## Glosario eSalud | eHealth Glossary

#### Glosario sobre eSalud | eHealth Glossary

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#### eHealth at WHO

eHealth is the use of information and communication technologies (ICT) for health. The eHealth unit works with partners at the global, regional and country level to promote and strengthen the use of information and communication technologies in health development, from applications in the field to global governance. The unit is based in the Department of Knowledge Ethics and Research in the cluster of Health Systems and Innovation.

#### Programmes and projects

WHO's work in eHealth includes programmes and projects in areas such as policy and governance, standardization and interoperability, research and global surveys, eLearning and capacity building, networking and South-to-South collaboration, as well as eHealth applications.

#### Contact information

eHealth
Department of Knowledge, Ethics and Research
World Health Organization
20 Avenue Appia
1211 Geneva 27
Switzerland
Email: ehealth@who.int

 Keyword(s): eHealthWHOOMS

#### Value-Based Care

 Keyword(s): Value-Based Care

#### Population Health Management

 Keyword(s): Population Health Management

#### Hospital CIOs: How to approach hiring your staff

 Keyword(s): Hospital CIOsApproachHiringStaff

#### ICD-10: Forget the Fear and Panic

ICD-10 is one of the hottest topics in the electronic healthcare management industry today. As such, Pulse Systems is here to help your practice focus on the transition, not the hype.

Pulse is on a mission to de-mystify ICD-10 so that you can understand how it will impact your documentation, claims processing, and most importantly, cash flow. Pulse wants you to understand what ICD-10 means for your specific specialty (it's not 69,000 codes) and help you prepare your practice by being well educated and prepared for the big change.

 Keyword(s): ICD-10

#### USING STANDARD TEXTING APPS

LEARN WHERE YOUR HOSPITAL MAY BE GOING WRONG WHEN IT COMES TO USING STANDARD TEXTING APPS

The majority of hospital communications are related to patient care, and messages are often critical in nature. Missing a text buried in a private inbox or not being able to send one quickly to the right on-call provider in the directory can compromise patient safety.

A Preview of the Six Mistakes:

• Can't automatically escalate an unanswered text

 Keyword(s): STANDARD TEXTING

#### 9 STRATEGIES FOR LEVERAGING BIG DATA IN THE HEALTHCARE INDUSTRY

The health care industry can potentially realize $300 billion in annual value by leveraging big data according to a 2011 McKinsey report. To successfully achieve this value, the healthcare industry must identify and establish best practices to manage big data since healthcare data is rarely standardized. Continue reading  Keyword(s): HEALTHCAREBIG DATASTRATEGIES #### IT struggles to innovate It seems that it’s virtually impossible for IT to meet all business demands with current budgets, resources, and approaches. But the business keeps changing and IT needs to respond rapidly and innovate in order to stay relevant to the organization. Why does IT struggle to innovate? Continue reading  Keyword(s): ITInnovation #### Convergence of Big Data and EHR Infographic #### THE CONVERGENCE OF BIG DATA AND EHR INFOGRAPHIC by “In the next 10 years, data science and software will do more for medicine than all of the biological sciences together,” said venture capitalist Vinod Khosla. Data science holds great promise for patient health, but patient data is only actionable in so far as it is digital. This is where Electronic Health Records (EHRs) come in. By 2019, the majority of physicians will have adopted a basic EHR system, and with good reason, too. EHRs may reduce outpatient care costs by 3 percent. The convergence of big data and EHR infographic created by UC Berkeley School of Information explores the how the growing relationship between health data and EHR adoption is transforming healthcare. Continue reading  Keyword(s): CONVERGENCEBIG DATAEHRINFOGRAPHIC #### MORE RESPONSIBLE INFORMATION MANAGEMENT #### TOP TIPS: MORE RESPONSIBLE INFORMATION MANAGEMENT By Charlotte Marshall You’d think that in today’s customer-focused economy most companies would try to avoid deliberately ignoring customer concerns. Yet a new study from Iron Mountain* reveals that over half (57%) of UK firms do exactly that with customer communications that arrive on paper. Many organisations seem happy to wait until their customer grows sufficiently frustrated to pick up the phone or send an email to ask why nothing has happened. So what can organisations do to tackle paper enquiries in an increasingly digital world? Here are my top tips for ensuring a gradual evolution to more responsible information management. Continue reading  Keyword(s): RESPONSIBLEINFORMATIONMANAGEMENT #### ESTRATEGIAS DE ANALÍTICA DE “BIG DATA” #### ESTRATEGIAS DE ANALÍTICA DE “BIG DATA” Con el incremento en la capacidad y velocidad de las computadores, ha surgido desde hace unos años la tendencia de analizar grandes volúmenes de datos para descubrir patrones, correlaciones e información que pueda ayudar a la empresa a tomar mejores decisiones de negocio sobre incidentes que pudieran haber quedado sin explotar con el solo uso de la inteligencia de negocio convencional. Continuar leyendo  Keyword(s): BIG DATAESTRATEGIASANALÍTICA #### Health IT hiring remains 'consistent' #### HIMSS: HEALTH IT HIRING REMAINS 'CONSISTENT' Clinical application support continues to be a major hiring need for healthcare organizations, according to the Healthcare Information and Management Systems Society's second annual workforce survey. Sixty-four percent of provider respondents (106 individuals) identified clinical application support as their top area of IT need for 2014, up from 51 percent the previous year. What's more, 58 percent of respondents said they would be most likely to hire clinical applications support staff in the future. Comparatively, 35 percent of respondents said they would most likely hire IT security staff in the future. Continue reading  Keyword(s): HEALTH ITHIRING #### Procesos defectuosos #### 7 señales de procesos defectuosos Existen muchos procesos de negocios en el entorno corporativo actual: en recursos humanos, finanzas, tecnología de la información, investigación y desarrollo, producción, ventas y hasta en marketing. Por supuesto, la lista podría alargarse. El costo para reemplazar a los empleados, o los bucles indefinidos en la ejecución de las órdenes de compra y en las facturas, afectan a la eficiencia de su organización. Continuar leyendo  Keyword(s): PROCESOSDISEÑO #### Predict and control patient behavior #### Hospitals mining credit card data to predict and control patient behavior Say hello to new risk scores. Yes, credit behavior is taking on a whole new meaning. Credit behavior is no longer only predicting your risk as a borrower, but additionally your risk as a health liability on society and to health providers. Hospitals are beginning to assign risk scores that predict how your personal spending habits will affect your health--and their profits--by mining credit card purchases and loyalty program transactions. If you're smart you'll start buying everything you consume from cocktails at happy hour and prescription refills to food at the grocery store in cash only and without using a loyalty card. Continue reading  Keyword(s): PredictControlPatient behavior #### Google Glass Adoption in Healthcare #### by Erica Garvin Google Glass adoption in healthcare is promising, but also has its share of challenges to overcome. We examine the thoughts of Dr. Rafael Grossmann and Pristine’s Kyle Samani on the subject. The little wearable optical computer that could, may be helping physicians and medical professionals see things a bit differently these days—but how Google Glass will seamlessly replace other devices to enhance clinical care has yet to come fully into focus. For even the device’s biggest enthusiasts say there are barriers between Google Glass and its potential.  Keyword(s): Google GlassAdoptionHealthcare #### Patient Portals #### Patient Portals: The Key to Patient Engagement Patient engagement is the new hot topic in healthcare information technology. Fueled by patient demands and Meaningful Use requirements, the need to get patients more involved in their own health management, and giving them a convenient platform to do so, is more important than ever. Continue reading  Keyword(s): PatientPortals #### ICD-10: 5 Steps to Take Now #### ICD-10: 5 Steps to Take Now In order to reflect advancements in medical knowledge and technology, the U.S. Department of Health and Human Services has mandated all health organizations begin use of the ICD-10 code set no later than October 1, 2014. This conversion will require tremendous effort from the health care community. The conversion to ICD-10 is daunting. Continue reading  Keyword(s): ICD-10 #### Myths about Health Data Sharing #### Push vs. Pull: 3 Myths about Health Data Sharing Dr. Robert Rowley shares three myths about health data sharing. Since the widespread adoption of Electronic Health Records (EHR) systems by most hospitals and a majority of community physicians, the fragmented, siloed nature of a given patient’s health story has become evident. Continue reading  Keyword(s): Push vs. PullMythsHealth DataSharing #### Acceso vs Privacidad #### Acceso vs Privacidad: Cuestiones de ética de la información enfrentan a los profesionales de datos Las preguntas sobre la ética de datos se han elevado en la palestra de profesionales de primera línea a raíz de las revelaciones de recopilación de datos de la NSA y otras noticias. Continuar leyendo  Keyword(s): AccesoPrivacidad #### Violencia contra el personal sanitario #### Violencia contra el personal sanitario Diariamente nos enteramos y padecemos ataques físicos y verbales, secuestros y muertes, en servicios de emergencia, ambulancias y centros de salud. “La tasa de asaltos en trabajadores de la salud es mas alta que en otras ocupaciones: 8 cada 10.000 comparada con 2 cada 10.000 en los lugares de trabajo en general”. (The Lancet, 19-4-2014). Continuar leyendo  Keyword(s): ViolenciaPersonal Sanitario #### Dissatisfaction with EHRs #### 9 Key Drivers of Physician Dissatisfaction with EHRs Recent RAND study provides the key drivers of physician dissatisfaction with EHRs and its affect on physician professional satisfaction. A recent RAND research report reveals that the current state of EHR technology significantly worsened professional satisfaction in multiple ways. The project sponsored by the American Medical Association (AMA) gathered data from 108 in-person interviews and received 447 written responses across 30 physician practices in six states: Colorado, Massachusetts, North Carolina, Texas, Washington, and Wisconsin. Continue reading  Keyword(s): PhysicianDissatisfactionEHRs #### Enfoque en el paciente y enfoque en el cliente #### ¿Cuál es la diferencia entre el enfoque en el paciente y enfoque en el cliente? David Laws, columnista de eyeforpharma, recurre a sus y nuestras propias experiencias sobre el "enfoque" hecho en la industria farmacéutica y se pregunta: ¿De qué manera la industria puede evitar repetir los mismos errores del pasado? Hace algún tiempo la industria farmacéutica parecía preocupada con la idea de estar más enfocada en el cliente. Parecía ser una estrategia para el futuro, la cual ayudaría a la industria a entender mejor a sus clientes y a ser más relevante para los mismos durante un periodo de comercialización del producto y acceso reducido. ¿Podría ayudar para diferenciar una empresa farmacéutica grande de otra para los ojos de sus clientes y podría mejorar el rendimiento de la empresa? Continuar leyendo  Keyword(s): Enfoque en el pacienteEnfoque en el cliente #### Gestión remota de pacientes #### Gestión remota de pacientes mediante dispositivos conectados El mundo de los dispositivos móviles, está llegando cada vez más a las empresas y mercados verticales con propuestas sumamente interesantes para el canal. Una nueva tendencia abre las puertas de un negocio que los proveedores pueden aprovechar de forma independiente e inmediata. Se trata de la utilización de dispositivos conectados en instituciones médicas para gestionar pacientes con enfermedades crónicas y de manera remota. Continuar leyendo  Keyword(s): Gestión remotaPacientes #### ePaciente y Redes Sociales Cuando pensamos en Internet, la primera imagen que nos viene a la cabeza es uno de esos rankings televisivos con los vídeos más vistos de YouTube: niños dándose golpes tontos, adolescentes teniendo caídas aún más tontas, y algún que otro gatito haciendo playback. Sólo hay otras dos acepciones de Internet que surgen de forma espontánea: “repositorio mundial de pornografía” y “peligroso para los menores”. Hasta que nuestra vida cambia. Continuar leyendo  Keyword(s): ePacienteRedes sociales #### Hospital Information System Crash #### 4 Things to Know in Case of a Hospital Information System Crash It's a nightmare any hospital hopes to avoid: a crash or prolonged outage of its central information system. As hospitals and health systems continue to transition to an all-electronic landscape, though, the possibility of an information system crash is just one unexpected disaster away from occurring. Michael Ward, director of information services at Anderson Hospital in Maryville, Ill., gives four considerations to shore up a contingency plan in case a hospital's information system hits a snag. Continue reading  Keyword(s): HospitalInformationSystem Crash #### EHRs and improved life expectancies #### Could there be a correlation between EHRs and improved life expectancies? Beckers Hospital Review - According to the National Center for Health Statistics, the current life expectancy in the United States is roughly 78 years. For the rural population served by the Peter Christensen Health Center in Lac du Flambeau, Wis., which is primarily composed of Chippewa Indians, the life expectancy was only 56 years in 2005. But in the past five years, the life expectancy of the community has gone up to 59 years. So what changed? Continue reading  Keyword(s): EHRsImproved life expectancies #### ePatient #### Conoce a Dave, un "ePatient" Cuando Dave deBronkart supo que tenía una forma rara de cáncer terminal, se dirigió a un grupo de pacientes por internet y encontró un tratamiento que ni sus médicos conocían. Ésto le salvó la vida. Ahora se comunica con todos los pacientes para hablar con ellos, conocer sus datos clínicos y así mejorar la atención médica de cada e-patient, uno por uno. Seguir leyendo  Keyword(s): ePatient #### SOA in the CLOUD age #### FAQ: THE BASICS OF THE CLOUD AND SOA ##### Some people may think SOA is irrelevant because of the cloud, while others assert the cloud and SOA go hand in hand. by: Maxine Giza Some people don't think SOA is relevant in the cloud age, but that isn't what industry insiders say. Coupling the cloud and SOA can translate into major cost-saving benefits for enterprises due to improved agility and flexibility. Read on to learn about the cloud, SOA and how they can be a powerful resource when combined. Continue reading on the site http://losnuevosguerreros.org  Keyword(s): CLOUDSOA #### Only 1 in 1000 mHealth Apps Have been Regulated by FDA #### Sólo una de cada 1000 aplicaciones de salud ha sido revisada por la FDA Sólo 100 de 100.000 aplicaciones de salud han sido revisadas por la FDA, según ha denunciado un grupo de expertos en derecho sanitario, qu eha pedido más regulación en este campo. Se trata de un mercado cuyo valor se estima en 27.000 millones de dólares para 2017 y en el que pueden encontrarse aplicaciones que tienen consecuencias para la salud de los pacientes, según advierten estos expertos de la Facultad de Derecho de la Universidad Southern Methodist de Estados Unidos. El problema, aseguran, es que muchos pacientes creen que al encontrar la aplicación en una fuente de confianza, como la tienda de iTunes o Google Play, es segura. La realidad es que hay errores, incluso en aplicaciones de farmacéuticas, como el que cometió un laboratorio con las dosis de insulina. #### Only 1 in 1000 mHealth Apps Have been Regulated by FDA by Gabriel Perna A trio of health law experts have advocated for more regulation and oversight of the mobile health (mHealth) application industry, saying that only 100 of 100,000 mHealth apps have been cleared by the Food and Drug Administration (FDA). The researchers, led by Nathan Cortez, the Southern Methodist University (SMU) Dedham School of Law associate dean of research, argue that an under-regulated mHealth industry would create a "Wild West" market. They say that additional FDA funding and technical expertise on how to regulate mHealthproducts is necessary. “Most consumers take mobile health app claims at face value, and think that because they’re available through a trusted retailer like the iTunes Store, they must have been reviewed by the FDA, which isn’t usually the case,” Cortez said in a statement. The mHealth app industry is booming, the researchers note, citing a study that predicts revenue from these apps will earn$26 billion in 2017. This makes it necessary, they argue, for it to be regulated. Many of the products, Cortez said, cannot fulfill the promises they allege and others make errors that could harm patients. He cites several examples in the research, including Sanofi Aventis’ 2012 recall of a diabetes app that miscalculated insulin dosages.

