough?
The statements in The Fickenscher Files [http://r20.rs6.net/tn.jsp?f=001-8SwCJd7WrUVgZzUy4Tjj7VrJTyS_iua8MynA9R2TbWORyt7PQJiSaRZXEN2xklCTbWWaX8i8bTufT1E28QzIsMzR7__bKAxVHE4g8yXA8R9Uh5hqHaKMONVtGgE7Z-Gqbv4wHCRfh4ZhEg0RZlDpnDNmsWlbUbRL_qjdfBpiSz2KmDSXAQJtiQNsUQfSOz6&c=VNeTH_urGkpMYC37jnt-aohB60M-2_2JwJd8Na6KMlxMAun70D4Dew==&ch=3f4XusItksm9ED_uC_npVh1m-HT6KuByYhTMFNVkZJSUY10hV-Nd1Q==]
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
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The Fickenscher Files | PO Box 840 | Kittery | ME | 039