Subject: News from Dr. Kevin Fickenscher
From: "The Fickenscher Files" <[email-masked]>
To: <[email-masked]>
Date: Thu, 24 Jan 2019 08:50:11 -0500 (EST)

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The Fickenscher Files [http://r20.rs6.net/tn.jsp?f=001C3ozWD-Yf0YQL4uxoVliU_lIhfZiiTIgi8A0xzW7IqX9anRm5LgqHm8MPRcQzscFOvL8j2ZUU_rLlK_0ljmIn55raBesn8fZDUW4n_477LiejECZ0m0V4nkxvRuTlQSdQC-mSYVhbHIYiJwWijFX3Zmf5HYaWD82P1ei0ujGHv2vqoIXT3FM0inan5pilCqF&c=ihQPG-6Zh74XA1CiHvU19KTm0Fe6KWS6uQlqCOvsNQxs3tM1XQmmLg==&ch=NrjVwNZQo7WxfxnGNQstmbcJmeLq0WZyOabORFe4HIwnVZEm2IIjXw==]
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The Fickenscher Files, Vol. 7, Issue 11
Kevin M. Fickenscher [http://r20.rs6.net/tn.jsp?f=001C3ozWD-Yf0YQL4uxoVliU_lIhfZiiTIgi8A0xzW7IqX9anRm5LgqHr3PcoBWKbwf4oQ-E9MvUj1fM9Qj4h2WXmOcHqugRQYvzYpZBnAXUiTPfQ7vkCv0A3ZKzPx05n9b7qxQVAfrCyRuzzP9WqsplbPFVxykezkJRjf7seY0qJvkDRHgyjvxGkDptLa8O5YVV7lHE9GiVJOGegGBoSR_fA==&c=ihQPG-6Zh74XA1CiHvU19KTm0Fe6KWS6uQlqCOvsNQxs3tM1XQmmLg==&ch=NrjVwNZQo7WxfxnGNQstmbcJmeLq0WZyOabORFe4HIwnVZEm2IIjXw==],
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 ethical questions are enormous. Gene editing is generating a ton of optimism
for treating and curing diseases, including some that our foundation works on (though
we fund work on altering crops and insects, not humans). But the technology could
make inequity worse, especially if it is available only for wealthy people. I am
 surprised that these issues haven't generated more attention from the general public.
Today, artificial intelligence is the subject of vigorous debate. Gene editing deserves
at least as much of the spotlight as AI."
Bill Gates, in his December Year-in-Review 2018 blog post [http://r20.rs6.net/tn.jsp?f=001C3ozWD-Yf0YQL4uxoVliU_lIhfZiiTIgi8A0xzW7IqX9anRm5LgqHrrzVyaUv42liOaPa2ecrjf0iGTH7-GnRXC4Tao-DblBicnlb5iX7sk4PEjARqxLQgYBl4PM1IksdYPdhxD6dM4LIBBPzRYW5mTD0X-Z5ame2Z1CiEtQrQg4AHBu9c11T3-_URiasdGwZjjAEZElKVzBUp52ApPyw1WF96I1EWVd&c=ihQPG-6Zh74XA1CiHvU19KTm0Fe6KWS6uQlqCOvsNQxs3tM1XQmmLg==&ch=NrjVwNZQo7WxfxnGNQstmbcJmeLq0WZyOabORFe4HIwnVZEm2IIjXw==]
on a variety of technology issues he follows on a regular basis.
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Readings To Consider
Books and Articles worth a Review...
If you want to read a book that will stop you in your tracks and get you to thinking
about the significance of humankind - let alone who we are as individuals - go out
and get a copy of Neil deGrasse Tyson's book, Astrophysics for People in a Hurry
 [http://r20.rs6.net/tn.jsp?f=001C3ozWD-Yf0YQL4uxoVliU_lIhfZiiTIgi8A0xzW7IqX9anRm5LgqHrrzVyaUv42lA-qHxKGEAOlOv-Nk0iAMbtY0doSQEnYo_YzYnJqJB_8jesBqvt8TXBJmMEQMuGREKpaOBPMz2eUASCyPuAVfn42oJM7o8VG_3pTgUAotHGiCuILitaWQUHy_qBUblFRcDZbA6i0XQCo4KV2Nv4XAQOqMRcKSqqaRRjK7BVloY9R_kzXb1_WpSVwOPipOIaLnL-lCK2E9gmrHhbJtG-h0mebhOSEtWyxvYaUUmmvkfAfN_k1vy-Iv-mThH1jqWSXYC7Z93g84nJY4jtn6CApPpYtqHrBeqZMii9Fr-QaJ_989bCOBU0dPYCujIhTHrZuMka5gCS4WlmfIL-Bx__gu_w==&c=ihQPG-6Zh74XA1CiHvU19KTm0Fe6KWS6uQlqCOvsNQxs3tM1XQmmLg==&ch=NrjVwNZQo7WxfxnGNQstmbcJmeLq0WZyOabORFe4HIwnVZEm2IIjXw==].