“The conventional wisdom is that FDA regulation will stifle innovation, and that’s a very short-term way to think about this,” Cortez said. “Most Silicon Valley firms aren’t used to much federal regulation, and Internet technologies have been subject to very little federal oversight.”

Read the source article at SMU Dedman School of Law

#### BOOMING MOBILE HEALTH APP MARKET NEEDS ROBUST FDA OVERSIGHT TO ENSURE CONSUMER SAFETY, CONFIDENCEHealth Law Experts in July 24 New England Journal of Medicine

Dallas (SMU) — Smart phones and mobile devices are on the cusp of revolutionizing health care, armed with mobile health (“mHealth”) apps capable of providing everything from cardiac measurements to sonograms.

While tremendous potential exists to broaden access to medical treatment and control costs, several health law experts say in a just-published New England Journal of Medicine (NEJM) report that more oversight is needed by the U.S. Food and Drug Administration (FDA) to ensure consumer confidence and safety. Out of some 100,000 mHealth apps on the market, only about 100 have been cleared by the FDA, while opponents see the FDA as deterrents to innovation — and profits.

“Consumers will be spending a lot of money on these products, and venture capital is flying into the industry,” says the article’s lead author, SMU Dedman School of Law Associate Dean of Research Nathan Cortez, adding that by 2017 mHealth apps are expected earn $26 billion— up from$2.4 billion in 2013.

The FDA needs “additional funding and in-house technical expertise to oversee the ongoing flood of mHealth products,” the authors note. An under-regulated mobile health industry could create “a Wild West” market, says Cortez, who has conducted extensive research into FDA regulation of mobile health technologies.

“Most consumers take mobile health app claims at face value, and think that because they’re available through a trusted retailer like the iTunes Store, they must have been reviewed by the FDA, which isn’t usually the case,” Cortez says.

Cortez, who also serves as an associate professor in SMU’s Dedman School of Law, co-wrote the NEJM article with Harvard Law School Professor I. Glenn Cohen, faculty director of the Petrie-Flom Center for Health Law Policy, Biotechnology & Bioethics and author of Human Subjects Research Regulation: Perspectives on the Future (MIT Press, 2014) andAaron S. Kesselheim, Associate Professor of Medicine at Brigham and Women’s Hospital/Harvard Medical School.

“Although the vast majority of mHealth products are very low-risk, some apps make promises they can’t fulfill, and others make errors that could harm patients,” Cortez notes, pointing out that life-threatening technical mistakes are not only possible – they also have occurred.

One of several examples cited in the study includes Sanofi Aventis’ 2012 recall of a diabetes app that miscalculated insulin dosages.

Several Congressional bills have been proposed to strengthen FDA jurisdiction over mHealth products, with one proposing the creation of a new Office of Wireless Health Technology within the administration, the article notes. Meanwhile, more restrictive bills also have been introduced to keep the FDA from regulating “clinical software” or “applying a complex regulatory framework could inhibit future growth and innovation in this promising market.”

“The conventional wisdom is that FDA regulation will stifle innovation, and that’s a very short-term way to think about this,” Cortez says. “Most Silicon Valley firms aren’t used to much federal regulation, and Internet technologies have been subject to very little federal oversight.”

If dangerous errors and disproven product benefits are allowed to proliferate, “some very useful products will be undermined by widespread consumer distrust,” Cortez contends.

“We’re trying to push lawmakers to empower the FDA, not hamstring it,” he says. “Clarity will help the industry create products more helpful than harmful.”

MEDIA NOTE:

To speak with Professor Nathan Cortez, please contact him at ncortez@smu.edu or call Denise Gee at dgee@smu.edu, 214-768-7658 (office) or 214-274-0888 (cell).

SMU is a nationally ranked private university in Dallas founded 100 years ago. Today, SMU enrolls nearly 11,000 students who benefit from the academic opportunities and international reach of seven degree-granting schools.

SMU Dedman School of Law was founded in 1925 and named Dedman School of Law in 2001 in honor of Dallas benefactors Nancy and Robert H. Dedman, Sr., and their family.  SMU Dedman Law offers both full-time, J.D. program, and a part-time evening J.D. programtwo joint degree programs, J.D./M.B.A. and J.D/M.A. in economicsfour graduate degree programs, LL.M. program for foreign law school graduates, LL.M. in Taxation, general LL.M., and an S.J.D. program. The law school enjoys a national and international reputation of distinction, with graduates that have distinguished themselves as global leaders in law, business and government, and as prominent members of the judiciary.

 Keyword(s): FDA RegulationMobile Health Technologies

#### Enrich your social capital with the right networks

Networking is not all that it’s cracked up to be; in fact it can even be downright harmful, so says Martin Gargiulo, an Associate Professor of Organisational Behaviour at INSEAD and expert on social network analysis.

“We know today that networks are an asset that helps you get things done … (but) networks can also be a liability.” At best, networks can be a window to the world that allows you to understand and work with the diversity and the complexity of that world. At worst, they can be ‘blinders’ that prevent you from doing so.

Continue reading on the site http://losnuevosguerreros.org

 Keyword(s): EnrichSocial CapitalRight Networks

### Intelligent Compliance

IT security and compliance have achieved a new prominence, with even mainstream news outlets reporting on issues such as the Heartbleed OpenSSL bug or the latest theft of payment card details from a retailer or a financial organization. The old ways of implementing compliance mandates are no longer acceptable, and the risk of high-profile consequences from incomplete or insufficient attention to security and compliance has never been greater. Organizations must find a way to meet organizational and legal requirements, even with the increased pressure on budgets, or face significant penalties or even criminal prosecution for the CIO, the CISO and other leaders within IT.

Source: bmcsoftware

 Keyword(s): IntelligentCompliance

## Big Data: The Godzilla of Healthcare

If you grew up watching Creature Double Feature movies, you know that Godzilla is a giant dinosaur-like monster that destroys Japan (and most recently San Francisco), and battles other monstrous creatures like Mothra and Destoroyah. In the early movies, Godzilla was the villain, but in the later movies he became a giant, albeit destructive, anti-hero. By the same token, big data can be a hero and save the day, or it can be a big, scary monster.

In its most basic form, big data is digital health information that comes from a variety of sources, including electronic health records, clinical trials, insurance claims, mobile apps like Fitbit and social media, where people post information about their health issues.

The power of big data is indisputable, but is it a force for good or evil?

Healthcare Hero?

A recent PwC study reported that 95 percent of healthcare CEOs said they were exploring better ways to harness and manage big data. Why are they so committed to exploring new ways to do this?

Experts predict that big data could improve everything from the drug-discovery process to predictions about patients' disease risks. In fact, a McKinsey and Co. report estimated that big data could help reduce U.S. healthcare expenses by as much as $450 billion. Here are some ways big data can transform healthcare: • Population health: Big data could allow physicians to study larger populations and analyze the data to cost-effectively implement treatment changes quickly to improve people's lives. • Preventive care: Carolinas HealthCare System, an integrated delivery network with 900 service locations in North Carolina and South Carolina, purchased consumer spending data to analyze purchases and anticipate patients' future healthcare needs. For example, if a patient buys a lot of alcohol or eats a lot of fast food, he or she could be at a risk for depression or diabetes. • Reduce healthcare costs: The July issue of Health Affairsidentified six ways that big data can help reduce healthcare costs, including improving treatment for high-cost patients; reducing readmissions; improving patient triage; treating patients with deteriorating health conditions; decreasing adverse events; and treating people with diseases that affect multiple systems. • Organ transplant matching: Hospitals can also use big data to find matching organ donors. Economic professors developed an algorithm to find organs for previously incompatible pairs that takes into account blood type, antibody information of the candidate and the antigen information of the donor. A Carnegie Mellon professor created an advanced algorithm to create a kidney exchange network featuring donor chains. The result: people can get the organs they need to lead healthy lives. Scary Monster? However, even with these promising outcomes, big data is still a giant, destructive monster. The problem facing big data is that no one has answered two very important questions: • What is the right way to collect this information? • Who should be allowed access to this data? Federal Trade Commissioner Julie Brill expressed concernsabout the way smartphone apps and mobile devices are collecting health information and sharing it with third parties. In addition, a recent FTC study reported that health app developers have collected consumer health data and shared it with third-parties, including marketers. The fact that mobile companies share people's health data with third-parties, without notifying people, raises some major legal and ethical concerns. There aren't any accepted standards for how patients agree to have their information used and shared. One terrifying scenario would be if this data is collected and shared with the wrong people. Imagine if the number of steps people walk a day, the number of hours they sleep per night, their blood pressure scores and whether they buy alcohol on a regular basis is shared with insurance companies. Independently, these facts might not mean anything, but together, they might indicate that people are at higher risk for diabetes or heart disease and insurance companies could raise their insurance rates. There are also concerns about whether the data used in predictive analysis is clean. While the data from the patientâ€™s medical record may be accurate, the data from external sources may not be. Combining data from different sources could impact the accuracy of the conclusions and ultimately, lead to prescribing the wrong treatment. Time will tell whether big data will save the day or destroy the world. But either way, the healthcare landscape will change dramatically. Let's just hope we won't have giant monsters battling in U.S. cities, smashing buildings, squashing cars and making a giant mess of things. Healthcare reform is one thing, but giant monsters that breathe radioactive steam is something completely different. Jenn Riggle is a vice president at Weber Shandwick Worldwide based in Washington, District of Columbia and member of its healthcare practice. Link: http://www.hospitalimpact.org/index.php/2014/08/07/big_data_the_godzilla_of_healthcare  Keyword(s): Big Data #### EHR Adoption Hits Record Levels for Hospitals and Physicians #### HHS: EHR Adoption Hits Record Levels for Hospitals and Physicians by EHR adoption for hospitals and physicians are higher than before, according to two new studies published today by the HHS Office of the National Coordinator for Health Information Technology (ONC). Finding Details The studies, published in the journal Health Affairs, found that in 2013, almost eight in ten (78 percent) office-based physicians reported they adopted some type of EHR system. About half of all physicians (48 percent) had an EHR system with advanced functionalities in 2013, a doubling of the adoption rate in 2009. The information in the studies was collected by the Centers for Disease Control and Prevention’s National Center for Health Statistics and the American Hospital Association in 2013. About 6 in 10 (59 percent) hospitals had adopted an EHR system with certain advanced functionalities in 2013, quadruple the percentage for 2010. Unlike the physician study, the hospital study does not have an equivalent, established measure of adoption of some type of EHR system; it only reports on adoption of EHRs with advanced functionalities. “Patients are seeing the benefits of health IT as a result of the significant strides that have been made in the adoption and meaningful use of electronic health records,” said Karen DeSalvo, M.D., M.P.H., national coordinator for health information technology. “We look forward to working with our partners to ensure that people’s digital health information follows them across the care continuum so it will be there when it matters most.” The data from the report provides an early baseline understanding of provider readiness to achieve Stage 2 Meaningful Use of the Medicare and Medicaid EHR Incentive programs. Stage 2 will begin later this year for providers who first attested to Stage 1 Meaningful Use in 2011 or 2012. According to the data, 75 percent of eligible professionals and more than 91 percent of hospitals have adopted or demonstrated Stage 1 Meaningful Use of certified EHRs. Stage 2 Meaningful Use Struggles According to CMS data from 2013, the meaningful use dropout rate was 20% when providers only had to attest for MU stage 1 and is expected to increase even higher as more providers prepare for MU stage 2. The CDC data also show that more work is needed to support widespread health information exchange and providers’ ability to achieve Stage 2 Meaningful Use requirements under the Medicare and Medicaid EHR Incentive Programs. Among the details include the following: • In 2013, health information exchange among physicians was relatively low: 4 in 10 (39 percent) reported they electronically share data with other providers, but only 14 percent electronically share data with ambulatory care providers or hospitals outside their organization. • In 2013, the vast majority of hospitals had capabilities that could be used to support many Meaningful Use Stage 2 objectives but were not being used. However, 10 percent of hospitals were providing patients with online access to view, download, and transmit information about their hospital admission. According to the 2014 Medscape EHR Report, 22% of physicians are opting out of meaningful use. Thesurvey found that 16% said they will never attest to meaningful use requirements, and another 6% of participants said they are abandoning meaningful use after meeting the requirements in previous years, up 2% from 2012. Overall, 78% of participating physicians said they were attesting to meaningful use Stage 1(30%) or Stage 2 (48%) in 2014. HHS: EHR Adoption Hits Record Levels for Hospitals and Physicians by Jasmine Pennic  Keyword(s): EHR Adoption #### Segments of Digital Health Consumers #### New Research Reveals 4 Segments of Digital Health Consumers Market research firm Park Associates has announced a new digital health research revealing four digital health consumer segments based on their attitudes toward their health and healthcare solutions: Healthy and Engaged, Challenged but Mindful, Unhealthy and In Denial, and Young and Indifferent. The research found that among all U.S. broadband households, 26% are Healthy and Engaged, 25% are Challenged but Mindful, 28% are Unhealthy and In Denial, and 21% are Young and Indifferent. The new research, Digital Health Consumers: A Lifestyle and Technology Segmentation analyzes consumer health habits and segments the market according to lifestyles and personal health conditions based on a survey of 2,500 U.S. broadband heads-of-household in 4Q 2013. It then identified which segments are most and least receptive to digital health products and services and provides a demographic and technographic profile of each segment. Parks Associates’ digital health consumer segments include: ##### Healthy and Engaged – Health conscious, don’t have chronic health problem (26%) - Offer the greatest market potential for digital health products and services. - Regularly exercise and eat fresh fruits and vegetables. - Have higher incomes, on average. ##### Challenged but Mindful – Health conscious, have chronic health problem (25%) - Offer the second-greatest market potential for digital health products and services. - Regularly exercise and eat fresh fruits and vegetables but have a chronic health condition. - Older consumer segment; unlikely to have children in the home. Unhealthy and In Denial – Not health conscious, have chronic health problem (28%) - Offer the third-greatest market potential for digital health products and services. - Lower income levels, on average; disproportionately likely to live in the Midwest and South. - Do not habitually exercise or eat fresh fruits and vegetables; have a chronic health condition. Young and Indifferent – Not health conscious, don’t have chronic health problem (21%) - Lowest market potential for digital health products and services. - Youngest segment; low income levels; least likely to be married. - Express the most enthusiasm for technology products and services. - Healthy but do not habitually exercise or eat fresh fruits and vegetables. The research found that the consumer segment Young and Indifferent reported the highest interest in new technologies; however, they have the lowest concern for their health. Only 28% looked up health information online in the last 12 months. The market research firm will discuss this research in detail as the host of the Connected Health Summit: Engaging Consumers on September 4-5 in San Diego and offer implications for consumer engagement strategies for healthcare providers and their health technology partners New Research Reveals 4 Segments of Digital Health Consumers by Fred Pennic  Keyword(s): SegmentsDigital HealthConsumers #### Healthcare Transformers #### StartUp Health Reveals New Class of 14 Healthcare Transformers by StartUp Health, a global startup platform accelerating health and wellness innovation, today announced from the Cleveland Clinic Medical Innovation Summit the addition of 14 digital health companies to its exclusive long-term coaching program and community. The selected class of 14 “healthcare transformers” represents an experienced group of entrepreneurs focused on building sustainable digital health companies across a broad spectrum of innovation from home healthcare, genomics, aging, sensors, patient and physician engagement, mobile health and wellness, nutrition analysis, concierge medicine, care coordination and price transparency. StartUp Health received more than 1,200 applications from 22 different countries for this class. A Three-Year Structured Program StartUp Health believes a three year structured program is the best approach to transforming healthcare to support and promote entrepreneurs with ongoing inspiration, education, and access to customers, capital, and other critical resources so that innovation and growth can occur more quickly. The three year location- and stage-agnostic program focuses on customer development, capitalization and fundraising, scaling team and talent, and streamlining operations to best position startups for growth. One of the key differentiators is StartUp Health’s long-term focus on connecting health and wellness startups with customers, pilot programs, strategic capital partners, and the critical resources designed to help Healthcare Transformers achieve 10x equity value for their businesses. As of October 2013, 46 StartUp Health companies have raised a total of$106 million in funding.

