Subject: News from Dr. Kevin Fickenscher
From: "The Fickenscher Files" <[email-masked]>
To: <[email-masked]>
Date: Mon, 16 Jul 2018 12:12:49 -0400 (EDT)

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The Fickenscher Files [http://r20.rs6.net/tn.jsp?f=001geDhZLCXG4kWAflj9HKd5OfIveKCQGcFis8IK-6UjYDep29AQrMpX2n3NFwdGE0RNJwmHK0rj685ZWXnFP2BabCvdzu3a1MILEoVExnSJgrHlw3BmJViFj9WUNN-S6F45wljypfOcPSgztqWgPNPmS_NQeM0nfFErJa2AOgKbMZUbNSve4MbOsQCJiHC45Mz&c=Nxg7pt5lrlEYY-sZ7_PbFSmeGfgPhdvSPbTc9ifjJ3vzMmeBvcJl6A==&ch=pGRktHg9AXwO2wN9iPPTeHgaeGjKk7Zy8BVWIFFzTAipBGwEvcXKwA==]
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The Fickenscher Files, Vol. 6, Issue 10
Kevin M. Fickenscher [http://r20.rs6.net/tn.jsp?f=001geDhZLCXG4kWAflj9HKd5OfIveKCQGcFis8IK-6UjYDep29AQrMpX_khtRb-yDeiN5kMsDMANessc51KNr9Ig46dU7WCHvHQc3kC8j6dld4vT99oZ3tqw_nEcTNhhmxgrfrvXiN9d1XVAlr8Jy-0Q_eML9l6Yj0_MU9XRLc-KWOzaHJvc8dgFifD4snJ0Acob0tTDjkWh-k1Mg9SmqxAYQ==&c=Nxg7pt5lrlEYY-sZ7_PbFSmeGfgPhdvSPbTc9ifjJ3vzMmeBvcJl6A==&ch=pGRktHg9AXwO2wN9iPPTeHgaeGjKk7Zy8BVWIFFzTAipBGwEvcXKwA==],
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
"We can be frank and outspoken without being reckless or abusive, polite without
 cringing, we can attack racialism and its evils without ourselves fostering feelings
of hostility between different racial groups."
Nelson Mandela, whose centenary is to be celebrated on July 18th and whose spiritual
and political leadership in woefully missing in today's political climate.
"I am concerned that our increasingly fractious political process, particularly 
related to federal spending, is threatening our ability to properly defend our nation,
both in the short term and especially in the long term."
Dan Coats, National Director of Intelligence, in comments [http://r20.rs6.net/tn.jsp?f=001geDhZLCXG4kWAflj9HKd5OfIveKCQGcFis8IK-6UjYDep29AQrMpX0PayQCqi11Vb7NlBgiZKBdXGd7WuPmvBSeIctG0VKJKkfFUCLj3yk4UAMLnEijocMUYbjUOU61_Vl2jA8lCe0YqwG1i0IDFrY1ZeYfJ5yvibSE_P3Nie50wQ_IvOPnsQ1f_wijyXnipLgwza7rE3nMZlFhQ1J76nPQzPpEnOA9Bhq5cMt-UwVsYJjRbnq2EkmRX6NWf9VDh&c=Nxg7pt5lrlEYY-sZ7_PbFSmeGfgPhdvSPbTc9ifjJ3vzMmeBvcJl6A==&ch=pGRktHg9AXwO2wN9iPPTeHgaeGjKk7Zy8BVWIFFzTAipBGwEvcXKwA==]
before the Senate Select Committee on Intelligence. Reading the "comments" will 
make your ears curl...
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Media To Consider
Books and Articles worth a Review...
A Quick Read - But, Looming Problem - Sometimes when we are in the thick of the 
problem right in front of us, we forget about the bigger problem that is on the 
horizon. It happens too often. Then, the bigger problem falls on our doorstep and
we are fully unprepared to deal with the crisis. Such is the state of antimicrobial
resistance (AMR) which causes an estimated 700,000 deaths annually. Read the article
in the May 18, 2018 issues of Lancet for an overview of the problem titled, "Global
Governance and Antimicrobial Resistance [http://r20.rs6.net/tn.jsp?f=001geDhZLCXG4kWAflj9HKd5OfIveKCQGcFis8IK-6UjYDep29AQrMpX0PayQCqi11Vd5Tgo8puS1Tt28wG3dVzJ-Q8qpAw2V7G4GqBLCDl7_GRAwh8T51V1nyNfKGhFQjwEkUN78UTiGS4wK_N2W4fKW76UoH4wDHtFv-hIbZqeoBEUrG1-V6V0M6pU3gd2mxz0m8pVu-KkQoV9v6UFIf7yymU2HhllyVna6JIJ6CJ3NxV2HcAUUHbNX0zwjXAai343i6ttuBJwKQ=&c=Nxg7pt5lrlEYY-sZ7_PbFSmeGfgPhdvSPbTc9ifjJ3vzMmeBvcJl6A==&ch=pGRktHg9AXwO2wN9iPPTeHgaeGjKk7Zy8BVWIFFzTAipBGwEvcXKwA==]".