It's compelling. It's thought provoking. And, while it's about astrophysics, it's
also about our presence in the multiverse. Finally, it has nothing to do with health
care but it's still important nonetheless. His metaphors bring into jarring clarity,
how small we are when considered on the scale of the multiverse. Read it. Ponder
 it. Get back to me with your thoughts... = [email-masked] [mailto:[email-masked]]
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Consulo Indicium
Information for your Consideration...
The State of International Medical Graduate Education - According to the National
Resident Matching Program (NRMP), international medical graduates (IMGs) who sought
residency positions in the US applied in smaller numbers than in prior years but
 had greater success in actually finding a postgraduate year 1 position in 2018.
 57% of US citizen IMGs matched versus 56% for non-US citizen IMGs. Both of those
rates are the highest since 1993. In addition, the most IMG-friendly specialties
 for the 2018 match were Pathology (45%), Internal Medicine (43%), Neurology (35%);
and, Family Medicine (30%).
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Future Health - 8 Predictions For The Coming Year
Delivering care in the new virtual world...
For the last 10 years now - yes, it's been 10 years - since I started The Fickenscher
Files [http://r20.rs6.net/tn.jsp?f=001C3ozWD-Yf0YQL4uxoVliU_lIhfZiiTIgi8A0xzW7IqX9anRm5LgqHrrzVyaUv42lypOENzuackcbVE3sjVWgrxMm9Na28rCt-TAlO-RCjIv2s4SkRJ7jmD7x2iVPWitKqaObL69RfhJEWMzwlFIVBSXQI5XJP_RLAssW0nDupMqLBkiBIEt6wQ_0c8mLC7bTDwVOL4r4TAUbgtQs76LHag==&c=ihQPG-6Zh74XA1CiHvU19KTm0Fe6KWS6uQlqCOvsNQxs3tM1XQmmLg==&ch=NrjVwNZQo7WxfxnGNQstmbcJmeLq0WZyOabORFe4HIwnVZEm2IIjXw==],
I've been putting forward my annual top trends to prepare for in the coming year.
This year, I settled on 8 major issues. As I considered all of the challenges facing
health care, the predictions became a bit murky after the top 8 so I stopped at 
that point. At the outset, let me apologize since I'm actually a bit late this year
in making my predictions. Usually, I get them out the first week of the new year.
However, now that I'm working without a lot of support staff (I do almost all of
 the work on the blog these days J ), it seems to take a bit longer to get the blog
out the door and published. Regardless, I've been giving a lot of thought to what
the major issues are that as leaders we should be monitoring in the coming year.
 Here's my top 8 list for your consideration:
#1     The Promising Side of CRISPR Becomes Potentially Ominous - The announcement
by the Chinese researcher that he had edited the germ line cells of a set of twins
deserves our special attention. For those who are not facile in the genomics area,
the germ line cells [http://r20.rs6.net/tn.jsp?f=001C3ozWD-Yf0YQL4uxoVliU_lIhfZiiTIgi8A0xzW7IqX9anRm5LgqHrrzVyaUv42lTT0GLNocG4GBwklmXtFEibS-LMwyDTB6wwDYzLIwKVXJQjm74YzbBZzm0FLHUaeLNQG7a9moXfjju4_EArHpKeCuDRE_DaF9O7SQzqoP7y3fQ6oIgUhttSgRfHgEawjX&c=ihQPG-6Zh74XA1CiHvU19KTm0Fe6KWS6uQlqCOvsNQxs3tM1XQmmLg==&ch=NrjVwNZQo7WxfxnGNQstmbcJmeLq0WZyOabORFe4HIwnVZEm2IIjXw==]
are those that pass along our genetic code to our children and the lineage. These
types of cells are in contradistinction from the somatic cells [http://r20.rs6.net/tn.jsp?f=001C3ozWD-Yf0YQL4uxoVliU_lIhfZiiTIgi8A0xzW7IqX9anRm5LgqHrrzVyaUv42lv0JOxhqBv0q4SYGV5u8IiapT1Ij9Z9avf9DIv3NofiM55jvVQLW7yTKR2s9SKE7MGIi3garjs0NV1PctN_zrUr1JB18ZxXn4P_dtboZeBKszNJE0DcH-VuFgefsdrYLNzIVXrX-zSt0=&c=ihQPG-6Zh74XA1CiHvU19KTm0Fe6KWS6uQlqCOvsNQxs3tM1XQmmLg==&ch=NrjVwNZQo7WxfxnGNQstmbcJmeLq0WZyOabORFe4HIwnVZEm2IIjXw==]
which are cells that have a function but do not pass along their genetic code to
 future cell lines. CRISPR is the new and evolving technology that allows for modification
of the genetic code. Essentially, it's a highly technical method whereby the researcher
removes and/or replaces snippets of DNA from the genetic code of our cells. When
 applied to genetically derived problems, it can be an amazing technology. For example,
the US Food and Drug Administration recently gave approval [http://r20.rs6.net/tn.jsp?f=001C3ozWD-Yf0YQL4uxoVliU_lIhfZiiTIgi8A0xzW7IqX9anRm5LgqHrrzVyaUv42lOBVBBUcLkA81Cq5gh0t25a7mL8-I3TzIK7Xaqf6_xgYQsiql6HLrmLqMI4_kkhuCiZL1eXMAjhdC0MR8lX99DO4_gUnIesZmhN19dorkLNcE6MixpKt3SKbO0VSzEG2ElZBP-qwD2Z-eYoHDC1o-OLP6qu52kGsR3EVSC9SdFTS4JFhO_O2A-xG7VTxU54eFRKvLiSQGcSU=&c=ihQPG-6Zh74XA1CiHvU19KTm0Fe6KWS6uQlqCOvsNQxs3tM1XQmmLg==&ch=NrjVwNZQo7WxfxnGNQstmbcJmeLq0WZyOabORFe4HIwnVZEm2IIjXw==]
for the testing of CRISPR technology related to treating sickle cell disease which
is caused by a genetic disorder that produces abnormal red blood cells. However,
 the interventions made are not passed along genetically in the germ cells since
 the intervention relates to genetic changes in somatic cells.