The new class of StartUp Health Companies and Healthcare Transformers include:

Point of Care 360

Sector Focus: Patient Engagement; Physician Engagement; Point of Care Reference

The @Point of Care360™ platform provides a streamlined practice-based tool to allow for the delivery of content at the clinician’s fingertips at the time it is acutely needed, enabling better decisions, better outcomes, and better care.

#### 1EQ

Sector Focus: Genomics; Wellness; Behavior Change

1EQ leverages both genetics and lifestyle information, provided through wireless devices and mobile apps, to produce a more comprehensive health picture an actionable steps for its users to live a better and healthier life.

A patented smart pill bottle to improve medication adherence. The bottle automatically determines the amount of medication in real­time, and wirelessly transmits this HIPAA­compliant data to the cloud via Verizon network. If a patient hasn’t taken his/her medication, AdhereTech reminds the patient via phone call or text message, as well as via on­bottle lights and chimes.

The company has secured trials with research institutions and pharma companies.

#### CoheroHealth

Melissa Manice, Ph.D., MPH is on a mission to give kids the tools to change their health. CoheroHealth has created AsthmaHero, a mobile solution for kids with chronic asthma, incorporating an inhaler sensor and mobile application to track real­time adherence and mobile spirometry through an engaging, gamified patient interface.

#### DataGenno

Sector focus: Genomics; Big Data

Fabricio F. Costa, Ph.D., and Marcelo P. Coutinho, MD, MsC, are on a mission to facilitate information exchange about genetic and rare diseases to translate the latest advances into effective clinical interventions. DataGenno (@datagenno) is an online medical information company created to be the one­stop source of information on genetic diseases and syndromes, connecting both clinical and molecular aspects of genetic diseases in a fully interactive environment.

#### Edamam

Sector focus: Wellness; Nutritional Analysis

Edamam, founded by serial entrepreneur Victor Penev, is organizing the world’s food knowledge. The company provides cost­effective, on­the­fly nutritional analysis and diet labeling to businesses and consumers through its proprietary semantic food and nutrition knowledge database and natural language processing algorithms. Edamam aims to become the default digital nutrition engine of the web.

#### Gene By Gene

Sector focus: Analytics; Big Data; Genomics

Gene By Gene, Ltd. is a leader in genetic DNA testing with ancestry and medical solutions. Founded in 2000 as the world’s first company to develop consumer DNA testing for ancestry and genealogy applications, Gene by Gene provides a comprehensive approach to diagnostics tests, including AABB certified relations tests, genome sequencing, data management and computational analysis. Gene by Gene recently acquired StartUp Health company Arpeggi.

#### Medicast

Sector focus: Concierge Medicine; Home Health

Sam Zebarjadi, Sahba Ferdowsi, MD, and Nafis Zebarjadi are on a mission to make it easy for anyone to receive access to a doctor with the click of a button. The Medicast (@medicast) web and mobile platform provides consumers with 24­hour on­demand medical services, including delivering high quality, compassionate doctors directly to a patient’s home, office or hotel.

#### Ondello

Sector focus: Home Health; Patient Relationship Management, Concierge Medicine, Telehealth

Mark Hadfield, a serial entrepreneur, is on a mission to revolutionize the home care market and simplify how doctors and patients connect online. Ondello(@ondellortc) delivers WebRTC­based software services that enable healthcare providers to seamlessly communicate in real­time with patients through in­context chat, video and voice.

#### Respondesign

Sector focus: Patient Relationship Management; Home Health; Wellness

John Grispon, Ted Spooner, and Jason Leighton are on a mission to increase patient engagement in physical therapy for more effective PT treatment and reduced readmissions. Respondesign’s flagship product, FitWorld (@fitworldapp), is a Kinect­based rehabilitation therapy platform that targets all segments of rehab from falls prevention and disease management to orthopedic and pulmonary rehab. The platform also enables therapists to deliver an engaging, personalized program that includes patient monitoring and clinician reporting for in­clinic and at home usage.

#### RxApps

Sector focus: Mobile Health; Patient Engagement; Wellness

John Moore is on a mission to ensure that patients’ emotional well­being is seen as equally relevant to their clinical health as any biometric measure. RxApps(@rxapps) supplements standard management of chronic illness using customizable text message prompts to track patient health, experience, and behavior metrics that influence outcomes.

#### Sense Health

Sector focus: Mobile Health; Patient Engagement; Patient Relationship Management; Home Health

Stan Berkow, Brad Hammonds and Paul Biancaniello are on a mission to engage people with their health and improve patient support. Sense Health(@sensehealth) unlocks the potential of mobile health support for patients by giving healthcare professionals a mobile platform to easily create, deliver, and monitor interactive support plans for their patients in between appointments.

#### TedCas

Sector focus: Hands­free Medical Care; Sensors and Tracking

Jesús Pérez­Llano (@jesusperezllano), Enrique Muñoz, Daniel Calvo, Gerardo Caballero and the rest of the TedCas team are on a mission to unleash the potential of touchless devices such as Kinect or LEAP inside the health sector. TedCas (@tedcas), powered by Wayra and Sodena, allows doctors to control and manipulate software through gestures and voice commands, without touching, saving time and reducing potential infections.

#### Yingo Yango

Sector focus: Wellness; Mobile Health; Employer Health; Patient Relationship Management

Marty Jaramillo (@martyjaramillo) and his team are on a mission to unite the highly fragmented health/wellness industry. Yingo Yango (@yingoyango) is a white­label, stand alone, mobile patient engagement platform that integrates ecosystems of care. The platform is designed to maximize long­-term employee/patient engagement, reduce readmissions, as well as brand clients as health minded, patient centric, and caring organizations. The low cost “connecting the dots” solution is designed for corporations, carriers, and providers.

StartUp Health Reveals New Class of 14 Healthcare Transformers by Jasmine Pennic

 Keyword(s): HealthcareTransformers

#### Can Google Glass Transform Medical Education?

Google Glass looks exciting for the medical world, and presents a particularly powerful opportunity for medical education(for examples, see Forbes article here or Phys.org here). A white paper by the Department of Emergency Medicine, Singapore General Hospital says, “simulation-based training has opened up a new educational application in medicine. It can develop health professionals’ knowledge, skills, and attitudes, whilst protecting patients from unnecessary risks”. Google Glass is taking simulation to the next level and making it more real, as the patients treated are real.

Yet the underlying concept of simulation-based-learning in medicine isn’t new. Neither are the individual components of Google Glass (such as the video recording feature and the possibility of sharing procedures online with any number of students). The biggest innovation might be having all this in one device. As Aristotle said, the whole is more than the sum of its parts.

Medical education is often a two stage process. In stage one, doctors in training need to study voluminous tomes and pass exams; stage one is the collection and storing of knowledge – perhaps too much knowledge. Richard Barker says in his book 2030, the future of medicine, that “as our bio-medical insights continue to fragment traditional diseases into multiple molecular disorders, keeping pace with advances gets tougher and tougher; … ‘head knowledge’ needs to be complemented by online decision support, distilling the wisdom and experience of the best specialist and putting it at the fingertips of the practitioner”. In other words, clinicians are starting to need real-time knowledge on tap.

Stage two focuses on learning through direct patient contact under the guidance of seniors, and Barker’s position suggests that stage two may never really end. Google Glass would support this stage of the curriculum, helping to simulate the practice of medicine, teach decision making, and then allow collaboration long after qualification. With a teacher demonstrating on patients (or that earlier revolution: a mannequin) with a headset camera, the learner is brought straight into the operating theater.

Google Glass is similar to a standard pair of glasses. It has an optical head-mounted display, sitting just above the right eye. Features include a built-in GPS, microphone and Bluetooth, and a camera which can record and live-stream videos to a Google hangout. Particularly useful is voice activation which would allow surgeons to, for example, do a web search for latest research or access EMRs or even real-time patient metrics without “breaking scrub” (compromising operating room sterility). As well as improving the provision of care, this ought to give students a more holistic understanding of each case.

Dr. Rafael J. Grossmann, Surgeon, mHealth Innovator and Google Glass Explorer was the first to perform a Google Glass-aided surgery, including remote teaching contexts and offering clinical advice remotely via Google hang-out. Orthopaedic surgeon Dr. Selene Parekh followed with a demo of foot and ankle surgery, and then plastic surgeon Dr. Anil Shah used the device while carrying out a rhinoplasty. Recently, Medical News Today wrote about a surgeon who live-streamed a procedureusing Google Glass and a tablet device.

Grossman says that exposing students to the real life of a surgeon and their problems is critical for training and students should learn and mimic best practices early on. Furthermore, he adds that Google Glass education goes beyond the operating room, “Google Glass is a great start with practically limitless opportunities. “For example, how to connect with patients, how to teach bedside manner, how to prepare patients for surgery can all be best taught from real life examples. Google Glass records it and demonstrates best practice, from A to Z through the responsibilities of a practitioner,” he says.

Plus, of course, these Google Glass recorded procedures can be shared across the globe. InnovatorArmando Iandolo, co-founder of Surgery Academy and his team have created an application for Google Glass that lets surgeons stream a heads-up view of procedures to students anywhere in the world. The big, bold innovation is to connect these streams in MOOCs (massive open online courses), says Iandolo. He and his co-founder are currently crowd-funding the idea on Indigogo. “Students will access an operating theatre online and watch a surgical intervention, live, for the procedure of their choice”, says Iandolo. “As we enter Universities, we want to become an integral part of the medical student’s study curriculum”.

MOOCs aren’t new either, but with the Surgery Academy everything seems to fall in place. By bringing the learner straight into theatre, simulation via Google Glass makes courses operate more like apprenticeships.

The patient would need to give their approval, but this is surely quite reassuring for the patient: which practitioner – and one good enough to teach – wants to screw up while being live-streamed to hundreds of students and fellow physicians?

The speed at which Google Glass eventually becomes a standard educational support tool is less certain, and we can learn from previous waves of innovation. In 2010, the Northern Ontario School of Medicine introduced a new mobile device program (medical students received laptops, iPhones and iPads). To assess its value, educators there how medical learners use mobile technologies. Their white paper concluded, “Students would adapt their use of mobile devices to the learning cultures and contexts they find themselves in.” Device value needs to be taught. It depends on how welcome new tech is perceived to be in classrooms, by students, teachers, and the wider ecosystem.

A typical fear is that, especially early in the curriculum (stage one above), medical students will miss out on basic knowledge. Search and find functions make it easier to zero in on an answer, but perhaps without the rich context and basic knowledge provided by reading cover to cover. Students – and teachers – could work just ‘for the test’.

Well, books have always had indices. It’s the process of search which has been accelerated, and there is no evidence that students would treat a digital medical textbook differently than its paperback version. In fact digital isn’t a replacement for the traditional textbook; it’s an opportunity to augment it. There is a generational shift in the learning styles of medical students, Mihir Gupta writes in aKevinMD article. Digital allows the stodgy textbook to be augmented with visual and multimedia, which will suit certain learning styles. “Innovative digital resources are vital for helping students retain knowledge and simplify difficult concepts”, says Gupta. These new resources are great for quick access to updated medical knowledge, but “it will not replace textbook learning, nor should it”.

Lucien Engelen, Director of the Radboud Reshape Center at Radboud University Medical Center, is currently working on various applications for Google Glass in medicine. He says that the only way to get Google Glass into education is “to make it part of education innovation”. He says, “Take some high profile doctors, professors and nurses and some patients and have them run some tests. All of a sudden the advantages (of Google Glass) seem to fall in place seamlessly”.

Frances Dare is Managing Director of Accenture Connected Health Services, which has partnered with Philips on a Google Glass proof of concept. She agrees with Engelen, cautioning that it is important to create an environment in which experimentation can take place and to understand the type of training needed to prepare clinicians to use Google Glass effectively and safely in practice.

But don’t bet against Google Glass. After all, educators have argued for decades over calculators in math class. Engelen says that he really doesn’t think of Google Glass as something special: it’s just another computer form-factor facing the same barriers of acceptance. It will take some time and discussion over privacy to achieve it, but the new wave is coming.

by Nick Saalfeld and Ben Heubl, Contributing Writers at HIT Consultant

Nick Saalfeld is a corporate journalist and entrepreneur based in London, UK. He has written for seven years about health-tech for clients including Microsoft, Imprivata and Howareyou.com. He also co-founded Yoodoo, the online platform devoted to delivering behavioral change through learning experiences, with many applications in public health and clinical/pharmaceutical adherence.

Ben Heubl is a digital health advocate, activist and journalist for health 2.0 innovation.Ben Heubl is speaker at various healthcare innovation conferences and events, a TEDMED delegate, founded the non-for-profit organization Health 2.0 Copenhagen, Mentor at the HealthXL accelerator, and currently passionately writes for various online magazines in the context of digital health innovation and technology. Ben also currently supports a UK health innovation SME to change how citizens access healthcare. You can follow him on Twitter at @benheub

Can Google Glass Transform Medical Education? by Nick Saalfeld and Ben Heubl

by

84 percent of US consumers believe they should have full access to their electronic medical records while only a third of physicians (34 percent) share this belief, according to an Accenture survey.