And, Another Looming Problem - According to the Centers for Disease Control and 
Prevention (CDC), 36,252 Americans died because of gun violence in 2015; 11.3 deaths
per 100,000 people - an average of about 100 gun deaths every day. By comparison
 in 2016, the approximate number of firearm-related deaths were about 39,000. Compare
that to motor vehicle-related deaths at 40,000 and drug overdose-related deaths 
at 64,000. Yet, while there is substantial ongoing research in both the motor-vehicle
area to improve the safety of our cars and in drug overdose to make treatment more
effective (although not enough resources, I might add) - there are almost NONE allocated
to gun research. As a clinician, I'm very data driven. But, the CDC nor any of the
other branches of government - which fund research on all matter of other problems
- discontinued gun-related research after the Dickey amendment took effect in 1996
which states that "...none of the funds made available for injury prevention and
 control at the [CDC] may be used to advocate or promote gun control...". And, the
Trump Administration has continued to provide only funds for monitoring the situation.
In anotherLancet issue on June 23, 2018 the article, "Gun violence research in the
USA: the CDC's impasse [http://r20.rs6.net/tn.jsp?f=001geDhZLCXG4kWAflj9HKd5OfIveKCQGcFis8IK-6UjYDep29AQrMpX0PayQCqi11VgqtBFNYxjoHAGu1qrP3JQn-iUReQkZqlJkGeB5Nq_hOIm9Ni4L2UViB4MX82OXPknnl3i1lSyBHhs09g0YdmcQmiepKEbjo8f4iCaMQnoCCuVRlYLbrLqzxEsSMc4rQyENIx7nnwSds3q5KDAkAxjn5WyBfIoQXNSv9jkLyy-0QWyH2ZKF3YjA7G-dvFOz_zPzJsD0Owc5oRdKeZ0xHO1-NA3uXVPaHlWXONR4p4ukI=&c=Nxg7pt5lrlEYY-sZ7_PbFSmeGfgPhdvSPbTc9ifjJ3vzMmeBvcJl6A==&ch=pGRktHg9AXwO2wN9iPPTeHgaeGjKk7Zy8BVWIFFzTAipBGwEvcXKwA==]"
touches on a big issue. Consider it. Think about it. Act on your thoughts...
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Consulo Indicium
Information for your Consideration...
Let's Start With Some Good (Wonderful) News - The Centers for Disease Control and
Prevention (CDC [http://r20.rs6.net/tn.jsp?f=001geDhZLCXG4kWAflj9HKd5OfIveKCQGcFis8IK-6UjYDep29AQrMpX0PayQCqi11VYT5gMXScF0RrN1ZDgME64ixc5CO7LaTl9O_-ijX2BgFGVYA1ExWQdlU-VfhND0KFcQFIO-4mbad9dU8kXPs9cHx1ktMjf_STq-9Wj2EZRs8bXDNbI7-6VOAv6nWM8-PgzUiYBiccupu8nZplnxLcBIYwvNjb6jbu5Zs4VjKnMcXIrH5UAEMOb0heLb74k_71Q43RnxK3oTbjZ8mYaWJwECQ1H2BgrBLybgcPT8mE55U=&c=Nxg7pt5lrlEYY-sZ7_PbFSmeGfgPhdvSPbTc9ifjJ3vzMmeBvcJl6A==&ch=pGRktHg9AXwO2wN9iPPTeHgaeGjKk7Zy8BVWIFFzTAipBGwEvcXKwA==])
recently announced that the rate of smoking continued to drop by reaching a NEW 
LOW of 14% last year!!! The prior year, in 2016, the rate was 15%. The anti-smoking
campaigns, cigarette taxes and smoking bans in cities and states across the country
were major factors contributing to the decrease. We've seen a drop from 42% in the
early 1960s. Wow! That's impressive...
Money, Money, Money - This past week, the updated changes to the 2019 Physician 
Fee Schedule and Quality Payment Program were sent out by the Centers for Medicare
and Medicaid (CMS). The good news is that for several decades, physicians have billed
Medicare after completely documenting the details of each patient visit with a set
of evaluation and management codes. Most clinicians would argue that the codes are
onerous without contributing much value to the ongoing care of a patient. However,
next year, the E&M documentation process is going to change dramatically by through
a proposed simplification of the documentation requirement process. The intent is
to provide clinicians more flexibility. We shall see... In addition - on a topic
 near and dear to my heart - CMS is also proposing that doctors be paid for the 
time they spend communicating with patients over the phone or via other telecommunication
channels, regardless of whether a face-to-face office visit or other service has
 been rendered. The proposals even call for physicians to be paid for the time they
spend reviewing patient images or video. All I can say is - It's about time!! Now,
the proof will be in the pudding as they say in the kitchen. But, lest we think 
that all is sweet smelling roses with the new CMS proposals, it also appears that
some specialties are going to take deep cuts in their payment schedules. Where one
part of the medical community wins, another part is gored. We need to move to value-based
payments if we want to get beyond these kinds of battles... At the same time CMS
 is moving to change physician reimbursement, the US Senate Finance Committee has
reported [http://r20.rs6.net/tn.jsp?f=001geDhZLCXG4kWAflj9HKd5OfIveKCQGcFis8IK-6UjYDep29AQrMpX0PayQCqi11V3_0nmi9bPLExa8ii79g8UvU7DopRFesTyobZCxRJjoGr3STTAuuRH3HDiIr-XutSBjNR4904xhaNFY7B9_rRJ88nIUFzQyhrPlvKVLbGzJ-dZ19OML-kIwYUVidiiDuFiOyMXYQFoaROw-gKdd_d_hBxdoulSIOhMD3OEa9aa7Xzzd1HG4wkSQErEtAgvWpZK6IoFDL-ojgqiGwso8h-Upj-ZcsEtoJlC8aG_u7yRCy4SOI6MF4IC_0Rx6D-n6HJqM1sdYso7H1tR8K6geHIX9RYsU-PzciKgcnGoMQKmM6J9LD5ARS3gAfNp7DPmirKJYPIxNxl7znjMaoRvW7rwbryKZ2--3XII4ukRfTA0FKfkz0iG1CCLvznD3Dbr4owag6Uu-R5-tAr-ZYvTy4iyV-_JhBtDCFzKjGGA9HY2D1kByPYIi5Vfpv0UTcFwA6zgM_LXIRoJgXVdtBQBQFbnIelJu9MJXPku5NfqR6oa8igHDiFxlEPH5FJnJ4UN0NKCUqNyE8eeAQJuJMsdxYxeqhYWlrVBsPDC46rQqM37Cvn5DcZYEH-m1Mmj7w4C_4Lcj0s80Cswutg--zsCcyL9g==&c=Nxg7pt5lrlEYY-sZ7_PbFSmeGfgPhdvSPbTc9ifjJ3vzMmeBvcJl6A==&ch=pGRktHg9AXwO2wN9iPPTeHgaeGjKk7Zy8BVWIFFzTAipBGwEvcXKwA==]
that it will be taking up reconsideration of how rural hospitals are paid under 
the national program. The Committee report stated that it would, "rethink Medicare
payment policy for rural hospitals". Committee members are evidently focused on 
considering a move toward the success of global budget demonstrations in contradistinction
to the current Medicare payment structure which is designed around the issues related
to high volume and frequency of inpatient stays.  In addition, the Committee recommended
that HHS Secretary Alex Azar "...do more for rural providers, particularly when 
it comes to regulatory relief."