Under "Quote(s) of the Week", I noted Bill Gates response to the evolving questions
on the use of genetic manipulation. I would go a couple of steps further. In my 
estimation, the public debate and discussion related to the use of CRISPR technology
is every bit as important as the nuclear disarmament debate was in the 1950s. If
 we thought Mutual Assured Destruction (MAD) was a scary outcome, then consider 
the possibility of Serial CRISPR Applications Revising You (SCARY) outcomes! Society
needs to be awakened from its slumber for this discussion. We are at the God Point
of genetic manipulation and beginning the walk across the bridge of creation. It
 should cause us pause. Just as we made a societal decision to "control" the spread
of nuclear weapons, we should also be considering - via a broad global discussion
and debate - the spread of genomic CRISPR applications. While I'm a big fan of genomic
research, I'm also a big fan of understanding how, when, where, who and what our
 technology does as part of its human application. These issues have not been untangled
in the CRISPR debate. What are your thoughts?
#2     AI/ML Becomes Integral To Health Care - It seems that all of the prognosticators
are suggesting a dominant role for Artificial Intelligence and Machine Learning 
(AI/ML) in health care. I'm one of the pack!! I've been predicting the coming of
 "Clinically Augmented Intelligence" for at least four or five years. Well, it's
 a reality!  AI/ML over the coming decade - yes, decade - will change the very fabric
of how health care is delivered, what is delivered, where and how it is delivered;
and, who delivers it. How about that for a disruptive change in business-as-usual?
This phenomenon hit me smack upside the head in 2016 when one of my MITRE colleagues
introduced me to a new AI/ML tool developed on behalf of the Veterans Administration.
The tool was able to diagnose post-traumatic stress disorder (PTSD) with a 95% concurrence
rate to experts in the field by simply listening to the conversation of PTSD victims.
When I learned of the tool, I was quite excited not only for helping to effectively
treat PTSD patients - but, also for the fact that the tool was essentially a "physician
whisperer" in the exam room that could suggest to me options during the course of
my exam. Applied to other problems like Parkinson's disease, depression versus back
pain or a host of other problems that patients present during the course of an exam,
and the approach was going to change care delivery. It was clear that the capabilities
used in in developing a tool for PTSD were generally applicable to a range of other
illnesses and diseases. And, in fact, that is exactly what is happening.
Let's take DeepMind, for example. It's an AI/ML tool founded in 2010 and purchased
by Google in 2014. It uses deep neural networks and learning algorithms where the
computer system teach itself about clinical problems - real time. The use of the
 system allows the computer to get better and better over time! As an example, researchers
at the University of Oxford have created an application called Watch, Attend and
 Spell [http://r20.rs6.net/tn.jsp?f=001C3ozWD-Yf0YQL4uxoVliU_lIhfZiiTIgi8A0xzW7IqX9anRm5LgqHrrzVyaUv42lK6wDLxCpAv0s_8IYgLVnXQQtMRyJtXfDRmzM6MHy5Vh2C166OJwgTAxJoicJLsAkKwZFey3ECwvbk5ScJdTMfv_c5tws9SXAlgVRvZx35-sVT9pdxVlGV20pTXvCpU3Wi9PhSerAZX_qO5oENjbUTQ3pYBKA45dGlwHmcd985LI3Merv3ec4XNbwkdIRvrzf&c=ihQPG-6Zh74XA1CiHvU19KTm0Fe6KWS6uQlqCOvsNQxs3tM1XQmmLg==&ch=NrjVwNZQo7WxfxnGNQstmbcJmeLq0WZyOabORFe4HIwnVZEm2IIjXw==]
(WAS) that trained DeepMind to lip read people talking on television with the sound
turned off by simply "watching" the tube and using computer vision coupled with 
machine learning. The system watched over 5000 hours of silent news coverage and
 ended up being 5X better than trained lip readers in determining what was being
 said about half the time. Lip readers were successful only 10% of the time. And,
that's just the beginning. It's just one of the applications where DeepMind has 
been deployed. DeepMind started with games like AlphaGo [http://r20.rs6.net/tn.jsp?f=001C3ozWD-Yf0YQL4uxoVliU_lIhfZiiTIgi8A0xzW7IqX9anRm5LgqHrrzVyaUv42lulMaxT-P3MPFBzDVVmyp0b4CNWjtdNxQ7_xkTmBB4vSu5M-jbkBz20iZqe4Q944yFhZJSmvgab_GWZrJ_oDWeIKHfKEvz5z5rdnwM1bSKIj_Jl2GuJxKyAXqDqZ0btP_VK58fjnA4WE=&c=ihQPG-6Zh74XA1CiHvU19KTm0Fe6KWS6uQlqCOvsNQxs3tM1XQmmLg==&ch=NrjVwNZQo7WxfxnGNQstmbcJmeLq0WZyOabORFe4HIwnVZEm2IIjXw==]
but is quickly moving into the non-gaming world of serving as an assistant for clinicians
managing real problems. DeepMind is now being used to diagnose acute kidney injury,
threatening eye conditions affecting eyesight and a host of other clinical areas.