The survey found that 41% of consumers are willing to switch physicians to gain online access to their EMRs highlighting the growing trend towards patient engagement. The online survey included more than 9,000 people in nine countries ages 18+ to assess consumer perceptions of their medical providers’ electronic capabilities across nine countries: Australia, Brazil, Canada, England, France, Germany, Singapore, Spain and the United States. The survey, which included 1,000 U.S. consumers, was fielded by Harris Interactive in July 2013.

To highlight the findings, Accenture has released an infographic that illustrates the key findings of the Accenture Consumer Survey on Patient Engagement and explores whether doctors are delivering on the growing patient demand for access to EMRs and other electronic capabilities.

Source: Accenture

Featured image credit: Zeusandhera via cc

Infographic: Patients Want Access To Their Electronic Medical Records by Fred Pennic

 Keyword(s): InfographicPatientsAccessElectronic Medical Records

#### UCSF First in Nation For Approval To Use Google Glass in Surgeries

by

The University of California, San Francisco, is the first healthcare provider in the nation to receive Institutional Review Board approval for use of Google Glass in surgeriesSacramento Bee reports.

With so much buzz around the potential of Google Glass in healthcare, the approval by UCSF is a great indicator of the emerging role Google Glass could play in the healthcare setting.

According to a report in HealthLeaders Media, Dr. Pierre Theodore, a cardiothoracic surgeon at UCSF has already performed 10 or 15 planned surgeries using Google Glass. Theodore noted that surgeons already use eyewear that magnifies the surgery site making Google Glass integration much easier (Mace, HealthLeaders Media, 11/26). UCSF performed a series of dry lab experimentations” to demonstrate:

• Minimal distraction between hand-eye coordination and use of the device
• The availability of images to and from the surgeons’ field of vision

Google is already working with major vision benefits and frames creator VSP Global to get Google Glass inside  optometrist offices.

The possibilities of Google Glass does not come without some concerns. Ensuring patient information is stored seerately store from the image along with Wi-Fi demands that could possibly interfere with Glass are two key concerns.

Google Glass, which could bring even more sophistication and even greater timeliness to care communications, according to Dr. Rafael Grossmann who became the first surgeon to use Google Glass in the operating room this past June. Expect to see Google Glass in the ER and exam rooms in the near future.

Featured image credit: The Ohio State University Wexner Medical Center

UCSF First in Nation For Approval To Use Google Glass in Surgeries by Jasmine Pennic

#### Google Glass Startup Augmedix Nabs $3.2M to Rehumanize the Doctor-Patient Interaction Google Glass startup Augmedix announced today it has raised$3.5 million in venture funding from DCM and Emergence Capital Partners to rehumanize healthcare through Google Glass. With 36 employees, the startup announced that it will be moving into their own 7,000-square-foot office in San Francisco’s Mid-Market neighborhood.

Founded by Stanford grads CEO Ian Shakil and Chief Product Officer Pelu Tran in 2012, Augmedix – a service powered by Google Glass — reclaims the hours physicians spend on the computer entering or retrieving data from electronic health records and refocuses them on what matters most: patient care.

Augmedix uses Google Glass to seamlessly push information to most major Electronic Health Records

Augmedix plans to utilize the capital to expand its growing team and scale up its efforts to reach outpatient doctors across the nation. After completing several successful pilot studies, the startup is already generating revenue with a select number of healthcare providers.

Ian Shakil, Augmedix CEO

“Doctors spend more than 1/3 of their day on the computer, inputting or retrieving data from electronic health records. The amount of data and documentation is overwhelming. Powered by Google Glass, Augmedix rehumanizes the doctor-patient interaction by delivering patient satisfaction, doctor efficiency, doctor satisfaction and health record quality.  Augmedix reclaims the majority of the time that would otherwise be spent feeding the beast,” said Shakil, referring to the time that doctors spend on the EHR.

“The Augmedix pilots also demonstrated high levels of patient satisfaction with the service. This is a testament to Augmedix’s investment in the patient experience. The company educates each patient about the service and gives each the opportunity to decline if he or she so desires. Patient acceptance and satisfaction has been resoundingly high throughout the country — from San Francisco to rural areas,” “added Shakil.

The startup is a graduate of Rock Health, a San Francisco-based digital health seed fund. Augmedix has established a host of other service partners, including Cooper, Fenwick & West LLP, PLC, Schox, Stanford Venture Studio, and others.