Then, Move On To The Problem Areas - Like The Growing Urban-Rural Economic Gap -
 A new report was recently released by the Brookings Instituteproviding an analysis
of metropolitan economic growth compared to their surrounding areas. In sum, the
 300 largest metros in the world accounted for 36% of global employment growth and
67% of GDP growth between 2014-2016. At the same time, these same metros only represented
21.9% of the population growth. The disproportionate growth of these metros is causing
an increased gap between them and their surrounding, more rural areas. And, most
 importantly - it's a universal phenomenon across virtually all the nations of the
world (See full report [http://r20.rs6.net/tn.jsp?f=001geDhZLCXG4kWAflj9HKd5OfIveKCQGcFis8IK-6UjYDep29AQrMpX0PayQCqi11VNimTGySQ9CCKdDkcWmtNjmS_h6xbmqQy4bHjKNY84iAIvmmJcl8_mSPVVEI_Ybe1G9Y0fOidRz57kzH3ZsoU7whM-alHw-tSYgo7WzRAw0XpFnUY3Mjrx0vDGNJusM1gFSSlte2f0lmZA8KxtsJKsCGaTA2ZU-4FiUD403BZqgc9kkHLBJ3Eripll6_AvHravyXayV2B-B9UAy7Q1I4uzUgDtfKUrTyS&c=Nxg7pt5lrlEYY-sZ7_PbFSmeGfgPhdvSPbTc9ifjJ3vzMmeBvcJl6A==&ch=pGRktHg9AXwO2wN9iPPTeHgaeGjKk7Zy8BVWIFFzTAipBGwEvcXKwA==]
here). And, increasingly, if one considers the politics as well as the economics,
the divide is not just economic. Witness the recent electoral votes in the UK, Austria,
Turkey and even the US where there were clear and distinctive divides in political
outcomes at both ends of the spectrum depending on where one lived. It's the rurals
(or, "populists" or "economic have nots") versus the urbans (or, "elites" or, "economic
haves"). As an example, what have we done to provide further education and support
for the dislocation in the coal mining industry? Promises of "bringing back" the
 industry are hollow at best. But, doing nothing is also hollow at best. We have
 a problem and it will only get worse in my estimation. I suggest we get on with
 it...because with the growing gap there will be continued growth in dislocation,
animosity and economic disadvantage.  And, over the long term that is simply not
 sustainable.
The Symbiosis Of A Diminishing Workforce And Rising Health Care Costs - Now that
 Boomers have moved through the red wagon-, Schwinn bicycle-, college experimentation-,
early mortgage-, child rearing-, empty nesting-stages of life - they are rapidly
 shifting gears towards retirement or a simple downshift in life at a rate of 10,000+
per day. The impact is reshaping the USA economy with fewer workers to support a
 burgeoning elderly population that will substantially increase their consumption
of health care services after age 65. According to the Centers for Medicare and 
Medicaid Services (CMS) [http://r20.rs6.net/tn.jsp?f=001geDhZLCXG4kWAflj9HKd5OfIveKCQGcFis8IK-6UjYDep29AQrMpX0PayQCqi11V5P4HI0m5VWl6JSG0PmWIechpHzRaGHjGBLWh1o2iIO2k00BjT7b71X4SZinbv0EnqRGswLwyUAsCViifvG4ozk938kU21657YBEoQdBvLOgIr_aetYBTLcldFclCdjctqKfHTOVz06TlIaFFB9SgbLb70GWNI_6rN3fKmmUF8ADz6h992shoQnHQ186sNQgIez3zCFzjjkU5S5fYESW81tjOdo2-YOsmRoztQ45kS15kGoJJ4Ee808x7g7xsaOcBBVEXtXkhIT_DF_e0HpeVZJXdyidL7Rno&c=Nxg7pt5lrlEYY-sZ7_PbFSmeGfgPhdvSPbTc9ifjJ3vzMmeBvcJl6A==&ch=pGRktHg9AXwO2wN9iPPTeHgaeGjKk7Zy8BVWIFFzTAipBGwEvcXKwA==],
the data falls out accordingly:

* Children (0 - 18) will consume $3,572 (female) to $3,680 (male) per capita
* Working-Age Adults (19 - 64) will consume $5,353 (male) to $6,892 (female) per
 capita with the Medicaid spend about a third higher for women and even more for
 men due to the number of disabled male enrollees; and,
* Elders (65 and older) will spend $17,530 (male) to $19,110 (female) with the larger
spend for women due to a higher percentage living in nursing homes in the later 
year at a rate of nearly twice that of men.