If only the sight loss application is considered, the software has the potential
 for affecting over 285 million people worldwide over the next 7 years - a figure
that is anticipated to triple by 2050 in large measure because of the aging population.
In another example, DeepMind has been at work in the area of "cooperative AI/ML"
 where computer systems work as "partners" with a team of individuals to support
 multi-agent learning which has been described as a very tough problem to solve.
 While we may think that getting teams of people to collaborate, managing a team
 of computers coupled with people is even more complex. The DeepMind technology 
was again applied to a game [http://r20.rs6.net/tn.jsp?f=001C3ozWD-Yf0YQL4uxoVliU_lIhfZiiTIgi8A0xzW7IqX9anRm5LgqHrrzVyaUv42lG5ZsYGGZAnmEmUOyOKYytF1CaDnBciqHFy5NXErCYCUXGCZQN_aHNTSAByUEMGHYh1OrC6KzrOoMLkjPDf0ps1V1UPsVxeqWm6gJxPDZ6Xhmd9rJgb61e9O2EiQz9MgXCa6vnfgHBfg=&c=ihQPG-6Zh74XA1CiHvU19KTm0Fe6KWS6uQlqCOvsNQxs3tM1XQmmLg==&ch=NrjVwNZQo7WxfxnGNQstmbcJmeLq0WZyOabORFe4HIwnVZEm2IIjXw==]
which demonstrated that AI/ML computer agents spontaneously developed tactics similar
to those used by human players in the game. Even more interesting was the fact that
the AI/ML agents were even more successful than their human counterparts in "teaming".
Couple the technology with clinicians and the whole notion of how-where-who "value-based
care delivery" will occur is altered and accelerated - most likely in ways we cannot
even imagine in today's world.
Long story short - AI/ML, in my estimation, is the most important disrupter on the
health care horizon. The challenge will be in deploying comprehensive solutions 
rather than piecemeal solutions. However, with the right "learning" structure integrated
into the solution, the overall impact of AI/ML will be tremendous.
#3
ACA Moves into The Amendment Stage -
The shift in the US House of Representatives from Republican to Democrat control
 will have significant implications across the board. One of the most important 
changes will be in the health care political playbook. The Democrats will need to
move from simply keeping the Accountable Care Act (ACA) alive to finally moving 
toward amendments to solve problems and make it better. As a lifelong advocate that
"health care is a right", I can be declared biased. ACA has: 1) been shown to slow
the rate of increase in health care costs, 2) created a mandatory set of 10 preventive
services that all insurance plans are required to offer as part of their benefits
package for all Americans, 3) dramatically decreased the number of uninsured in 
the nation by creating tax credits for middle income Americans and expanding the
 Medicaid programs across most of the US; and, 4) lowered the projected budget deficit
[http://r20.rs6.net/tn.jsp?f=001C3ozWD-Yf0YQL4uxoVliU_lIhfZiiTIgi8A0xzW7IqX9anRm5LgqHrrzVyaUv42lFKAPodn9N53vmHuQfpIkpXSSQH93yjSYbmgULvT10EBDYdfcqbiXrQ4ckYrBlXSfHnO2mskgVuar6DQHKmiue_tdJkRAbmxyKAKMN-Foc1ZqGb7K-wQTjdahYYGZELrSna51iOTMYdbepf4wlKL3GWR9FHtlVkmZ2jladsQf8UI=&c=ihQPG-6Zh74XA1CiHvU19KTm0Fe6KWS6uQlqCOvsNQxs3tM1XQmmLg==&ch=NrjVwNZQo7WxfxnGNQstmbcJmeLq0WZyOabORFe4HIwnVZEm2IIjXw==]
by $143 billion through 2022 according to the Congressional Budget Office [http://r20.rs6.net/tn.jsp?f=001C3ozWD-Yf0YQL4uxoVliU_lIhfZiiTIgi8A0xzW7IqX9anRm5LgqHrrzVyaUv42lhIvlPnchlMP6-J0xtamvNnnXrYIFMEzFn78eXIUZ--Sxcjq-GQG1MLIkM1fa4030O6Zgf4HlZ7nSF9LvvWe29l80QGdcH5d1QcQ3FBpxEdRdccP_Ylyz6ZWAU7fzu5H2fxtE-Zv8EhEz5YPW3DFnRw==&c=ihQPG-6Zh74XA1CiHvU19KTm0Fe6KWS6uQlqCOvsNQxs3tM1XQmmLg==&ch=NrjVwNZQo7WxfxnGNQstmbcJmeLq0WZyOabORFe4HIwnVZEm2IIjXw==].