Google Glass Startup Augmedix Nabs $3.2M to Rehumanize the Doctor-Patient Interaction by Fred Pennic  Keyword(s): Google GlassRehumanizeDoctor-Patient Interaction #### Reduce Healthcare Supply Chain Costs for Providers #### 10 Ways to Reduce Healthcare Supply Chain Costs for Providers GHX outlines a list of documented opportunities to reduce supply costs healthcare supply chain costs for providers. The healthcare supply chain is the second highest and fastest-growing operating expense for healthcare providers. Faced with significant medical supply costs and evaporating reimbursements, healthcare are increasingly seeking ways to reduce their supply chain expenses. GHX, provider of healthcare supply chain solutions has provided the following ten ways healthcare providers can reduce healthcare supply chain costs: • 1. Understand the total cost of ownership of your supply chain;in addition to the price paid, consider the financial implications of procurement, logistics, inventory management, charge capture and reimbursement, among others. • 2. Develop data governance policies and synchronize product data with suppliers (using global industry data standards as much as possible) to help ensure that your item master is up-to-date and can be used as the “one source of truth”to feed clinical and financial IT systems. • 3. Reduce manual invoice reconciliation by having line level PO-to-invoice match on implant purchase orders. • 4. Streamline electronic medical record (EMR) system roll-out and maintenance by using up-to-date, clean, accurate data. • 5. Save an average$12.00-$27.00 per order by improving data synchronization and conducting as much of your purchasing electronically with as many of your trading partners as possible. • 6. Improve contract effectiveness by loading group purchasing organization (GPO) and local contracts into your purchasing system and validating price at the point of purchase order creation. You can save an estimated 1-3 percent in avoided overpayments by validating contract pricing and using the most up-to-date contract information. • 7. Centralize purchasing across your organization to provide visibility into and control over as much of your supply spend as possible. • 8. Create visibility into both the total cost and efficacy of the products being used in patient care, so that you can determine the role supplies play in improving cost, quality and financial outcomes (e.g., reimbursement). • 9. Focus on bringing more non-file and off-contract spend under contract, especially high-cost implantable device items;but don’t forget other spend, such as products purchased by facilities and engineering that have an impact on the environment of care. • 10. Collaborate with your trading partners to achieve mutual benefits. Share insights into what happens to products once they arrive at your facility and ask your suppliers for insights into how you can become a lower-cost customer to serve. photo credit: Best In Plastics via cc 10 Ways to Reduce Healthcare Supply Chain Costs for Providers by Jasmine Pennic Link: http://hitconsultant.net/2014/08/06/10-ways-to-reduce-healthcare-supply-chain-costs-for-providers/  Keyword(s): HealthcareSupply Chain #### EMRs Are First Source For Population Health Management Functionality for Providers #### KLAS: EMRs Are First Source For Population Health Management Functionality for Providers by Enterprise EMR vendors are the number-one source for population health management functionality, according to the latest KLAS report. The latest KLAS report “Population Health 2014 Perception: Who Are Providers Betting On?” found that despite a veritable flood of new best-of-breed entrants into the marketplace, providers are having an increasingly hard time finding a one-stop PHM solution. For the report, KLAS spoke to 105 provider organizations across the country about their population health solutions and their future plans surrounding this segment. These providers mentioned a total of 69 vendors as currently playing a role or being considered for the future. “With so many new vendors and solutions, it is getting increasingly confusing for providers to know which vendors in the population health market can help deliver their needed functionality,” said report author Mark Allphin. “The dream of the one-stop shop that meets all of population health’s needs is not yet a reality, but some providers have told us that they hope their enterprise vendor will eventually be that one-stop shop.” To learn more about the population health marketplace, check out the full “Population Health 2014 Perception: Who Are Providers Betting On?” report at www.KLASresearch.com/KLASreports KLAS: EMRs Are First Source For Population Health Management Functionality for Providers by Jasmine Pennic  Keyword(s): EMRsSourcePopulation Health Management FunctionalityProviders #### Sustainable Population Health Management Program #### Keys to Implementing a Sustainable Population Health Management Program by White paper from Siemens examines some of the critical success factors for a sustainable population health management program. Population health management (PHM) has become and will continue to be a top priority for healthcare providers as the industry shifts from the current fee-for-service to new value-based purchasing models. Provisions of the Affordable Care Act (ACA) are driving the adoption of these models, which are designed to improve the quality of American healthcare, while large employers and other payers across the country are also establishing new value-based purchasing models. Delivery of high-value, cost-effective care requires a focus on—as well as a new approach to—population health management. By coordinating the care of a population across the continuum, healthcare providers can deliver improved quality at decreased costs, and share these benefits with their partners in models such as accountable care organizations (ACOs). Performance-based contracts enable providers to gain additional revenue if they meet quality standards. Similarly, by using PHM strategies to reduce hospital readmissions, healthcare providers can avoid costly penalties under the Centers for Medicare and Medicaid Services’ Hospital Readmissions Reduction Program. With great potential to deliver a return on investment across multiple federal programs and quality-driven initiatives, PHM is a critical component in today’s healthcare transformation. In order to execute on this enormous and complex undertaking, , however, healthcare organizations must develop and implement PHM strategies that leverage healthcare information technology to successfully manage the unique health needs and risks factors of an increasingly diverse population. This new shift requires strategies and tools for PHM to evolve toward more efficient and consistent management of an entire population in order to help providers achieve quality and cost objectives as well as keep patients engaged in their wellness. So what are the keys to implementing a sustainable population health management program? This white paper examines some of the critical success factors for a sustainable population health management program and how the CareXcell™ solution can provide the IT infrastructure needed to address new value-based care requirements. Download the white paper below to learn more. Know when, why and how your current EHR platform may fall short of delivering a transformative community of care—and develop a new value-based care model that elevates population health and grows revenue across your organization. • Click here to discover how MEDHOST YourCareCommunity can help enhance patient and physician experience, engagement and value. This IDC Health Insights white paper, sponsored by Imprivata, presents key findings of interviews with three healthcare IT executives at Atlantic Health System, Carolinas Pathology Group, and Beaufort Memorial Hospital regarding the deployment of Imprivata Cortext, a secure communications platform. Consistent findings across the three healthcare organizations are as follows: ease of use leads to quick clinician adoption, there is broad application of secure communication across various hospital workflows, and instant communication can save time for care team members and can improve collaboration. Read this report to learn more about how these organizations streamlined clinical workflows such as patient admission notifications, specialist referrals, pathology consultations and code team activations. Detecting and preventing errors that threaten patient safety is a closed-loop process that begins at the point of care, extends to independent laboratories, and then back to the caregiver. Download to learn more! Healthcare providers face an urgent, internal battle every day: security and compliance versus productivity and service. For most healthcare organizations, the fight is an easy one: Providing quick, high-quality care wins every single time. To prepare for value-based care models, Mercy Health System uses interoperable solutions to attest for Meaningful Use, implement 24 ACO clinical quality measures in three months, and achieve PCMH Level 2 Certification in eight sites. With a healthy EHR core, Mercy is prepared for future growth. Maximizing patient safety and improving the quality of care is the ultimate goal for healthcare providers. Doing so requires staying within regulatory compliance, while also advancing staff retention and meeting fiscal constraints. Barcode technologies provide a “virtual voice” to patients, applications and workflows. Barcoding accomplishes this by laying a solid foundation for enhancing patient identification, providing visibility into medical practices, and driving efficiencies throughout healthcare applications, and is an integral part of electronic medical record (EMR) adoption. Download to learn more! Efficient communication and collaboration amongst physicians, nurses and other providers is critical to the coordination and delivery of patient care, especially given the increasingly mobile nature of today’s clinicians and the evolution of the accountable care organization (ACO) model. Download to learn more! This case study focuses on the implementation of single sign-on at The John Hopkins Hospital which streamlined provider access to applications. Optimizing revenue cycle performance has become even more critical for practices. Especially with today’s changing healthcare landscape of ICD-10, consumer-directed health plans, and declining reimbursements. Our new eBook “Seven Revenue-driving Best Practices of Successful Healthcare Organizations” will help you identify opportunities to take control of your revenue cycle and get paid every dollar you deserve.  Keyword(s): SustainablePopulation Health Management #### Role of Claims Data in HealthIT #### The Role of Claims Data in HealthIT: The Good, The Bad and The Ugly by As we move towards building a universal patient-centered data platform in health IT, several sources of data are useful. Data coming from transitions of care, clinical summary documents (C-CDAs) which can be shared between healthcare providers taking care of a patient, and claims data from insurance payers – these are all sources of data that can build the universal health record. With all the focus in interoperability discussions around sharing data found in clinical Electronic Health Records (EHRs) and sharing them in some way between disparate systems, we have lost sight of the potentially important role of health plan data. It might serve well to consider the pluses and minuses of this data, in order to best understand where it might fit in. #### The good Health plans have been keeping data based on insurance claims that they have paid for many years. Their historical archives will therefore pre-date the information found in clinical EHR systems in hospitals and doctors’ offices, since EHRs are a relatively recent arrival on the healthcare scene. Therefore, one advantage of health plan data is that it has longitudinal depth. Another advantage of this type of data is that is collects information from all the different parties that have submitted bills for a given patient’s care – all the different doctors, hospitals, laboratories, imaging centers, pharmacies, etc. Thus, a second advantage is that health plan data is multi-sourced, irrespective of what each biller uses to send claims. Such data can, then, help determine who is the care team taking care of a given patient, so that a patient-centeredhealth record can show the involved providers in a hub-and-spoke fashion. The kind of information sent on a bill to a health plan is limited in scope, but still valuable. Clinical notes, vital signs, allergy lists, etc., are not things that appear on bills. What does appear, however, are procedure codes (CPT codes) and their associated diagnosis codes (ICD-9 codes). Prior to 2012, up to 4 different ICD-9 codes could be associated with each CPT code in a bill (the 4010 standard), but since then the new standard (the 5010 standard) allows up to 12 different diagnosis codes to be associated with each procedure code line. There is considerable incentive for medical providers to use as many diagnosis codes as are appropriate on their bills. Medicare’s HMO offering, Medicare Advantage, will pay contracted private insurers a per-member-per-month premium that is adjusted on how “sick” their enrollees are. This is determined by HCC codes, which weight the level of acuity of a given patient based on their health conditions, and is determined by ICD9 codes found on their bills. Therefore, for those participating in Medicare Advantage plans, there is considerable incentive to be as complete as possible in capturing all the patient’s diagnoses in their billing every single year. Thus, another advantage to health plan data is that the Problem List for a patient, especially when it is incentivized in an environment of maximizing HCC coding, is robust (as well as multi-sourced). #### The bad Many important elements of a patient’s record are not captured in bills. There has been an attempt to capture certain clinical items used for Clinical Quality Measures – such as blood pressure ranges for diabetic patients, or other similar clinical data points – using claims. Medicare has introduced CPT-II and otherHCPCS codes which are zero-dollar codes intended to submit clinical information to Medicare and other payers, for use in certain pay-for-performance programs such as PQRS. Such data could be helpful in building a clinical record, but the use of these codes in billing is spotty at best. After all, they are non-payable codes, and represent a coding burden to providers. In addition, there are other non-claims-based methods of submitting quality measures to PQRS and Meaningful Use, so the absolute need to use these is not compelling. Thus, a major weakness of claims data is its incompleteness, particularly when it comes to reporting data important for Clinical Quality Measures. The other weakness from health plan data is that patients often will switch health plans frequently over time. It is rare for an individual to keep the same health insurance their whole life. Therefore, in order to build a complete patient data record over time, data would need to be obtained from each different health plan that they were covered under, since no one plan would likely provide the whole story. #### The ugly Health plan data may be accurate when it comes to identifying who has taken care of the patient, when certain procedures were done, when the patient was hospitalized, and when medications were dispensed. But diagnosis data can be inaccurate, largely based on source. Community physicians in their offices are often directly involved in declaring the diagnoses on their claims. This is especially true for those involved in HCC environments. Diagnosis data from outpatient claims, therefore, are the most likely to be accurate. In hospitals, billing is generally done by billing staff, and diagnoses are extracted from examining the record rather than by the physicians themselves. A degradation of diagnosis-coding accuracy is inherent in this arrangement. In addition, hospital bills are often bundled, or paid globally based on Diagnosis Related Groups (DRGs), so individual ICD9 codes are often not relevant. Therefore, problem lists built from hospital-based claims can be quite inaccurate. As famously chronicled in 2009 by e-Patient Dave’s efforts to put his medical records on a PHR, he found widespread inaccuracies in his problem lists as recorded by the hospital’s system. Granted, such systems have improved in the past 5 years, but the point is that hospital diagnosis data can harbor many inaccuracies. Perhaps the worst source of diagnosis data is from laboratory claims. Often, a diagnosis is placed on a lab order form simply to make sure the needed test is paid. The concurrence between the diagnosis submitted on a lab order and the diagnoses in a physician’s EHRs is less than 100%. #### Using claims data Insurance companies, in their efforts to keep their enrollees healthy and avoid unnecessary costs, spend considerable efforts identifying “gaps in care.” These can be from lapses in filling of maintenance medications, to suggesting medications that are appropriate for the conditions the patient seems to have but is not on (such as asthma controllers, or ACE/ARBs for diabetics). These kinds of alerts are sent to physicians daily, at considerable cost, often by fax. And entirely based on claims data. And often ignored by physicians as an “annoyance” that does not fit well within their already-overburdened workflows. Clearly, insurance companies look to the data within their own data silos, and try to make the most of it. For all the good, bad and ugly of it, it remains actionable data. Perhaps the best way to look at claims data, as a potential source for building universal patient records, is as a supplement to data from other sources. There are distinct advantages to insurance-based information, and there are distinct shortcomings as well. Why would insurance companies share any of their data? Two reasons: 1. Like health providers and healthcare clearing houses, health plans are HIPAA Covered Entities. They can share their data for the purposes of healthcare, governed by the rules of HIPAA. As a covered entity, just like healthcare providers, if a patient requests their records, then they must be provided within 30 days (per the HIPAA Final Rule of September 2013). Though this is currently seldom done (most requests for data are directed at care providers rather than health plans), it is possible that such requests might increase in the future. 2. Insurance companies already spend large sums on their “gaps in care alerts” efforts, which struggle with low effectiveness. Partnering with outside sources of data can allow them to more effectively identify the right patients needing the right alerts, and present them to the right doctor taking care of them in a way that integrates with (rather than distracts from) the ordinary workflows of healthcare. Claims-based data from health plans represent a source of data that can supplement a universal health record. It is part of the larger puzzle, and serves a useful role. Dr. Robert Rowley is the Co-Founder and Chief Medical Officer of Flow Health, a next generation communication platform for care teams and patients, facilitating transitions of care, and aggregating patient-centered data from all the sources where it is found. From its inception through 2012, Dr. Rowley had been Practice Fusion’s Chief Medical Officer, having created the underlying technology in his own practice, and using that as the original foundation of the Practice Fusion web-based EHR. photo credit: urbanbohemian via cc Link: http://hitconsultant.net  Keyword(s): RoleClaims DataHealthIT #### Applying Automation to Healthcare #### 6 Big Benefits of Applying Automation to Healthcare James Dias, Founder & CEO at Wellbe shares six big benefits that can be realized by applying automation to healthcare for overall cost reduction and efficiency. Three out of four hospital and health systems CEOs cite overall cost reduction and efficiency as one of their top two financial priorities, HealthLeaders recently reported. With the healthcare industry continually looking to cut costs and waste and improve efficiency and throughput, automation of manual tasks can be an important part of a strategy for performance improvement. Automation is defined as the use of control systems and information technologies to reduce the need for human work in the production of goods and services. The introduction of the assembly line at Ford Motor Company in 1913 is often cited as one of the first forms of automation. With this innovation Ford achieved a dramatic reduction in the time to produce a car from 12 hours down to 1.5 hours! Now automation surrounds us every day in our lives, including automated teller machines (ATMs), Redbox DVD rentals, self-checkout at the grocery store, cellphone-controlled thermostats, auto park assist in vehicles, and many more routine activities managed by technology. Despite its use for years in banking, retail and other industries, healthcare has lagged behind in its use of automation. The recent pressure from healthcare reform and increased competition is driving a heightened interest to reduce costs and eliminate waste in healthcare delivery. And that has brought the adoption of automation to the spotlight. An aging population along with more people in the healthcare system will require more care, and staffing levels in healthcare will not be able to keep up. In the July/August 2009 issue of Health Affairs, Dr. Peter Buerhaus and coauthors found that despite the current easing of the nursing shortage due to the recession, the U.S. nursing shortage is projected to grow to 260,000 registered nurses by 2025. A shortage of this magnitude would be twice as large as any nursing shortage experienced in this country since the mid-1960s. The looming shortage of RNs demands efficiency and the elimination of redundant work and manual tasks. John Dragovits, chief financial officer of Dallas-based Parkland Health & Hospital System, toldHealthLeaders in 2012: “If you look at an average hospital’s financial statement, 50%-60% of their expenses are salaries and benefits. By definition healthcare is an inflationary model, but it’s exacerbated by the fact that everyone wants to hire more people rather than think about how they can live with fewer people… The challenge in this industry has always been getting people excited and intrigued and rewarded for looking at things innovatively and using technology to do things quicker and cheaper.” Once the industry transitions to population health, automation goes from a “nice to have” to a “must have.” There are not enough care providers to continuously monitor and check in with large patient populations for this new model of care. A report by the Institute for Health Technology Transformation says, “Automation makes population health management feasible, scalable and sustainable.” Automation is often linked to a negative connotation in association with the loss of jobs in manufacturing industries. When automation and robotics were first introduced into the pharmacy, some feared it would be the end of pharmacists, with robots taking the place of human workers. However, ultimately it let them get rid of medication counting tasks that required little cognitive value, and instead let them focus on more clinically-relevant work for productive and rewarding work time. Critics also point out that automation can’t replace doctors and nurses. And they are correct. However, automation can be blended in to their workflows to make a wide swath of care delivery processes much more efficient and to improve productivity. Patient engagement, for example, can get a big boost from automated check-ins and reminders. Here are 6 big benefits that can be realized by applying automation to healthcare: 1. Labor Savings Using automation to replace manually intensive tasks that are better done by machine can be a big time saver. It doesn’t have to eliminate employees, but rather elevate them into higher-functioning roles that make use of the clinical expertise they have been trained for. 2. Improved Quality and Consistency Automation tools are not subject to human error or fatigue, so they can help provide a consistent basis of care activities. A Texas hospital study found that greater automation in the areas of medical records, order entry, and decision support appeared to result in a reduction in deaths, complications and cost. 3. Reduced Waste Use of paper and spreadsheets and other workarounds needed for an overfull workload can lead to a lot of waste. For example, rather than playing phone tag with a discharged patient in the free minutes between hospital nursing duties, automation can help get nurses and patients connected more efficiently. 4. Increased Predictability of Outcomes When patients follow a standardized care path supported by automation, it is more likely they will stay on track towards predicted outcomes. Additionally, automation can help detect when a patient has deviated from the recommended care plan so the care team can intervene. 5. Higher Throughput A nurse supported by automation tools can handle a larger population of patients at one time. Instead of scaling up and down your headcount as patient volumes grow and shrink, an automated platform can scale flexibly to address groups of all sizes. 6. Data-Driven Insights Technology used to automate processes can also deliver a wealth of data in a continuous feedback loop that can be used for performance improvement and optimization. With every cycle, automation systems can collect data on how the process is working and use that information to improve the program. This way it improves on itself over time, becoming even more efficient, more accurate and more helpful to the team’s workload. When looking for good areas to apply automation in your healthcare environment, a standardized, repeatable process is the first thing to look for. Within hospital walls, a common procedure that is performed on a large population of patients on a routine basis, like joint replacements, is a prime area to apply automation tools. Ask yourself this question: Which program would you rather have? Program A: • 3 full-time nurse navigators working the phone 10 hours a week with lots of spreadsheets to move patients through their episodes of care • Very little quantified feedback data • Patients that are highly dependent on your staff for everything in the course of their treatments and care Program B: • Patients using self-service tools to manage their care from home, with alerts when they go off track • Two half-time nurse navigators (1 FTE) working off a risk-based, prioritized patient list • On-demand actionable feedback to see how your program is working in real time Between programs A and B, automation is what makes the difference. So the next time you’re ready to tackle a new process and realize you need to hire 3 more FTEs to support it, first do a gut check and see if there’s a better way to do it through automation. James Dias is the Founder & CEO at Wellbe where he leads innovations program to empower people and providers with new tools to improve health. He is also the co-inventor of the Patient Guidance System. 6 Big Benefits of Applying Automation to Healthcare by Jasmine Pennic Link: http://hitconsultant.net/2014/07/21/6-big-benefits-of-applying-automation-to-healthcare/  Keyword(s): AutomationHealthcare #### Project Planning Templates for the CIO #### Project Planning Templates for the CIO Sample project scope and technology roadmap documents Successful IT project planning requires today’s technology leaders to document project scope and define a technology roadmap. This e-guide compiles a complimentary collection of downloadable templates, hand-picked by the editors of SearchCIO.com, that serve as a model for success –and that help you fine-tune your short and long-term IT objectives and stay on track throughout all stages of your initiative. Please read the attached whitepaper.  Keyword(s): CIOPlanning Templates #### De-identification effective in maintaining patient privacy if done right #### De-identification effective in maintaining patient privacy if done right By Katie Dvorak As hospitals and healthcare organizations adopt new ways to store and share data, privacy and security of the information is a top priority--and with that comes de-identification of data. When it comes to HIPAA, there are two standards that allow for the sharing of data while maintaining privacy protections, according to privacy attorney Scot Ganow and Khaled El Emam, senior scientist at the Children's Hospital of Eastern Ontario Research Institute, both of whom spoke with HealthcareInfoSecurity.com. The first HIPAA method for de-identifying data, according to Ganow, of Faruki Ireland & Cox, is to strip out the data and identifiable elements, though, he added that doing so doesn't offer a lot of value. The second, he said, is to de-identify data through the expert determination standard, which allows researchers to "retain a lot of the value of the info ... [while] at the same time carrying a very low risk of re-identification." Emam, who also serves as the director of the multidisciplinary Electronic Health Information Laboratory at the Children's Hospital institute, also emphasized using the expert determination method, saying it allows for more flexibility. He told HealthcareInfoSecurity.com that not every organization uses the standards, and in those cases, the data won't be protected. In addition to HIPAA, the Federal Trade Commission also has de-identification standards, including that an organization takes reasonable steps to de-identify protected data and announces that re-identification of data will not occur. However, some are not sure that de-identification goes far enough in protecting patients. Some studies have shown the possible ease with which de-identified data can be linked with a patient, including one by Harvard University researchers who were able to identify and link anonymous participants in a public DNA study with their personal data. And while HIPAA specifies how data should be de-identified, a report by the Bipartisan Policy Center maintains that too much variability exists in the execution of anonymization. Emam, though, said that if the process is done right, it is very difficult to re-identify data. He stressed that problems occur when organizations do a "lousy job" with de-identification, and that makes it easy for someone to reverse. To learn more: - listen to the HealthcareInfoSecurity.com interview Related Articles: Read more about: Federal Trade Commission, Deidentification  Keyword(s): De-identificationPatient privacy #### Majority of Physicians Remain Happy with Career Choice #### Majority of Physicians Remain Happy with Career Choice Of the 1,311 physicians taking our 2014 Great American Physician Survey, Sponsored by Kareo, 8 in 10 said they still like being a physician. Furthermore, given the choice to change history and choose another path, 56 percent said thanks, but no thanks. Here's more data on the ups and downs of being a physician from this year's survey.  Keyword(s): PhysiciansCareer Choice #### States Could Soon Require Random Drug, Alcohol Tests for Docs #### States Could Soon Require Random Drug, Alcohol Tests for Docs By Ericka L. Adler I recently spoke with a physician seeking guidance concerning a colleague in her office she believed might be impaired by drugs. She was alarmed at the risk this posed to patients, as well as her practice’s liability, and wanted to report the physician to her superiors. In this particular case, we decided together there was insufficient factual knowledge of any wrongful activity to support my client taking action, without further evidence. As I have discussed before, presenting information to a third party without factual evidence, when such information can be damaging, will open a physician to liability for defamation. Because physicians are typically afraid to report their suspicions, and can actually face liability for doing so, how should physician drug use in the workplace be addressed? Given the subversive habits of drug users, how can practices catch physician drug-users before a patient is harmed, and do so in a manner that can help a provider receive assistance he may require? The use of drugs and alcohol by physicians is a well-known public health risk. Statistics indicate that physicians are about as likely as the general public to abuse alcohol or illegal drugs, but five times more likely to misuse prescription drugs, according to the University of Florida’s Center for Addiction Research and Education. In a profession where clear thinking, decision-making, and a steady hand are all essential tools, physician drug use is a grave concern. To address this growing problem, experts around the country have argued that it’s time physicians, like others who have roles affecting public safety, be randomly drug and alcohol tested. After all, why are physicians treated differently than pilots or bus drivers when they all have jobs that can hurt innocent victims? California is taking a stab at addressing the problem of physician drug use, and will present its residents with the issue of random physician drug testing on a ballot this November, known as “Proposition 46.” Apparently many in the medical industry don’t like Proposition 46, and The New York Times reports that the medical industry, including doctors, hospitals, and medical insurance companies, have already raised more than$35 million to defeat it.

The problem with Proposition 46, in particular, is that the motivation for the measure appears to be driven by lawyers.  In fact, the proposed law would mainly impact the malpractice industry, increasing the ceiling for pain and suffering awards in medical negligence suits from $250,000 (set by the State legislature in 1975) to$1.1 million to reflect inflation.