These data points do not bode well for the USA economy. Why? Because the rate of
 health care spend has been outstripping the GDP growth [http://r20.rs6.net/tn.jsp?f=001geDhZLCXG4kWAflj9HKd5OfIveKCQGcFis8IK-6UjYDep29AQrMpX0PayQCqi11VzrKDRotnSSfoLhG_3N_j451xYTKgpXvAYMnz7dQJQ3l8g9UrNOS17FPn1s2EnbCUnIe-PCC8AVf2bkHeVScgIjRHMm_1xpfYnwpiQmByY3g6F7OuSZLiNnZB06z4U4b1jhmy5NZ0sp7CcidtKqGUVZnufrWBFOosCEqSLEyAw03Qr0rGVy1FL2rwF3uBQdTNs2g7bHvgE70FkjnJhJLLIwTXkY0NSXzobncxgjDfiXf5thYVEMNL9u1cFMZ2Zhu5r2m4G3Y8ML2mOq12EAXPW3i_y0LolUsh&c=Nxg7pt5lrlEYY-sZ7_PbFSmeGfgPhdvSPbTc9ifjJ3vzMmeBvcJl6A==&ch=pGRktHg9AXwO2wN9iPPTeHgaeGjKk7Zy8BVWIFFzTAipBGwEvcXKwA==]
since 1970. We are now at nearly 19% of GDP devoted to health care. Furthermore,
 in 2017 there were 25 Americans 65+ for every 100 working age folks growing to 
35 by 2030 and 42 by 2060. If we don't do something, the burden will become unsustainable.
Either a massive backlash will occur among the Millennials who will be stuck with
the costs or some other solutions will need to occur (immigration for instance...).
While I don't anticipate reaching 2060, I hope my kids will and - I don't want them
to be burdened by bad decisions we made in the early part of the 21st century. Make
sense? If so, we need to raise our voices...
Then, There's Workforce Automation - It seems like every day there's a new report
on the automation of work. From self-driving vehicles (think taxi cabs and long-haul
trucks) to intelligent algorithms and predictive analytics (think statisticians 
and financial analysts) to machine learning and artificial intelligence (think dermatologists
and hospitalist physicians) the tools which are driving workforce automation are
 at play. A study [http://r20.rs6.net/tn.jsp?f=001geDhZLCXG4kWAflj9HKd5OfIveKCQGcFis8IK-6UjYDep29AQrMpX0PayQCqi11VWi00euil_7XOBlPt6bO5RpEC8gJCQvaHvE-kgurO40Dj6pDKjbjVgC2r3fMbsA9Xym_xyfpcTaM21uvibOvPQRERbuofpyQ2vO3u8dysxn-5_nJHkoQ5cA22p2zXuxRwEY8S3xgBh_2C4IBhWITreCZKlzIgWwnRxhbt1o_Fx84Hmr8PclaEKw-9HP77fZta&c=Nxg7pt5lrlEYY-sZ7_PbFSmeGfgPhdvSPbTc9ifjJ3vzMmeBvcJl6A==&ch=pGRktHg9AXwO2wN9iPPTeHgaeGjKk7Zy8BVWIFFzTAipBGwEvcXKwA==]
done by researchers at Oxford University in 2013 suggested that nearly half of all
jobs in the USA were at risk of "computerization." More recently, the Pew Research
Center [http://r20.rs6.net/tn.jsp?f=001geDhZLCXG4kWAflj9HKd5OfIveKCQGcFis8IK-6UjYDep29AQrMpX0PayQCqi11VwXkhoxSl8tU9WpYzN5AsmBiZy-OV5k1jiCpopnS_bp2Vvpi33sDz7X18gHRkuZjMfrkGtUPXHmb2CEDFzO0ckJuOlcZ3g77suRtRkuzv0g-nStiy7LOg4LLWh5FlG_XGMLX15ohnrZJ5DTHEWYcxvprsjdiLroh1&c=Nxg7pt5lrlEYY-sZ7_PbFSmeGfgPhdvSPbTc9ifjJ3vzMmeBvcJl6A==&ch=pGRktHg9AXwO2wN9iPPTeHgaeGjKk7Zy8BVWIFFzTAipBGwEvcXKwA==]
surveyed experts in the field of robotics and computing and found similar predictions
on the displacement of jobs over the coming decades which will have profound implications
for both workers (i.e. our children and grandchildren) and society as a whole. Perhaps
all this talk is having an impact on worker attitudes. Fully two-thirds of workers
feel that by 2050 their work will be done by robots! Hmmm - that leaves a lot of
 time for exercise to stay healthy so that we can live better longer, engage in 
real human interaction that is truly connected to the person we are engaging; and,
participate in other kinds of activity where robots are not so good like cooking,
art, music and dance renaissance. First, let me say that all of these areas are 
very, very hard professions that require a commitment just as strong as STEM, the
professions or any other areas of professional pursuit.