These are clearly results that benefit the American economy and the American people.
At the same time, I would be one of the first to tell you that the ACA could be 
improved.
On the downside, we've seen an exodus from small business insurance plans in part
because of incentives and in part due to continuing escalation of insurance costs.
In addition, short-term costs for health insurance have gone up because people are
taking advantage of their first-time use of certain preventive services. The problem
is that the overall savings will not kick in for a while. In addition, the tax impact
has been a bit uneven. For example, the "Cadillac tax" which is a 40% tax assessment
on high premium plans has had some unintended consequences. The problem is that 
these plans are often made available for those workers who are in high-risk jobs
 which require the higher premiums.
The end result is that the ACA needs to be fixed - not discarded. I've said it before
and I'll say it again. Medicare and Medicaid when they were first created in the
 mid-1960s had issues as well. But, instead of dismantling the program - Congress
went to work and fixed the program which continues to this day. I have not heard
 anyone suggesting that we should dismantle either program. They are part of the
 staple of commitments made by our nation's government to the people. The same phenomenon
is evolving for the ACA. So, let's get on with the approach of debating the fixes.
For a listing of the pros and cons check out this non-partisan website [http://r20.rs6.net/tn.jsp?f=001C3ozWD-Yf0YQL4uxoVliU_lIhfZiiTIgi8A0xzW7IqX9anRm5LgqHrrzVyaUv42lGk08Uu1v-nWRE-o6zUmQB3zbyU-IMdzxXOrjuQb88m1yptAHWHsXENGq2NbzvCUkmq2ivdINVXYWqTH58s2Oslplis8z5oWDqs0tPsh-R4SiKYuZ4ASgRlwP78GgvvN4cKIEPq7XjNnyeE2LZ0iyw9kIkvvF2FR2&c=ihQPG-6Zh74XA1CiHvU19KTm0Fe6KWS6uQlqCOvsNQxs3tM1XQmmLg==&ch=NrjVwNZQo7WxfxnGNQstmbcJmeLq0WZyOabORFe4HIwnVZEm2IIjXw==].
#4     Integration Moves from Horizontal to Vertical - Most of the industry integration
has been on the horizontal front. Hospital systems have gobbled up hospitals. Physician
groups have extended their reach by acquiring like-minded organizations. The pharmaceutical
industry has consolidated along with the health information technology and medical
device industries. But, the next wave which is only now beginning will be vertical
in orientation. The CVS-Aetna merger of a retail pharmacy chain with an insurance
company is only the first step. The same is happening with health systems getting
into insurance. The entry of the big kahunas (e.g. Amazon, Google, et. al.) will
 only drive the vertical moves - which takes me to my next prediction...
#5     A GAMA-plosion (Google, Amazon, Microsoft, Apple) of Investments Moves from
Millions to Multi-Billions in Health Care - GAMA (Google, Amazon, Microsoft, Apple)
is clearly intending to play in health care. Why? Because health care is one of 
the biggest components of our nation's overall Gross Domestic Product. It's a huge
opportunity for those focused on efficiency and effectiveness. Each of these companies
is engaged in specific health care market plays. For example, Amazon [http://r20.rs6.net/tn.jsp?f=001C3ozWD-Yf0YQL4uxoVliU_lIhfZiiTIgi8A0xzW7IqX9anRm5LgqHrrzVyaUv42l-0iy8bv4eiHeINmrX6HXXRl3OIUADvRSux8ndQeAS1salL4UqOLtSoNkO-4Szz95FRARJdq6S9Z7UeFiLIfl8O8z2AMD9V-dDBfhZrlEdZPt9SlvVlOBbA==&c=ihQPG-6Zh74XA1CiHvU19KTm0Fe6KWS6uQlqCOvsNQxs3tM1XQmmLg==&ch=NrjVwNZQo7WxfxnGNQstmbcJmeLq0WZyOabORFe4HIwnVZEm2IIjXw==]
is offering software that mines medical records for approaches toward improving 
treatment and cuttings costs in health care treatment. In another move, Amazon paid