Under this new law, results of random drug tests on doctors would also be reported to the California Medical Board and hospitals would be required to report the names of doctors suspected of abusing drugs or alcohol.

It’s important to note that those who oppose Proposition 46 do not necessarily believe that drug testing of physicians is inappropriate, just that it should not be applied in the manner developed by California state trial lawyers.  Instead, it should be focused on helping impaired physicians and protecting patients in a manner that physicians and others in the industry can support. This requires some thoughtfulness in developing an acceptable approach, which many believe Proposition 46 lacks.

There is no doubt that an issue of drug and alcohol abuse in the medical profession exists.  The vote in California will be important in how it impacts other state laws around the country.

 Keyword(s): Random Drug Alcohol TestsDocs

#### Seven Principles that Can Help Stressed Out Physicians

By Carol Stryker

Physicians are busy. They often have little time for friends and family, have no time for the community, and seldom feel as though they have covered all their bases. Their lives have way too much in common with a hamster in a wheel.

Still, there are some things physicians can do to experience improved work-life balance. Here are seven principles to keep in mind next time you feel like your sense of balance is spiraling out of control:

1. Acknowledge and accept the fact that time is limited and there is no way to create more. This fact is both mind-numbingly obvious and generally ignored. Time can be made more productive but it cannot be increased, and there are upper limits on productivity.

2. Accept the fact that there will never be enough time.  The only people who never run out of time are lethargic and unimaginative, the antithesis of most physicians. Some tasks and interests have to be abandoned forever, while others will simply need to wait their turn.

3. Be intentional about the use of time, and be aware that it involves choices as well as decisions. Deciding to do something is deciding not to do something else. The decision is a choice, a corollary to the principle that two things cannot concurrently occupy the same space. The challenge is to distinguish between the urgent and the important, as well as the important and the less important. Without intention, priorities tend to be clear only in retrospect when different action is impossible.

4. Abandon guilt about what is not getting done. If you are making good use of your time and investing it in what is most important to you, there is no reason to feel guilty. You may wish you could do it all, but you must realize you bear no responsibility for an immutable law of nature.

5. Seek alternate resources. Nowhere is it written that you must do everything. If something essential is not getting done, find a way to delegate it.

6. Refuse to be bullied. This is particularly difficult because many physicians have so routinely been bullied during their training. When someone demands more research, more revenue, more whatever than is reasonably possible, push back and negotiate the demands. (I am not oblivious to the fact that this may involve finding another job or practice. You need to weigh the pros and cons.)

7. Do not engage in self-bullying. This kind of bullying may be the most common. Physicians have a tendency to be driven, and to be offended at the notion that they must make trade-offs. Unchecked, it leads to serious over-commitment, stress and, eventually, burnout.

Now that you have read the above, the key is applying these principles to your daily life. To help, I've provided an example below. Take a look, while it may not apply directly to you, it will get you thinking about some ways you may be able to improve your own work-life balance.

To help other physicians identify similar opportunities, I encourage you to share your thoughts in the comments section below.

Example: Dr. Jones is a mid-30s cardiologist with a wife and three small children. He loves soccer and biking. The family is anxious to retire its debt, build its dream home, and live the life they have been planning since the beginning of medical school. At present, Dr. Jones is feeling very stressed.

In order to generate the revenue that will generate the income he needs and feels he deserves, he needs to see about 40 patients a day. The senior partners in the practice refuse to hire a nonphysician provider for him until his numbers are up, and they give him the least experienced medical assistants. There is no way Dr. Jones can keep his schedule on track and do the business development he needs to do to increase his volumes.

His wife is very frustrated, and she lets him know it. She was moderately OK with being broke in school and even training, but she is ready for the struggle to be over. She is also tired of being a single parent and worried that the children do not have enough time with their father. Both money and time with the children are a concern for Dr. Jones, too. He also laments his lack of exercise.

He is constantly pedaling as fast as he can but no one is happy. Things do not seem to be getting better.

Based upon the seven principles above, what can he do?

 Keyword(s): HelpStressed OutPhysicians

#### Why healthcare info governance must be 'proactively managed'

By Katie Dvorak

While working on Wall Street, Laura Zubulake dealt with information convergence and governance, later becoming a key player in landmark opinions on preservation of electronically stored information. In an interview published this week in the Journal of the American Health Information Management Association, Zubulake spoke about her experiences and how they translate to healthcare.

The patient care industry shares many similarities with both the finance and banking industries, Zubulake told the Journal of AHIMA. Much of her work on Wall Street likely mirrored that of health information management professionals, Zubulake said, particularly when it comes to electronic health records.

"It is important for HIM professionals to become knowledgeable about all technology at their disposal, how to use it, communicate feedback, demand accuracy, and have patience," she told the Journal of AHIMA.

She also said that information for healthcare organizations is a strategic asset that greatly impacts their ability to advance goals and outcomes. It requires more than just the addition of CIOs, whom she said should not hold sole responsibility of information.

To that end, in AHIMA's fist study on information governance, it found 35 percent of the 1,000 respondents didn't know if their healthcare organization had any information governance efforts underway or did not recognize a need for it.

All levels of management need to endorse that information is as important as other assets, Zubulake said. It must be proactively managed, assembled and secured.

"It should be natural and intrinsic to employee's roles and responsibilities and the organization as a whole," Zubulake told the Journal. "Failure to instill this thinking exposes organizations to significant risks."

 Keyword(s): HealthcareInfo governance

#### Data De-Identification: Getting It Right

Khaled El Emam and Scot Ganow

### Data De-Identification: Getting It Right

#### Listen Now

When patient data is used for secondary purposes, such as research, it must be de-identified. But is this process consistently reliable in protecting patient privacy?

A privacy attorney and an experienced researcher explain in an interview with Information Security Media Group that de-identification is reliable if specific methods, as spelled out under HIPAA, are actually used. Too often, they say, those de-identifying data don't do the job effectively because they fail to follow best practices and standards.

#### Two Methods

Only two methods of de-identification can be used to satisfy the HIPAA Privacy Rule's de-identification standard, explains privacy and security attorney Scot Ganow of the law firm Faruki Ireland & Cox P.L.L.

The "safe harbor" method calls for removing 18 identifiers from patient information, including patient names, ZIP codes, Social Security numbers and birthdates.

The second method, "expert determination," is a more flexible standard that allows professionals to calibrate data de-identification based on the context for which data will be released for secondary purposes, explains Khaled El Emam, senior scientist at the Children's Hospital of Eastern Ontario Research Institute and Director of the multidisciplinary Electronic Health Information Laboratory.

The expert determination method involves using an expert "with appropriate knowledge of and experience with generally accepted statistical and scientific principles and methods for rendering information not individually identifiable," according to federal guidance material on the subject (see De-Identification Guidance Offered).

De-identified data is considered HIPAA-compliant "and defensible" if either of these two-approved methods are used in de-identifying patient data, Ganow says.

Some privacy advocates complain that even HIPAA-compliant methods of data de-identification fall short, creating a risk that patients can be re-identified, especially if mistakes are made in the processes (see Sizing Up De-Identification Guidance).

But El Emam contends that privacy protection problems mainly arise when HIPAA guidance is not followed or is applied improperly. "Another mistake is applying only part of the standards. In that case, data is not going to be protected," he says.

"If you do a poor job with de-identification not based on standards, then it's easy for someone to reverse that. But if you do a good job, it's really hard to re-identify the data," El Emam contends.

One of the top reasons why data de-identification is sometimes done improperly is that there's a shortage of skilled individuals who know how to de-identify data according to best practices and standards, El Emam says. "There's a need to increase the pool of individuals who can do this work, he says.

#### Not Foolproof

But no method of de-identification is guaranteed to be 100 percent perfect. "When applying data de-identification methods in accordance to HIPAA, the standard is to have a very low risk of re-identification as opposed to saying something is completely de-identified," Ganow says. De-identification "doesn't happen in a silo. You have to think about: Who am I giving the data to? What's the purpose? What agreements and security do I have in place? It's not a silver bullet."

In the interview, Ganow and El Emam discuss:

• Why de-identification is important to managing risk and ensuring patient privacy;
• How the identities of patients with unusual and rare diseases, such as Ebola, can be protected;
• How a shortage of skilled individuals is contributing to poorly de-identified data and why training programs and professional certifications can help.

Ganow is an attorney in the Dayton office of Faruki Ireland & Cox P.L.L. He had more than 10 years of corporate and compliance experience in Fortune 500 companies prior to becoming an attorney, including serving as a chief privacy officer for healthcare and pharmaceutical informatics companies. Ganow also holds the Certified Information Privacy Professional certification; has presented and written extensively on the topics of data protection and de-identification.,In addition to his work at the Children's Hospital of Eastern Ontario Research Institute, El Emam is founder and CEO of Privacy Analytics Inc., which offers enterprise software to safeguard data used for secondary purposes. Previously, Khaled formerly was a senior research officer at the National Research Council of Canada. He holds the Canada research chair in electronic health information at the University of Ottawa and is an associate professor on the faculty of medicine at the university. He has a PhD from the department of electrical and electronics engineering, King's College, at the University of London, England.

### SaaS application development on PaaS: 5 steps to reduce risk

by Judith M. Myerson

#### Developers need only follow these five steps to mitigate the risks of SaaS application development.

AWS Elastic Beanstalk (beta) is a useful tool for cloud architects and developers who want to deploy, monitor and scale Web applications quickly, on an as-needed basis. All they have to do is upload a code and let Elastic Beanstalk automatically handle the deployment -- from capacity provisioning, load balancing and autoscaling to application health monitoring. At the same time, they can retain full control over the AWS resources powering the application. They can even use the Elastic Beanstalk console to access the underlying resources at any time.

That said, developing Web applications on platform as a service (PaaS) comes with vulnerabilities. Threat agents include hackers, software design flaws or poor testing methods. These can take advantage of vulnerabilities in order to infect or halt the application.

By mitigating the risks of SaaS application development on PaaS, cloud architects and developers become more aware of the significant threats to their application. These insights can then contribute to higher return on investments, simply by implementing cost-effective safeguards. They also can reduce the costs of disaster recovery by reducing the frequencies of vulnerability exploitation.

Here are five steps to start reducing your risks:

• Identify assets
• Identify vulnerabilities and threats
• Assess risks
• Fix with safeguards
• Implement risk mitigation policy

#### Step 1. Identify assets

Identify assets associated with software-as-a-service (SaaS) applicationdevelopment on PaaS, then assign a value to each asset. Determine the categories where the assets should belong. Here are some examples:

Users: SaaS developers and SaaS users would both fit into this category. The value of each user group should be based on the average number of man hours spent in developing and testing the application.

These insights can then contribute to higher return on investment, simply by implementing cost-effective safeguards.

Resources: These are any resources that are used by PaaS developers to run and store the SaaS application. For example, Elastic Beanstalk leverages Amazon Elastic Compute Cloud (EC2),Amazon Simple Storage Services, Amazon Simple Notification Service,Amazon CloudWatch, Elastic Load Balancing and Auto Scaling. The value is based on pay-as-you-go for these resources.  Elastic Beanstalk is free.

Security: This could mean encryption mechanisms, firewalls and industry security standards, including SecaaS (security as a service). The value is based on the man-hours used to implement security.

Documentation: Training manuals, administration guidelines, security standards, network standards, contingency planning, disaster recovery plans and service-level agreements (SLAs) are just a few examples of documentation. The value is based on the type of media used to publish the documentation -- print, online or digital media (CD).

Software: Operating systems; vulnerability testing tools; office tools (documents, spreadsheets, presentations); log analyzers; and programming languages (Java, .NET, the PHP script language, the Node.js programming language, Python and Ruby) would all qualify as software. The value is based on the purchase price or the pay-as-you-go subscription needed to develop the SaaS application on PaaS.

#### Step 2. Identify vulnerabilities and threats

Hackers are not the only threat agents who could take advantage of PaaS vulnerabilities. Here are other examples of threat agents:

• Software design flaws could let in malicious SQL injections.
• Improper access control configurations could result in theft of the sensitive data the application is processing for storage.
• Improper firewall configurations could result in accidental PaaS outages.
• The vulnerability of data recovery due to the cloud characteristics of pooling and elasticity. This means resources allocated to one user would be accidentally reallocated to a different user. It is not always possible to recover data from a previous user.

#### Step 3. Assess risks

Users want to be assured that PaaS will be available continuously and that their demand for more traffic can be met. One method of assessing the risk of unavailability is quantitative. Some examples include:

• Estimated frequency per year that the PaaS would become unavailable due to infrastructure as a service (IaaS) outages
• Estimated frequency of PaaS attacks due to improper firewall configurations
• Estimated frequency of not meeting performance guarantees set forth in an SLA
• Estimated frequency of unsuccessful failover of network routers and switches that the support the IaaS on which the PaaS runs.

#### Step 4. Fix with safeguards

Implementing cost-effective safeguards is one way to mitigate the risks of SaaS application development on PaaS. Here are some examples:

• The application has been properly designed with no software flaws. PaaS developers and cloud architects have the adequate skills and instructions to develop well-designed applications on the PaaS.
• Access control configurations have been properly configured for users based on their different roles and/or data sensitivity. The logging option has been activated.
• Firewalls have been properly configured. Intrusion detection systems and load balancers are in place. A PaaS failover mechanism policy is enforced. The traffic to and from the PaaS has been encrypted.

#### Step 5. Implement risk mitigation policy

The process of identifying assets, identifying vulnerabilities and threats, assessing risks, and implementing safeguards can vary from one department to another within an organization. To standardize and reduce the cost of the process, a risk mitigation policy should be implemented.

The policy should include the AWS resources, programming languages and servers that are used to develop, run and store the application on the PaaS -- in this case, Elastic Beanstalk -- and how often the policy should be reviewed due to major technology changes, as well as changes in both user and organizational requirements.

In conclusion, have a good team follow the five steps involved in mitigating the risks of SaaS application development on PaaS. A quality group of PaaS developers will help to plan ahead and determine what the cost-effective risk mitigation process should entail.

This was first published in July 2014

#### eGuide: 8 Ways to Stop IT Alert Fatigue

Reacting to a never-ending stream of IT alerts takes up valuable time and resources, costs money, and prevents IT departments from playing a more strategic role in a company's success. Read the eGuide and learn what you can do right now to stop alert fatigue in 8 easy steps so you can begin to focus on addressing your real business needs.

### Edge Consolidation Delivers Peace of Mind for IT

As organizations consolidate backup and disaster recovery operations, WAN optimization plays a key role in mitigating risk without sacrificing performance. Discover a new architectural approach that extends the virtual edge of the data center to the branch for complete server and data consolidation without a performance compromise.

 Keyword(s): Edge ConsolidationPeaceMindIT

### How wearable cameras can help those with Alzheimer's

The wearable camera is being touted as the latest must-have accessory for social-media obsessives, but is a real boon for helping people with serious medical conditions recall important events in their lives.