But, the fact of the matter is that we are at the formative stages of the digital
revolution which much like the Neolithic Revolution and Industrial Revolutions before
it caused massive societal disruptions. The difference was that the Neolithic lasted
several thousand and the Industrial nearly 150 years. The Digital will likely last
just about another 20 years. The data listed below from the Pew Research Center 
shows clearly that people are concerned.

The extent to which robots, algorithms and protocols make the human workforce more
efficient and, therefore, less dependent upon sheer brute force of people power 
is an open question. But, it's safe to say that we are on the horizon of a major
 shift in how work will be accomplished.
Studies were recently completed by ShiftLabs - a collaboration between the Rockefeller
Foundation and New America on the shakeup [http://r20.rs6.net/tn.jsp?f=001geDhZLCXG4kWAflj9HKd5OfIveKCQGcFis8IK-6UjYDep29AQrMpX0PayQCqi11Vb8o-jWkweOZ6xkNNBiIvlKLRGskpDBXYgr0xA3Rc7jRlIYkPaxFIF-wq33lsXuiqgiuwBymC1WF8CWogV5ZRdOOjqFOONNHaAoJcz8eC_9-8fzXSilrZfQ5xhejlPyppJR2wfSbnJ3rZNuAPJR621pmsBtciM74qSQ3aDpcZ4QY7hrxG5KusDuKSS-dgR5On&c=Nxg7pt5lrlEYY-sZ7_PbFSmeGfgPhdvSPbTc9ifjJ3vzMmeBvcJl6A==&ch=pGRktHg9AXwO2wN9iPPTeHgaeGjKk7Zy8BVWIFFzTAipBGwEvcXKwA==]
in the jobs market for Phoenix and Indianapolis. It's very clear from the study 
that people are going to be required to learn new skills [http://r20.rs6.net/tn.jsp?f=001geDhZLCXG4kWAflj9HKd5OfIveKCQGcFis8IK-6UjYDep29AQrMpX0PayQCqi11VPFzTIE7qzfYfHZFPJrceFi_euQ3gUyvOqWaUvL-m9GFMY-pRDJjclIT2Vdp7l5vH42UIBK5YyMvuwDxjesf6rMqlEXoNBHwoOeQhZf3iGDEtlHMKoOGFkGr3oXrUhkjkwY3Oh52uQqXU5rqo5y1-zxkTP0TbO9DVtRimpFqBjf84hdWEEA6n_bsiY7RfjgJumUhWY-N17cvMr_XGvV5GIumk9tGEo5T8Dv5-sCtc-yxyt4imc3LmhjOmCUvfljaKgQnOHgAboYc=&c=Nxg7pt5lrlEYY-sZ7_PbFSmeGfgPhdvSPbTc9ifjJ3vzMmeBvcJl6A==&ch=pGRktHg9AXwO2wN9iPPTeHgaeGjKk7Zy8BVWIFFzTAipBGwEvcXKwA==]
that will radically reconfigure their occupation and the training/education required
for it. To give you a flavor of their findings, the study noted that restaurant 
workers (e.g. food service workers, waiters and cooks) will lose the most jobs, 
followed by retail and sales people with cashiers at a 97% risk of losing their 
job to automation - think going to the grocery store and those quick, automated 
lines or, simply the automation of the regular lines. And, the list goes on.
In the field of health care, the risk is slightly less with the study showing that
nurses had only a 50% risk of professional automation.  I actually have likened 
the use of these new technologies as the renaissance of health care through the 
use of "clinically augmented intelligence [http://r20.rs6.net/tn.jsp?f=001geDhZLCXG4kWAflj9HKd5OfIveKCQGcFis8IK-6UjYDep29AQrMpX0PayQCqi11VFOS02VoOPq9whZy1yJ81sN6HyoDSANDqUCVCJgWmE2xWwo5bKGULLymjGM_a9fbkciVlOgScXPt_zkQTog8dO-QaolQjT1VqyyIce4Ol7LHlhrBF4DFA1AnxIFxE1FG348X97G6WOa6mpp-h4e-YvW0SXC6HwoHuSWKJlYDMGtwEIWMVnZB5JL7Jz9UrA-ZZxdunbWe1rd4WJJfXoAz8WCwghoCcs1OH&c=Nxg7pt5lrlEYY-sZ7_PbFSmeGfgPhdvSPbTc9ifjJ3vzMmeBvcJl6A==&ch=pGRktHg9AXwO2wN9iPPTeHgaeGjKk7Zy8BVWIFFzTAipBGwEvcXKwA==]."
I've said this before having once been a patient in the ICU and surrounded by the
best of the best technology that medicine had to offer. It was not the technology
that made me feel "taken care of". Rather, it was the nurse who held my hand and
 reassured me that all would be well. Such is health care. So, we should anticipate
that we will become more efficient, more effective and less reliant upon people 
power to manage the care delivery process. Learning how to integrate these new capabilities
will be the challenge. Anticipate more discussion on this topic as the journey continues.
A Plethora Of Telehealth Information - It seems that the floodgates have been lifted.