$1 billion for Pillpack, a company that packages prescription medications for delivery
to the home. Apple [http://r20.rs6.net/tn.jsp?f=001C3ozWD-Yf0YQL4uxoVliU_lIhfZiiTIgi8A0xzW7IqX9anRm5LgqHrrzVyaUv42lHIwpFpEcBXJo7oSo9EJ7t7UrNuK35DM3v1X7YQDnob9-qUGOXKpgKCKfNKv25mIlhSpCod0P6EmUwW2zRMd7GTQ2D-VXHQzbeWBWzyEdFe_dzr5GhM1olg==&c=ihQPG-6Zh74XA1CiHvU19KTm0Fe6KWS6uQlqCOvsNQxs3tM1XQmmLg==&ch=NrjVwNZQo7WxfxnGNQstmbcJmeLq0WZyOabORFe4HIwnVZEm2IIjXw==]
is working with the US Department of Veterans Affairs to make available the health
records veterans on their iPhones [http://r20.rs6.net/tn.jsp?f=001C3ozWD-Yf0YQL4uxoVliU_lIhfZiiTIgi8A0xzW7IqX9anRm5LgqHrrzVyaUv42l7E1jIjLmuBsA1slWYQs3NeOW6f0N8lrq1m6pXLGzeUOZTDzNQJXxxQc_pk_Nkz3s0hWhzFaS6s_MYbcVb14rKmA4EMIiUtaR78I7OKlhPeYYf2sUQoGiaCkrXW4VkwQN7hhLYm-sRj9SGTyQONpCUhWzVqdFJaNLkzajDwq-HAI24db-UgWlTpah25QefA9_dsdx6xqvaIX6BzhcZiPjdrckMz8pvMsaYN5lGX6AmYXAPlH1ZHMjc7cTu4zEwxpT&c=ihQPG-6Zh74XA1CiHvU19KTm0Fe6KWS6uQlqCOvsNQxs3tM1XQmmLg==&ch=NrjVwNZQo7WxfxnGNQstmbcJmeLq0WZyOabORFe4HIwnVZEm2IIjXw==].
These are but two examples on the horizon. Google [http://r20.rs6.net/tn.jsp?f=001C3ozWD-Yf0YQL4uxoVliU_lIhfZiiTIgi8A0xzW7IqX9anRm5LgqHrrzVyaUv42lzvsUr-5J9FPMi8vyU9gcVzQFRKPwMe2qzicxDE4orVCSITHwMCsJoD0uBKbB1DQr3P0RxeOFuWz6Q5Sj4JyFbKnUVrp66XuQJk42DT_FKCfXRV_E-hqYbMIQhQtayEZWGrODatoRGGknmVwiReC0Pg==&c=ihQPG-6Zh74XA1CiHvU19KTm0Fe6KWS6uQlqCOvsNQxs3tM1XQmmLg==&ch=NrjVwNZQo7WxfxnGNQstmbcJmeLq0WZyOabORFe4HIwnVZEm2IIjXw==]
and Microsoft [http://r20.rs6.net/tn.jsp?f=001C3ozWD-Yf0YQL4uxoVliU_lIhfZiiTIgi8A0xzW7IqX9anRm5LgqHrrzVyaUv42lw2Qr73yzDmtmyN1_eXaT8IxNyB9aLL9IWRSw0z7vz2Vv9plbA-x4MIrT8U4jzgUn1QIg-hgjB5ws157uW8QdH4N1IlxoeMbtzeP8wb2IS-uEPRdwmBwdfVbdFB5CujxgY6gwRODiqO4tRqSYxBoavA==&c=ihQPG-6Zh74XA1CiHvU19KTm0Fe6KWS6uQlqCOvsNQxs3tM1XQmmLg==&ch=NrjVwNZQo7WxfxnGNQstmbcJmeLq0WZyOabORFe4HIwnVZEm2IIjXw==]
are not far behind.
#6     Value-Based Care Delivery Models Will Only Expand - I keep saying it over
 and over. The US health care system's future is inextricably tied to a move toward
value-based care delivery. Our economic tolerance for the traditional fee-for-service
model is waning at best. In fact, if we don't shift gears toward the value-based
 models, health care will bankrupt the nation. As a Boomer, I'm part of the problem.
When I talk with my Boomer friends and indicate that I've spent more health care
 dollars in the last 5 years than in the previous 63 years of life - almost all 
of them nod their heads in agreement. And, there are a ton of us out there that 
are beginning to stress the system. So, the move toward value-based care delivery
is tied to economic survival. If one adds on top of that phenomenon the increasingly
competitive economies throughout Asia and Europe which are moving other industrial
production overseas - the issue of cost management in health care becomes even more
of a dominant concern to sustain the competitiveness of American products.
In fact, Frost & Sullivan - a health care consulting and advisory firm - predicts
that "...by end of 2019, up to 15% of global healthcare spending will be tied in
 some form with value/outcome-based care concepts" (emphasis added). Why? The problem
is with those countries that are spending more than 10% of their respective GDP 
on healthcare. It's also the countries with a large, growing elderly population.
 The key leaders on the list include the United States, Netherlands, Sweden, France,
Germany, Canada, and Japan. From my perspective, those health care systems that 
aggressively develop value-based care delivery models will stand the test of time.
The others will fall by the wayside. Mark my word.