The Microsoft Research SenseCam has spawned a new generation of technology aimed at tech-savvy twentysomethings.

Some people hang out with their friends on yachts or play pool with pretty girls. Others like to go on treetop zip-wire adventures and holiday on wooded Thai islands. These examples of images on the websites ofAutographer and Narrative Clip, two leading wearable cameras, reveal the kind of things their makers imagine we might do with their devices.

These gadgets automatically snap hundreds of photos per day from their user's perspective. The much-awaited Google Glass, expected to go on general sale within months, will be able to do the same thing. Some believe future historians will peg 2014 as the dawn of the "life-logging" era, in which many or even most of us will carry devices that record images or video of our daily lives.

Beyond the huge privacy implications, the big question is: can this technology improve our lives? For the current market leaders, it is about providing tech-savvy twenty- and thirtysomethings with a way to generate automatically digital photo albums of unprecedented detail and supercharging their social media-sharing capabilities. Some "self-quantifiers" are already using continuous image-gathering as part of personal improvement projects such as losing weight or boosting their productivity.

But such applications are far removed from those envisaged by the technology's early developers, who set out to create visual aids for people with failing memories. And those pioneers may yet be vindicated. Early research suggests that these devices can not only help those with amnesia and dementia recall important events, but may also be able to improve their memory abilities.

One of those innovators was Lyndsay Williams, who probably has the best claim to have been the first to come up with a device capable of taking large numbers of still images automatically. In 1999, shortly after having joined Microsoft Research Cambridge, she attached a digital camera linked to an accelerometer to her bicycle's basket. Her "SenseCam" was designed to take pictures when she was forced to brake hard, in order to capture the details of careless drivers. Williams had temporarily lost six months of memories as a result of being the victim of a hit-and-run road accident aged 17, and she hoped her invention could help others in the same boat. "After that bang on the head I couldn't remember whether I'd been to a concert I had a ticket for or whether I'd done my exams, so I was keenly aware of the frustration of memory difficulties," says Williams, now an independent design consultant. "I also wanted to help a friend who was always losing their keys and their spectacles."

In March 2004, Microsoft filed a patent application for a "recall device" that could help "a victim of Alzheimer's disease and his/her care-giver to reconstruct a portion of the individual's daily activity". Researchers at Addenbrooke's hospital's memory clinic began a collaboration with nearby Microsoft Research in Cambridge to investigate the technology's potential for its patients.

In a case study published in 2007, they revealed that a 63-year-old librarian known as Mrs B, who had amnesia caused by a brain infection, could recall more than 80% of key facts about significant events after a fortnight of reviewing SenseCam images every couple of days and that a similar level of recall persisted for months after she stopped looking at the pictures. This compared with being able to recall just under half of the details using a written diary and no recall at all without either intervention after five days.

Two years later, they published a study in which Mrs B showed increased activity in the parts of the brain linked to experiences associated with time and place, known as episodic memories. They concluded that the device could provide cues that help bring back stored but inaccessible memories, including thoughts, feelings and occurrences not in the images themselves.

Amnesia sufferer Jonathan Eason.

This finding was reinforced by work with Jonathan Eason, a politics student who suffered amnesia, anxiety and depression after being assaulted by two strangers. In the same year, the Addenbrooke's-Microsoft Research group reported that a Mrs W, who had memory problems, was able to recall twice as much detail about events six months old when she viewed streams of SenseCam images over two weeks compared with discussing a written diary for the same amount of time.

The first study involving a number of Alzheimer's patients was published earlier this year by an Addenbrooke's team led by neuropsychologist Dr Emma Woodberry. Six patients with mild to moderate Alzheimer's were able to recall an average of 85% of key factual details about events after a fortnight of viewing SenseCam images every other day. When this was replaced by discussion of a written diary, this fell to 56% and with no intervention it was 33%. Three months later, without any image-viewing, they could still recall an average of just under half of key details, more than three times better than when using a diary.

"Sharing experiences with loved ones is really important to our sense of wellbeing, identity and closeness with the people we love," says Woodberry. "Losing that is debilitating and has a profound effect on your relationships. It's too early to say whether it can slow progression of Alzheimer's, but I think it can improve quality of life in the here and now."

Dr Doug Brown of the Alzheimer's Society believes larger studies are needed. "These findings are interesting but the study is too small to draw any firm conclusions about whether this particular technology is something that we should make widely available to people with dementia, but it's an area that warrants further investigation." His wish could soon be granted: two larger trials are being conducted in France and Portugal.

Others are not only more bullish about the technology's ability to help patients cope day to day, but believe it can have more profound, longer-term effects. A decade ago, Claire, a nurse who lives in Cambridgeshire, awoke from a coma brought on by viral encephalitis, an infection that affects the brain. Then aged 43, she no longer recognised the five people around her bedside as her husband, Ed, and their four children and remembered nothing except some vague childhood memories.

She began using a SenseCam several years ago as part of research led by Dr Catherine Loveday, a cognitive psychologist at the University of Westminster. She uses it most days and views sequences of the images to help her in various situations, such as when she is about to meet a friend. "It can be the oddest little thing in the corner of a picture or somebody's expression that triggers a memory," she says.

"In my friendships, I often feel inadequate because the other person knows about me and the parts of our lives we've shared and I can't remember a single thing about them, their families, or things they might have told me about yesterday. Looking over the images gives me a feeling that I can feel part of our friendship and a tremendous sense of security." Claire is now able to retain recent memories of events as a result of repeated viewings of SenseCam images of them.

'Sometimes, an inventor comes up with the perfect solution but the world isn’t quite ready for it.' Photograph: Katherine Rose for the Observer

Loveday believes pictures from the device help cue recall because they are similar to the snapshots of moments we store and stitch together into narratives to form our natural autobiographical memories. "We think viewing the images in sequence triggers activity in the same brain circuits that were triggered when you first experienced the events and that by doing so repeatedly you can prod the memory into consciousness. I think anyone who has a problem with memory could get a good degree of day-to-day support from using this technology, and, although the evidence is too limited to say for sure at the moment, I think that for some people there is also the possibility that it could lead to recovery of some function."

These encouraging early findings led UK company Vicon Motion to license the technology from Microsoft and launch it in 2010 as the Vicon Revue, a £500 device aimed mainly at people needing memory aids. However, sales were disappointing and it stopped selling the device in 2012. The newer Autographer, marketed more as a visual diary gathering tool, is also based on SenseCam, using sensors to identify action and trigger picture-taking.

Steve Hodges, who leads Microsoft Research Cambridge's sensors and devices group, believes it won't be long before the use of wearable cameras by those with memory loss becomes commonplace.

"Sometimes, an inventor comes up with the perfect solution but the world isn't quite ready for it," he says. "This technology has great deal of potential for those with memory problems and as the devices become more acceptable and commonplace, and they get cheaper and storage and access technologies become more mature, I think we'll see larger trials and more patients using it."

#### A sufferer's story

Their vows were exchanged beneath a potted maple. The bride wore white and the groom a silver waistcoat and a teal tie. Happy by Pharrell Williams was playing as they left the church.

Jonathan Eason suffers from a form of amnesia that means that even though he was the groom in question, these details of his wedding day at St Ives methodist church, Cambridgeshire in May would all have been lost to him within 24 hours without employing techniques to retain important memories. His use of SenseCam has taught him how to recall things by repeatedly viewing images of them.

"I've lost so many memories and forgetting my wedding day was one of my greatest fears," he says. "It's such a special memory and knowing that it is one I can keep, talk about and share with other people makes me very happy."

Eason, 33, suffered severe head injuries in an unprovoked attack by two strangers while celebrating his 21st birthday in Cambridge. He was about to start his third year studying politics at Queen Mary University of London. The assault left him suffering significant memory impairment, attention problems and anxiety. A subsequent car crash made matters worse, causing low self-esteem, panic attacks, depression and agoraphobia.

Eason first used SenseCam in 2006 as part of a course of treatment devised by experts at the Oliver Zangwell Centre for Neuropsychological Rehabilitation in Ely, Cambridgeshire. Now he uses it alongside note-taking when doing things he wants to remember, such as going on holiday – or getting married. He did not wear the camera during his wedding, but his previous experience of using it taught him how repeatedly viewing the pictures others took would help him retain the memories. He still needs to be accompanied when he goes out, but the device has helped him overcome his social anxiety to the extent that he was able to get married in front of 100 guests, something he wouldn't previously have been able to do.

"Having memory problems can make you inhibited, preventing you from doing new things or even just things that other people consider routine," he says. "But being able to view a record of myself doing things successfully acts as a reminder and has given me more confidence. It has allowed me not only to keep hold of precious memories but also to do normal things like going shopping."

 Keyword(s): Wearable CamerasAlzheimer's

### 7 ways the cloud can elevate your practice

Cloud technology lets physicians build high-performance private practices capable of handling the demands of the ever-changing healthcare landscape. This technology also helps practices reduce spending on technology infrastructure and supports the trend of greater mobile usage. Cloud software helps streamline processes, improve accessibility, monitor projects more effectively, reduce staffing and training costs, and reduce capital costs.

Practices weighing the advantages of cloud software over in-house, client-server software are wise to consider not only the visible costs of the monthly subscription fee for onsite software but also the hidden costs of in-house software ownership. Additionally, cloud software provides solutions, like mobility and connectivity, once only available to large group practices and hospitals.

This guide identifies the basics of cloud software, why using the cloud is an effective solution for eliminating the hidden costs of supporting in-house software, and explores how cloud technology will benefit today’s private practices.

 Keyword(s): wayscloudelevatepractice

#### Meaningful Use and Medical Assistants: What Does this Mean for their Career?

by Nancy Gabl

As physicians strive to align their practices with the conditions of the required meaningful use stages this year and continue to be involved in healthcare reform and all it entails, they find themselves reaching out for help in regards to workflow issues. The answer: proper utilization of medical assistants.

What is it in the medical assistant’s training that allows them to be the perfect contribution within the team of the physician’s office? It is their interdisciplinary role that enables them to fulfill not only the needs of the physician, but the patients’ needs as well. The medical assistant has been trained to run the front and back office, work on insurance claims, coding, schedule appointments and procedures, give medications, assist with procedures, meet with pharmacy representatives, take patient histories, vital signs and do medication refills. Phlebotomy and EKG are also an advantage. Their training allows work side by side with the physician every day, allowing them the opportunity to meet the physician’s every need.

Meaningful Use, along with ICD 10, and EHR has definitely challenged our abilities to adapt to change. This ongoing building block of healthcare reform has us all spinning, learning new information and documentation regarding meeting the needs of our number one goal — quality patient care. It is so easy to lose sight of the purpose of these changes when we are struggling with so many advances and changes that are evolving around us so quickly. The answer to quality improvement lies with the medical assistant who can assist all physicians in all areas of their operations and allow for a smoother cost effective workflow. Keep it simple, it is right there in front of you. These allied health professionals will move you into the new prototype of patient care and will be your assistant in every area of your practice. The medical assistant will allow you the capacity to focus on your patients and the ability to have a life outside your practice.

Download this White Paper to find out how proper utilization of medical assistants can ease this burden and maximize reimbursements!

 Keyword(s): Meaningful UseMedical Assistants

### New Study Finds 91% of Physicians Practice Defensive Medicine

Mark Crane

The fear of being sued for medical malpractice is pervasive, leading 91% of physicians across all specialty lines to practice defensive medicine — ordering more tests and procedures than necessary to protect themselves from lawsuits — a new study finds.

A survey by researchers from Mount Sinai School of Medicine, New York City, also found that the same overwhelming percentage of physicians believe that tort reform measures to provide better protections against unwarranted malpractice suits are needed before any significant decrease in the ordering of unnecessary medical tests can be achieved.

Investigators questioned 2416 physicians from a variety of practice and specialty backgrounds in a survey conducted between June 25, 2009, and October 31, 2009. Their findings were published today in the June 28 issue of the Archives of Internal Medicine.

"Physicians feel they are vulnerable to malpractice lawsuits even when they practice competently within the standard of care," said Tara Bishop, MD, associate, Division of General Internal Medicine at Mount Sinai School of Medicine, and coauthor of the study, in a news release. "The study shows that an overwhelming majority of physicians support tort reform to decrease malpractice lawsuits and that unnecessary testing, a contributor to rising healthcare costs, will not decrease without it."

Physicians were asked to rate their level of agreement to 2 statements:

• "Doctors order more tests and procedures than patients need to protect themselves against malpractice suits," and

• "Unnecessary use of diagnostic tests will not decrease without protections for physicians against unwarranted malpractice suits."

There were no statistically significant differences between sex, geographic location, specialty category, or type of practice. The largest difference was that 92.6% of male physicians said they practice defensive medicine vs 86.5% of female physicians.

Although physicians in relatively low-risk specialties such as general internal medicine and pediatrics are much less likely to be sued for malpractice than obstetric/gynecologic specialists and emergency physicians, their fear is just as real, Dr. Bishop asserted in an interview with Medscape Medical News. "There's just a visceral response to the word 'malpractice,' " she said. "The entire medical community worries about being pulled into a lawsuit."

Determining the true costs of defensive medicine may be impossible because so many factors go into decisions about ordering tests, Dr. Bishop noted. Malpractice fears play a large role, but so does a desire to be thorough and careful. In a fee-for-service system that often rewards overuse, it is difficult to say how large a part defensive medicine plays in the decision to order a test.

A 2003 study by the US Department of Health and Human Services estimated the cost of defensive medicine at $60 billion a year, but the American Medical Association pegs it at$200 billion. A 2008 study by PricewaterhouseCoopers' Health Research Institute calculated the cost of defensive medicine at $210 billion per year, or 10% of all healthcare spending. The new Mt. Sinai study coincides with several earlier surveys about how prevalent defensive medicine is. Some of the findings of those studies follow here. • Ninety percent of physicians said they practice defensive medicine, according to a poll published in April by Jackson Healthcare, a medical staffing and information technology company. About three quarters of physicians surveyed said defensive medicine decreases patient access to healthcare and will exacerbate the growing physician shortage. • A 2008 study by the Massachusetts Medical Society found that 83% of its physicians practice defensive medicine at a cost of at least$1.4 billion a year in that state alone. More than 20% of x-rays, computed tomography scans, magnetic resonance images, and ultrasounds; 18% of laboratory tests; 28% of specialty referrals; and 13% of hospital admissions were ordered for defensive purposes.

• A survey of 824 Pennsylvania physicians, published in 2005 in the Journal of the American Medical Association, found that 93% admit to risk-aversion tactics such as overordering tests, abandoning high-risk procedures, and avoiding the sickest of patients.

"We practice maximalist medicine to avoid missing any problem our clinical judgment tells us may be extremely remote," said Alan C. Woodward, MD, an emergency physician and past president of the Massachusetts Medical Society, to Medscape Medical News. Defensive medicine is rampant because "the threat of being sued is pervasive, and doctors simply don't trust the legal system."