We are awash in a rising tide of information on the use of telemedicine technologies
related to the delivery of care. While I can say, "It's about time", I can also 
say, "Let's be diligent!" I would encourage any executive team that is considering
the use of telehealth technologies to pursue it with vigor and resolve. It is the
future. But, go into the future with eyes wide open. Here is a starter list of information
from various websites on nuggets of information to consider related to telehealth:

* telemedicine reimbursement [http://r20.rs6.net/tn.jsp?f=001geDhZLCXG4kWAflj9HKd5OfIveKCQGcFis8IK-6UjYDep29AQrMpX0PayQCqi11VOxkEGy06i31nod0jXy9Z5cc8oy4-9rsCaCgPv69WTf2JpjSuv7gzWBSRMa8CweMNQdIKxoGL6CirCG0bIVoW5Tf3AAYxgDEeiIpbzVuZCgb5p2KHX1G6cK3FJPGWDxKKwE7nzSyeaTK1Rjghdh56MEKYitjMC4KjhN1DK7Q41FYCqb5B-8XeAuQeI5sEdwXUSD-Hv0pvsqBoopG5pzrjMCQhRHjQ4p5gNXAiyAGLIhg=&c=Nxg7pt5lrlEYY-sZ7_PbFSmeGfgPhdvSPbTc9ifjJ3vzMmeBvcJl6A==&ch=pGRktHg9AXwO2wN9iPPTeHgaeGjKk7Zy8BVWIFFzTAipBGwEvcXKwA==]
* lessons learned [http://r20.rs6.net/tn.jsp?f=001geDhZLCXG4kWAflj9HKd5OfIveKCQGcFis8IK-6UjYDep29AQrMpX0PayQCqi11VD_V0Rbgxp4p0EL31R24lVjtucO0bW33_ZSZfSenL1YXfelvbaSy8qA3pHU0sh6U2EyLf_3Ds3Slj14AzLwrNK2oyz5XZP5fIiqu0HbBDeCdtMOJP2ujsBPLRXodNKOflhpyWjndTnMT1am_uyvdrtRTVWFPqpyJpu6c5Ip9_kgbT5igLhQml_ZsLpTUyZQx-RXdtI77EZS5t2XVbK5ZZAw==&c=Nxg7pt5lrlEYY-sZ7_PbFSmeGfgPhdvSPbTc9ifjJ3vzMmeBvcJl6A==&ch=pGRktHg9AXwO2wN9iPPTeHgaeGjKk7Zy8BVWIFFzTAipBGwEvcXKwA==]
* good examples of telehealth programs = Mercy Virtual [http://r20.rs6.net/tn.jsp?f=001geDhZLCXG4kWAflj9HKd5OfIveKCQGcFis8IK-6UjYDep29AQrMpX0PayQCqi11V3N5D3ZFgbwvOSYXs_3iIC60Ep79HrTAb8-heMesher-W1XQp-v_Zo4Qx1D9FF-Amypn20dP_mW6SHkuIbNs7R0T5Ooo6xWYBdPerpdO0Zq5DlWLTqrwm8M4Hi-pevAdZ&c=Nxg7pt5lrlEYY-sZ7_PbFSmeGfgPhdvSPbTc9ifjJ3vzMmeBvcJl6A==&ch=pGRktHg9AXwO2wN9iPPTeHgaeGjKk7Zy8BVWIFFzTAipBGwEvcXKwA==]
* reimbursement for e-visits [http://r20.rs6.net/tn.jsp?f=001geDhZLCXG4kWAflj9HKd5OfIveKCQGcFis8IK-6UjYDep29AQrMpX0PayQCqi11V1Qo2mIFjLsReoV-0YoT4A3uHp0DonyluCwHpuxj6DYRF63MeW2HVGAnX_K_lkiPwIKyT_dB1gcBsfI58foOmATkbcFq0lsaPsnqPz521372MYX-dFXNd2s02M-KrsxbvP5e9GYZkP1ZzGJFqGVtprQ==&c=Nxg7pt5lrlEYY-sZ7_PbFSmeGfgPhdvSPbTc9ifjJ3vzMmeBvcJl6A==&ch=pGRktHg9AXwO2wN9iPPTeHgaeGjKk7Zy8BVWIFFzTAipBGwEvcXKwA==]
plus, detailed explanation on e-visit restrictions and limitations [http://r20.rs6.net/tn.jsp?f=001geDhZLCXG4kWAflj9HKd5OfIveKCQGcFis8IK-6UjYDep29AQrMpX0PayQCqi11Vty0-8KCkC189S7w_QPZLPTOOpDNGwoqIAH7eBgUHGvqD2-OXHEX1IgZVV230f3xJr2ySO6MRQdzQagyTYw05LckMsfxIIjD43pwMz9vajilgHJdCfvoL-R8pfk8T8IqB5b-ZoXOUkaq8yiJEVwPsKQ==&c=Nxg7pt5lrlEYY-sZ7_PbFSmeGfgPhdvSPbTc9ifjJ3vzMmeBvcJl6A==&ch=pGRktHg9AXwO2wN9iPPTeHgaeGjKk7Zy8BVWIFFzTAipBGwEvcXKwA==]
* pending Congress [http://r20.rs6.net/tn.jsp?f=001geDhZLCXG4kWAflj9HKd5OfIveKCQGcFis8IK-6UjYDep29AQrMpX0PayQCqi11Vts_M1ZjMVi1X80bag7FiSNu4rGtEvWAkl9zWZXQAONO7mMQOqRr2Rg1BGxRY5-K3UrxZas0aMQyJ1AvBwPqq7TMRU2Qu55oZXNjFsxErwlhdk3gKUl88tPvcKtOG5uCQ9sHEE6YD2Wkwu_39fnBdG1Rg4gfBOoBHpLea_xdDYz3UqwzTQg0PPA==&c=Nxg7pt5lrlEYY-sZ7_PbFSmeGfgPhdvSPbTc9ifjJ3vzMmeBvcJl6A==&ch=pGRktHg9AXwO2wN9iPPTeHgaeGjKk7Zy8BVWIFFzTAipBGwEvcXKwA==]ional
legislation
* Telehealth Resource Centers [http://r20.rs6.net/tn.jsp?f=001geDhZLCXG4kWAflj9HKd5OfIveKCQGcFis8IK-6UjYDep29AQrMpX0PayQCqi11VR1Xcp5O7jUX1G5ZgR5C6-67KOzgIlREWPh1d8P-sTb851HCnEe5URQYm6gXFtvtkKEN0knxpiNgcS0Nj5ogNz9ibzem5hjUVJgVt2sdXIQRKe0EN4GiKNvvEhIeVQW8sDBS6lkVy8wggK4LJPn3EODuIFXE15wkPwee8c9O6T6OqbtikjEby4Prvew8x4y_0rbOWADdGYTUDe27sSSSzNA==&c=Nxg7pt5lrlEYY-sZ7_PbFSmeGfgPhdvSPbTc9ifjJ3vzMmeBvcJl6A==&ch=pGRktHg9AXwO2wN9iPPTeHgaeGjKk7Zy8BVWIFFzTAipBGwEvcXKwA==]
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
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The Weekly Whisk
Musings from a foodie...