#7     Virtuality Explodes - Perhaps the most disruptive short-term change will 
be the explosion in the use of virtual health care services. It's very clear that
upwards of 75% of primary care can be delivered using virtual services. However,
 the major impediment has been three major issues. First, licensure requirements
 have precluded providers offering services across state lines. The move by the 
Federation of State Medical Boards to use the Interstate Medical Licensure Compact
will resolve many of those issues in the coming year. Second, as the nation moves
toward "value-based care delivery" (SEE #6 immediately preceding this prediction),
the ability to use health care professionals at the top of their license and simultaneously
reduce costs will be an imperative that health care systems will not be able to 
ignore. And, third, the lack of integration of the splinter solutions and telecare
options that are disconnected from traditional face-to-face care causes major problems
in fostering and supporting good outcomes.
#8     Blockchain Moves Out of the Test Lab - The hype on blockchain has been fairly
strong and there are a number of commercial product development companies that will
no doubt be moving into the deployment stage in 2019. Companies such as Change Healthcare
[http://r20.rs6.net/tn.jsp?f=001C3ozWD-Yf0YQL4uxoVliU_lIhfZiiTIgi8A0xzW7IqX9anRm5LgqHrrzVyaUv42la3gB4aIfHc2E5oNsLF6Q6mwzHqjbvg4Shv4uEsQ-UE8v-rgT5aQwsxdDulHz_zu5iXO9SMa2gsfZCQfJ9see_gImkvvUYE_JBruu9FbhEGEV3tOYf8kIag==&c=ihQPG-6Zh74XA1CiHvU19KTm0Fe6KWS6uQlqCOvsNQxs3tM1XQmmLg==&ch=NrjVwNZQo7WxfxnGNQstmbcJmeLq0WZyOabORFe4HIwnVZEm2IIjXw==],
Hashed Health [http://r20.rs6.net/tn.jsp?f=001C3ozWD-Yf0YQL4uxoVliU_lIhfZiiTIgi8A0xzW7IqX9anRm5LgqHrrzVyaUv42lnaqBnhG5cNvixFC0VkLTqZfVuWOqJDrTFtvt6hsDz4grMIXuPaZCyuNPzYVPlysnG2AX07g6FbTnWNW-_dskPDU4Chd-4mk-YtOSTsDDW0s=&c=ihQPG-6Zh74XA1CiHvU19KTm0Fe6KWS6uQlqCOvsNQxs3tM1XQmmLg==&ch=NrjVwNZQo7WxfxnGNQstmbcJmeLq0WZyOabORFe4HIwnVZEm2IIjXw==],
and Guardtime [http://r20.rs6.net/tn.jsp?f=001C3ozWD-Yf0YQL4uxoVliU_lIhfZiiTIgi8A0xzW7IqX9anRm5LgqHrrzVyaUv42l5WYk9dWCV-D6i3Aq59XQdabt3-LyKZ_C3BNtTsbSqTHvXv9lvQRRbQgE88oEhFLN0PCi0astLT_jpl_icILUHofLY-EJgsuVSFF-WRZH2p8=&c=ihQPG-6Zh74XA1CiHvU19KTm0Fe6KWS6uQlqCOvsNQxs3tM1XQmmLg==&ch=NrjVwNZQo7WxfxnGNQstmbcJmeLq0WZyOabORFe4HIwnVZEm2IIjXw==],
among others are at the vanguard of a shift in how technology will manage and support
changes in how health systems manage health information. Blockchain is not the end
all/be all solution for health information technology. My friend and colleague, 
John Halamka, MD said it best in a 2018 interview, "Blockchain is not meant for 
storage of large data sets. Blockchain is not an analytics platform. Blockchain 
has very slow transactional performance. However, as a tamperproof public ledger,
blockchain is ideal for proof of work. Blockchain is highly resilient"
From here on down the line, there are lots of other changes on the horizon but they
pale in comparison to the first 8!
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

The Weekly Whisk
Musings from a foodie...