Over the years - as I have had the opportunity to travel the world and engage in
 culinary delights - I can't think of another situation where I've had back-to-back,
over-the-top gastronomic experiences. So, in some respects, my trip to Montreal 
was an unexpected first. The first such experience was at Toque! [http://r20.rs6.net/tn.jsp?f=001geDhZLCXG4kWAflj9HKd5OfIveKCQGcFis8IK-6UjYDep29AQrMpX0PayQCqi11VyFjApUKegw77QhFKZTWH0h7LK445LedJ-3Y9DlUStjgk1ZcPYfuLp8tJ6mBoMVDPdjKCvjiD9R1vzE09M36SjRaIgt3Oy69fzOK-29upmdzSkUKtInmndA==&c=Nxg7pt5lrlEYY-sZ7_PbFSmeGfgPhdvSPbTc9ifjJ3vzMmeBvcJl6A==&ch=pGRktHg9AXwO2wN9iPPTeHgaeGjKk7Zy8BVWIFFzTAipBGwEvcXKwA==]
[* * * * *]. It's a wonderful gem near Le Westin Hotel in the downtown area near
 Old Montreal. In fact, it was so wonderful that we actually went there twice. On
both days, we ended lunch with a rhubarb cannolo stuffed with mascarpone and juniper
cream layered over black currant leaf syrup with a dab of mint sorbet. Wow!! The
 menu changes regularly so reviewing our selections would be for naught - except
 for one dish which our attendant indicated is "always" on the menu. It's the lamb
shoulder with carrots, parsley and broccolini. It's probably the best lamb I've 
had in a very long time. It was braised perfectly and the vegetables were just beyond
crunchability. OUTSTANDING!! We tried other items as well. The guinea fowl was cooked
to perfection as was the walleye pike. You can't go wrong. But, it wasn't just the
food. The attention to detail by the staff and the ambiance along with the culinary
delights makes it must go to culinary experience. Chef Normand Laprise will no doubt
continue his efforts to please.  Go to: Restaurant Toque! - 900, Place Jean-Paul-Riopellle
- Montreal, Quebec H22 2B2 - Canada -(514) 499-2084 -www.restaurant-toque.com [http://r20.rs6.net/tn.jsp?f=001geDhZLCXG4kWAflj9HKd5OfIveKCQGcFis8IK-6UjYDep29AQrMpX0PayQCqi11VyFjApUKegw77QhFKZTWH0h7LK445LedJ-3Y9DlUStjgk1ZcPYfuLp8tJ6mBoMVDPdjKCvjiD9R1vzE09M36SjRaIgt3Oy69fzOK-29upmdzSkUKtInmndA==&c=Nxg7pt5lrlEYY-sZ7_PbFSmeGfgPhdvSPbTc9ifjJ3vzMmeBvcJl6A==&ch=pGRktHg9AXwO2wN9iPPTeHgaeGjKk7Zy8BVWIFFzTAipBGwEvcXKwA==].
But, if that were not enough in Montreal, I happened to have a similar experience
at Chasse-Galerie [http://r20.rs6.net/tn.jsp?f=001geDhZLCXG4kWAflj9HKd5OfIveKCQGcFis8IK-6UjYDep29AQrMpX0PayQCqi11VurOeYWgYcTAEwgROoZ4xqnWq0qcM0tPlfUJq_3sWNZTxu8uolZnR1bOUVBS4msXk3KgiUxGnWxD_vl0XnM4iQpyyVWMuh81yYY3iSbR4xk_x3RRVhPi45g==&c=Nxg7pt5lrlEYY-sZ7_PbFSmeGfgPhdvSPbTc9ifjJ3vzMmeBvcJl6A==&ch=pGRktHg9AXwO2wN9iPPTeHgaeGjKk7Zy8BVWIFFzTAipBGwEvcXKwA==]
[* * * * *]. First, the restaurant is far different in ambiance from Toque! It's
 basically the Chef, the Sous Chef, a couple of wait staff and a small restaurant
that could seat 20 some comfortably. Dinner is a prix fixe affair and well worth
 it. Again, the attention to detail and personal needs was highlighted at the start
of the meal. We then moved on to fois gras with an apple sauce puree which not only
was incredibly tasty but had a wonderful presentation with small edible flowers.