I must admit that I'm a sucker for pasta. Sfoglina Pasta House [http://r20.rs6.net/tn.jsp?f=001C3ozWD-Yf0YQL4uxoVliU_lIhfZiiTIgi8A0xzW7IqX9anRm5LgqHrrzVyaUv42lJhF3ZSaCu5yPhQg6CAmq2jbSvBG-UzJ4pP0vdGxSRWodQbVZrhISxvS_6gcncQ8BKg_0mdmIT_e3_QwscOzAoa9VbD-2o8TBVKZ3ytAMcV9twm_123Wr_A==&c=ihQPG-6Zh74XA1CiHvU19KTm0Fe6KWS6uQlqCOvsNQxs3tM1XQmmLg==&ch=NrjVwNZQo7WxfxnGNQstmbcJmeLq0WZyOabORFe4HIwnVZEm2IIjXw==]
[* * * *] has several locations in the DC area and, if you're so inclined to indulge,
you should consider a visit. It's basically pasta heaven. In fact, it's the only
 thing I've ever had and, there are all types pastas on the menu - all of which 
are made in house. Fabio Trabocchi is the founder learned from the Sfogline, who
 are the masters of pasta making in Italy. He learned the craft and brought it to
America. You can't go wrong. Enjoy with family and friends. Sfoglina Pasta House
 - 1099 New York Avenue, NW - Washington, DC 20001 - (202) 525-1402 - www.sfoglinadc.com
[http://r20.rs6.net/tn.jsp?f=001C3ozWD-Yf0YQL4uxoVliU_lIhfZiiTIgi8A0xzW7IqX9anRm5LgqHrrzVyaUv42lJhF3ZSaCu5yPhQg6CAmq2jbSvBG-UzJ4pP0vdGxSRWodQbVZrhISxvS_6gcncQ8BKg_0mdmIT_e3_QwscOzAoa9VbD-2o8TBVKZ3ytAMcV9twm_123Wr_A==&c=ihQPG-6Zh74XA1CiHvU19KTm0Fe6KWS6uQlqCOvsNQxs3tM1XQmmLg==&ch=NrjVwNZQo7WxfxnGNQstmbcJmeLq0WZyOabORFe4HIwnVZEm2IIjXw==]
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

The Good, The Bad, And The Ugly
The ongoing saga...
The Good - In these times of division which seem to have ahold of the nation, we
 need to keep in mind Martin Luther King, Jr's memorable words: "Darkness cannot
 drive out darkness; only light can do that. Hate cannot drive out hate; only love
can do that."
The Bad - Recent Kaiser Family Foundation polls suggest a consensus among the public
on what health care issue they want Congress to address but, 34% are "not very confident"
and 35% are "not at all confident" that Congress will be able to work on bipartisan
legislation to solve the problems. Gridlock is not the answer for solving the issues
of health care.
The Ugly - I am part of the 71% of the American public [http://r20.rs6.net/tn.jsp?f=001C3ozWD-Yf0YQL4uxoVliU_lIhfZiiTIgi8A0xzW7IqX9anRm5LgqHrrzVyaUv42ljHXUjPqJeFWteKWyuSH7TAcozJ48FcST-WnjA38Wt1QLWScjNlC2UUvzTqqmgv22QVewMf61lZ8Ubo2OKAF1cXMf8R9KEyBFAOVmnq_UwOpa1dpZK90UzGbamXFwTMT3gMIxZYW2rmX7Z8waOsuuz0v1L_KrVzUnqJyEjz2E8J5FYH99fLok39xEE1g-yygMuc9TX7DZ2KieSn1S9BQ6yX2ZXCkwNlu7pXGRJ0Gcm-2jH10_UUj64QQyfkEsQtfEa9LCOLREwlYGEGPfzI7p2_KWarSC2nRiQfJ1aFGs0384xTFqjhh4rH29YEd0OC687629Coj5Rb4QhyeStFYB4uBS8SfIGaFwb3KNIiG6RIPOuwNHj5Z2Mg==&c=ihQPG-6Zh74XA1CiHvU19KTm0Fe6KWS6uQlqCOvsNQxs3tM1XQmmLg==&ch=NrjVwNZQo7WxfxnGNQstmbcJmeLq0WZyOabORFe4HIwnVZEm2IIjXw==]
calling on Congress to pass a bill reopening the government while budget talks continue.
And, I'm also in the majority when the first order of business should be immigration
reform and health care policy changes to make existing laws better. The government
shutdown is a quagmire...
The statements in The Fickenscher Files [http://r20.rs6.net/tn.jsp?f=001C3ozWD-Yf0YQL4uxoVliU_lIhfZiiTIgi8A0xzW7IqX9anRm5LgqHm8MPRcQzscFOvL8j2ZUU_rLlK_0ljmIn55raBesn8fZDUW4n_477LiejECZ0m0V4nkxvRuTlQSdQC-mSYVhbHIYiJwWijFX3Zmf5HYaWD82P1ei0ujGHv2vqoIXT3FM0inan5pilCqF&c=ihQPG-6Zh74XA1CiHvU19KTm0Fe6KWS6uQlqCOvsNQxs3tM1XQmmLg==&ch=NrjVwNZQo7WxfxnGNQstmbcJmeLq0WZyOabORFe4HIwnVZEm2IIjXw==]
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=001C3ozWD-Yf0YQL4uxoVliU_lIhfZiiTIgi8A0xzW7IqX9anRm5LgqHm8MPRcQzscFOvL8j2ZUU_rLlK_0ljmIn55raBesn8fZDUW4n_477LiejECZ0m0V4nkxvRuTlQSdQC-mSYVhbHIYiJwWijFX3Zmf5HYaWD82P1ei0ujGHv2vqoIXT3FM0inan5pilCqF&c=ihQPG-6Zh74XA1CiHvU19KTm0Fe6KWS6uQlqCOvsNQxs3tM1XQmmLg==&ch=NrjVwNZQo7WxfxnGNQstmbcJmeLq0WZyOabORFe4HIwnVZEm2IIjXw==]
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The Fickenscher Files | PO Box 840 | Kittery | ME | 039