 The breads were brought - and, being in Montreal - we had our choice of regular
 or maple butter. We selected both! It was followed by an asparagus mousse with 
morel mushroom topping and a coddled egg as a centerpiece. Shortly after those bits
we had scallops with cauliflower puree and shiitake mushroom and rice chips. Out
 of this world! Perhaps my favorite of the evening - or, even the couple of days
 - followed. It was a mixed mushroom saute with caramelized butter over a potato
 puree. I could have eaten this all week... The main entrée then emerged with the
duck marguette and zucchini blossoms and a celery root puree. The French ambiance
over the entire meal was clear and it wafted out the door and tumbled on to the 
street. And, finally, we got to dessert which was a lavender mousse over a strawberry
gel topped with a flourless chocolate torte and a butter cracker sprinkled with 
strawberries drizzled in a balsamic dressing. I'd go back in a microsecond. Reachable
at: Restaurant Chasse-Galerie - 4110 Rue Saint Denis - Montreal, Quebec H2W 2M5 
- Canada - (514) 419-9601 -www.lechassegalerie.com [http://r20.rs6.net/tn.jsp?f=001geDhZLCXG4kWAflj9HKd5OfIveKCQGcFis8IK-6UjYDep29AQrMpX0PayQCqi11VurOeYWgYcTAEwgROoZ4xqnWq0qcM0tPlfUJq_3sWNZTxu8uolZnR1bOUVBS4msXk3KgiUxGnWxD_vl0XnM4iQpyyVWMuh81yYY3iSbR4xk_x3RRVhPi45g==&c=Nxg7pt5lrlEYY-sZ7_PbFSmeGfgPhdvSPbTc9ifjJ3vzMmeBvcJl6A==&ch=pGRktHg9AXwO2wN9iPPTeHgaeGjKk7Zy8BVWIFFzTAipBGwEvcXKwA==].
However, at the end of the day, it was a toss-up as to which of the two restaurants
was better. They basically came out equal which is not bad when you're at the top
of your game. If you go to Montreal, try one or the other - and, if you're really
into food - both!! It is well worth it.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

The Good, The Bad, And The Ugly
The ongoing saga...
The Great - The clarion call by Former Senator Dan Coats (R-IN) - now National Director
of Intelligence and the Defense Intelligence Agency that the "United States is threatened
by cyberattacks every day" [and] "The warning lights are blinking red again." See
the "comments [http://r20.rs6.net/tn.jsp?f=001geDhZLCXG4kWAflj9HKd5OfIveKCQGcFis8IK-6UjYDep29AQrMpX0PayQCqi11Vb7NlBgiZKBdXGd7WuPmvBSeIctG0VKJKkfFUCLj3yk4UAMLnEijocMUYbjUOU61_Vl2jA8lCe0YqwG1i0IDFrY1ZeYfJ5yvibSE_P3Nie50wQ_IvOPnsQ1f_wijyXnipLgwza7rE3nMZlFhQ1J76nPQzPpEnOA9Bhq5cMt-UwVsYJjRbnq2EkmRX6NWf9VDh&c=Nxg7pt5lrlEYY-sZ7_PbFSmeGfgPhdvSPbTc9ifjJ3vzMmeBvcJl6A==&ch=pGRktHg9AXwO2wN9iPPTeHgaeGjKk7Zy8BVWIFFzTAipBGwEvcXKwA==]"
section in the quotes section above.
The Good - The sun came up. The sun will most likely go down. The earth will continue
to rotate. Life will go on. Politicians will ultimately bend to the requirements
 of the populace - if you believe in America. And, I do...
The Bad - The continuing crisis of getting immigrant children reconnected with their
parents and loved ones. This is a human tragedy that I predict will haunt us for
 decades to come.
The Ugly - The US House hearings and the approach of yelling and insults and innuendo
totally unbecoming of an approach toward understanding and learning. Our politicians
have been totally unleashed from civility.
The statements in The Fickenscher Files [http://r20.rs6.net/tn.jsp?f=001geDhZLCXG4kWAflj9HKd5OfIveKCQGcFis8IK-6UjYDep29AQrMpX2n3NFwdGE0RNJwmHK0rj685ZWXnFP2BabCvdzu3a1MILEoVExnSJgrHlw3BmJViFj9WUNN-S6F45wljypfOcPSgztqWgPNPmS_NQeM0nfFErJa2AOgKbMZUbNSve4MbOsQCJiHC45Mz&c=Nxg7pt5lrlEYY-sZ7_PbFSmeGfgPhdvSPbTc9ifjJ3vzMmeBvcJl6A==&ch=pGRktHg9AXwO2wN9iPPTeHgaeGjKk7Zy8BVWIFFzTAipBGwEvcXKwA==]
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=001geDhZLCXG4kWAflj9HKd5OfIveKCQGcFis8IK-6UjYDep29AQrMpX2n3NFwdGE0RNJwmHK0rj685ZWXnFP2BabCvdzu3a1MILEoVExnSJgrHlw3BmJViFj9WUNN-S6F45wljypfOcPSgztqWgPNPmS_NQeM0nfFErJa2AOgKbMZUbNSve4MbOsQCJiHC45Mz&c=Nxg7pt5lrlEYY-sZ7_PbFSmeGfgPhdvSPbTc9ifjJ3vzMmeBvcJl6A==&ch=pGRktHg9AXwO2wN9iPPTeHgaeGjKk7Zy8BVWIFFzTAipBGwEvcXKwA==]
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

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