In an invited commentary accompanying the Mt. Sinai study, Sen. Orrin G. Hatch (R-UT) acknowledged that consensus on Capitol Hill about tort reform "has been an elusive commodity" because of division and partisanship. "It is my hope that, as the American people see more evidence that they are paying for redundant and unuseful medical procedures, they will demand in larger numbers that real reforms be enacted to address this problem," Sen. Hatch writes. "That is what makes studies like the one by Bishop, et al., so important."

Arch Intern Med. 2010:170:1081-1084.

### Physicians Are Talking About: The Culture of Defensive Medicine

Nancy R. Terry

The practice of defensive medicine -- the ordering of excessive tests and procedures by physicians -- is regularly targeted as a major contributor to the high costs of healthcare. But how widespread is it?

A recent posting on Medscape's Physician Connect (MPC), an all-physician discussion group, asked the question: Do you practice defensive medicine? Most physicians responded with an emphatic YES.

"Defensive medicine is practiced everywhere, everyday. And the costs have got to be simply enormous," says a radiologist.

"Here in southeastern Michigan, home of [notable] malpractice attorneys, we practice defensive medicine every day, with every patient," replies a neurologist.

Why do physicians practice defensive medicine? A second neurologist says it is to save your behind in the unlikely event of a 1:1000 outcome.

Reports from physicians suggest that defensive medicine is widespread, and recent studies appear to confirm this. The Massachusetts Medical Society found that about 83% of physicians responding to a survey reported that they practiced defensive medicine, with an average of between 18% and 28% of tests, procedures, referrals, and consultations, and 13% of hospitalizations ordered for defensive reasons.[1] An earlier study published in the Journal of the American Medical Association (JAMA) surveyed physicians in 6 specialties affected by high malpractice liability costs (ie, emergency medicine, general surgery, neurosurgery, obstetrics/gynecology, orthopaedic surgery, and radiology) and found that 93% of respondents reported practicing defensive medicine. Assurance behavior -- such as ordering tests, performing diagnostic procedures, and referring patients for consultation -- was found to be very common (92%).[2]

The JAMA study suggests that defensive medicine is more prevalent in certain settings. A health maintenance organization (HMO) medical director gives examples of what he views as routine in the emergency department and in-patient care. "A hospitalized patient with pneumonia will be seen by the primary care physician, an infectious disease physician, and even a cardiologist if his chest hurts when he coughs. Every patient in the emergency room gets a CT [computed tomography] scan and a cardiac cath." And equivocal tests frequently lead to more tests. The HMO director says that as many as 80% of imaging studies are normal or show insignificant findings that require another study.

An emergency medicine physician remarks that excessive testing has become a regrettable necessity. "In the ER [emergency room], patients often give histories that could conceivably (less than 2%) be from a life-threatening condition," says the emergency physician. "In our current system, we really can't miss these things anymore."

"Nobody wants to get sued, especially in the ER setting," comments a radiologist. "Why else would a 22-year-old with a tummy ache but no fever, no white count, and no localizing symptoms get a CT of the abdomen and a pelvic ultrasound before she leaves?"

"Most doctors would agree that the threat of a potential lawsuit significantly adds to the cost of medicine in the ER and in the hospital setting," says a radiologist. A second radiologist agrees. "The cost to the system for CYA medicine is enormous."

In fact, the actual cost of defensive medicine is open for debate, depending on whether you talk to doctors or lawyers. According to an article in The Seattle Times,[3] doctors estimate that defensive medicine and malpractice insurance accounts for up to 10% of healthcare spending. Lawyers say malpractice settlement costs amount to less than 0.5% of the $2.5 trillion spent each year on healthcare. ### Defensive Medicine: Impacts Beyond Costs Summary of Findings Overview Between October 2009 and March 2010, Jackson Healthcare conducted a series of national physician surveys to quantify and qualify physician attitudes, perceptions and recommendations regarding healthcare reform and defensive medicine practices. Physicians estimated that between$650 billion and $850 billion are spent each year on medically unnecessary tests and treatments in an effort to avoid lawsuits. In addition, significant consequences surfaced beyond wasted costs, consequences negatively impacting the physician/patient relationship. In March 2010, Jackson Healthcare conducted its third national physician online survey to quantify the impact of defensive medicine beyond cost, including the areas of access, quality and innovation. Key Findings from Jackson Healthcare Survey • 76 percent of respondents reported that defensive medicine decreases patients' access to healthcare. • 72 percent of respondents reported that the practice of defensive medicine negatively impacts patient care. • 71 percent of respondents reported that defensive medicine has had a negative effect on the way they view patients. • 67 percent of respondents reported that defensive medicine comes between the doctor and patient. • 57 percent of respondents reported that defensive medicine hampers their decision-making ability. • 49 percent of respondents reported that defensive medicine has a negative impact on medical innovation. Likewise, 53 percent reported delaying adoption of new techniques/procedures/treatments due to fear of a lawsuit. • Defensive medicine is now being taught as standard medical practice. The survey found that 83 percent of physicians ages 25 to 34 reported being taught in medical school or residency (by an attending physician or mentor) to avoid lawsuits. • Patients most likely affected by defensive medicine are 1) those requiring surgery, 2) women and 3) those visiting emergency rooms. • Surgeons and OB/GYNs are most affected by lawsuits. • 83 percent of OB/GYN respondents have been named in lawsuits • 79 percent of surgeons and surgery subspecialists respondents have been named in a lawsuit • 68 percent of emergency room physician respondents have been named in a lawsuit • Of the physicians surveyed, 75 percent reported that defensive medicine will impact the physician shortage by decreasing the number of physicians in the U.S. Jackson Healthcare Survey Metholodology In March 2009, Jackson Healthcare invited 124,572 physicians to participate in a confidential online survey in an effort to quantify the costs and impact of defensive medicine. Over 1,400 physicians spanning all states and medical specialties completed the survey, a 1.13 percent response rate. The survey error range is at the 95% confidence level: +/-1.7 percent. ### Defensive medicine practices could signal a new ‘norm’ in the climate of fear Orthopedics Today Defensive medicine is a hot topic about which nearly everyone has an opinion, and much like spiritual beliefs, each party feels that its view is entirely correct. The prevailing wisdom is that defensive medicine is a crisis of sorts in our health care system, contributing billions of dollars in costs that could be saved by federal intervention aimed at reassuring physicians, or immunizing them against lawsuits alleging medical negligence. In such an environment, physicians would be free to practice medicine, exercise professional judgment, and make health care more efficient and less expensive. In reality, defensive medicine is difficult to define and there are many sides to each argument that can be taken in relation to this complex subject. We have invited a number of legal scholars and physicians to opine on this subject in this Orthopedics Today Round Table. As the responses suggest, there are many perspectives on this vexing issue that is of interest to the medical, legal and political fields, as well as the lay public. Your comments are welcome; please add to the debate by visitingwww.OrthoMind.com; a website that is accessible exclusively to orthopedic surgeons, where you and your colleagues can discuss this subject freely. B. Sonny Bal, MD, JD, MBA Moderator University of Missouri School of Medicine Columbia, Mo. B. Sonny Bal, MD, JD, MBA: There are several definitions of “defensive medicine;” how do you define defensive medicine? Ramon L. Jimenez, MD: Defensive medicine is the practice of evaluating and treating a patient with the belief that certain patient is potentially litigious, and who will file a malpractice claim against you if he or she believes you have done anything wrong. This practice may entail ordering unnecessary tests or over treating to protect oneself from any untoward legal action. Theodore J. Choma, MD: I view defensive medicine as the ordering of tests, consultations or confirmatory studies that would not necessarily be needed in addition to the current clinical impression to guide treatment. I also view defensive medicine as the refusal to offer treatment options to patients that one might deem as prone to litigation. In either circumstance, there is a barrier to full trust and disclosure between physician and patient. Michael T. Archdeacon, MD, MSE: I would define defensive medicine as the practice of medicine where imaging studies, diagnostic tests or laboratory values are obtained primarily to protect a physician from missing a diagnosis regardless of whether the study is clinically indicated or even useful. I believe there are two situations in which defensive medicine occurs. First, defensive medicine occurs when a physician is not confident in a diagnosis and is concerned with missing a clinically significant diagnosis, such as a neoplasm or infection. The second defensive medicine scenario arises when a physician is concerned about the risk of malpractice; therefore, defensive actions are taken to theoretically reduce the risk of litigation. David H. Sohn JD, MD: I would define defensive medicine as tests, imaging and documentation performed primarily to limit exposure to malpractice liability. Stuart L. Weinstein, MD: Defensive medicine is defined as providing medical services that are not expected to benefit the patient but are undertaken to minimize the risk of a subsequent lawsuit. There are two types of defensive medicine – diagnostic defensive medicine has a much greater impact on costs and therapeutic defensive practices impose greater risks to patients Robert B Leflar, JD, MPH: Defensive medicine falls into two categories: (a) indicated treatments and procedures foregone because of fear that adverse results might offer opportunities for litigation; and (b) unindicated treatments and procedures performed in part because of fear that failure to provide the treatment or procedure might open the door for litigation. This category broadly includes foregoing areas of practice perceived to be litigation-prone. Neil Vidmar, PhD: I would define defensive medicine as practicing medicine to avoid errors. There are two types as discussed by Studdert and Mello inTexas Law Review in 2002: (a) avoiding errors that can harm the patient– e.g., errors such as not doing additional tests that would detect a condition and (b) doing unnecessary tests out of fear of a lawsuit or to collect additional fees. Studdert and Mello make the point that some defensive medicine clearly helps save lives. Jeffrey Segal, MD, JD, FACS: Defensive medicine includes practices which are designed primarily to keep the doctor from being sued. Such practices typically, although not always, benefit the doctor by avoiding litigation rather than benefiting the patient. Lawrence H. Brenner, JD: There is only one definition of defensive medicine – the performance of medically unnecessary procedures (usually diagnostic) for the sole benefit of the provider without any expected benefit to the patient. David Teuscher, MD: Medical tests and procedures ordered to mitigate risk for physicians’ liability that do not commensurately and significantly contribute to the patient’s diagnosis or outcome given the costs and/or risks to the patient. Bal: How prevalent do you believe defensive medicine is in the United States today? Jimenez: It is my belief that the practice of defensive medicine is quite prevalent in the everyday practice of medicine today, especially in states where there is minimal tort reform or protection from malpractice liability. I practice in California where the Medical Injury California Reform Act (MICRA) was enacted in 1975. This placed a cap of$250,000 on pain and suffering awards. I believe its effect was to decrease the number of frivolous or non-meritorious malpractice lawsuits. As a practitioner, I do not look at every patient as a potential lawsuit. I try to engage and empathize with my patients and therefore gain their confidence and trust. There are a few in which I am not successful. In those cases, I am straightforward with them and I inform them why I wish to order a test and what I expect to prove or learn from it. I always ask if their permission to do so.

Choma: I suspect that defensive medicine plays a small part in the practice of almost every physician, and a substantial part in the practice of a few physicians.

Archdeacon: I would guess that defensive medicine occurs more commonly than we think. Many times our decisions are so ingrained into our daily practice, that we really don’t re-evaluate our rationale for making them.

Sohn: I believe defensive medicine is widely prevalent in the United States. Survey results indicate that more than 90% of physicians practice defensive medicine.

Weinstein: Although hard data are difficult to acquire, several studies on physician attitudes indicate that a fear of lawsuits tends to drive providers to adopt behaviors that lead to increased health care costs. One study, for example, showed that 93% of physician respondents reported engaging in some form of defensive medicine Assurance behavior, as reported by 92% of physician respondents, involves ordering tests (particularly imaging tests), performing diagnostic procedures and referring patients for consultation.

Avoidance behavior, as reported by 42% of physician respondents, includes restricting their practice, eliminating high risk procedures and procedures prone to complications, and avoiding patients with complex problems or patients perceived as litigious. A recent study in Massachusetts showed that 83% of physician respondents ordered imaging and laboratory tests or made specialist referrals defensively. Unfortunately, if these assurance behaviors continue over time, they become the standard of care. Patients also become educated through the Internet and media about this new standard and change their expectations of their care.

On the therapeutic side, defensive therapeutic measures, such as Caesarean sections or invasive procedures such as breast lump biopsies, are accompanied by significant risks to patients and increased health care expenditures.

Leflar: Unindicated treatments and procedures performed in part to avoid the possibility of litigation appear to be common, especially since they are backed up by income opportunities. For more information, see the work of Atul Gawande, MD.

Vidmar: I do not have empirical evidence on either, and thus, I am unwilling to estimate.

Segal: I believe it is extensive. A recent study suggested 91% of doctors admit to practicing defensively. One cynic suggested the other 9% are not being candid.

Brenner: I don’t know.

Teuscher: Pervasive universally, but more prevalent in pockets of perceived potential plaintiffs.

Bal: Do you support federal reform that may immunize physicians against medical malpractice lawsuits? Do you truly believe such reform will lead to noticeable cost savings by reducing the incidence of defensive medicine?

Jimenez: I do not believe that tort reform alone will result in minimizing the incidence of defensive medicine. It does offer some sense of protection, but a physician would be a fool to think that tort reform alone offers immunity from malpractice liability. On the other hand, I believe that the practice of good communication skills, thereby gaining the trust and confidence of your patient goes much further in reducing your exposure to malpractice claims. In short, I do support tort reform but I do not believe that it should be sold as an “immunity law.” If so, it may backfire and not produce any savings whatsoever.

Choma: I would support such federal reform. I believe that it would break down the barriers between physicians and patients, and on the whole, foster an environment for improved medical care. It seems to me that in this age of easy and instantaneous mass communication, and in this time of database construction on physicians’ and hospitals’ outcomes, there are many other vehicles that will serve quality control functions for health care other than the threat of lawsuit.

Archdeacon: I am not certain that federal reform, which immunizes physicians, is necessary. There are circumstances which occur where we as physicians need to be held accountable. Additionally, reform might decrease the occurrence of defensive medicine that is attributed to a fear of malpractice, but it is unlikely to reduce defensive practices related to physician indecisiveness over a diagnosis.

Sohn: I support federal reform to limit medical malpractice risk for physicians. We have more than 35 years of public policy research which clearly show that when malpractice risk is limited, at least in the form of caps on noneconomic damages, doctors utilize less medicine. With hard caps on noneconomic damages, physicians utilize 5% to 9% less medicine. With soft caps, physicians utilize between 3% to 4% less.

Weinstein: Unfortunately, the current medical liability system is ineffective; it neither effectively compensates patients injured from medical negligence nor encourages addressing system errors to improve patient safety. Currently, there is a “patchwork quilt” of laws addressing medical liability across 50 states. In addition, state liability laws are continually under attack. For these two reasons, I think we have a compelling case for a federal solution to this problem. With that said, any federal solution should not preempt effective state laws that exist in states like California and Texas.

An effective federal program must ensure that patients harmed by medical negligence are made whole and patient safety in the health care system is improved. All agree that defensive medicine exists and is costly. While the actual costs of defensive medicine are hard to calculate (range from $5 billion to$650 billion a year), they are considerable. I think that there will be definite health care savings if the medical liability question is effectively addressed at the federal level.

Leflar: I do not support such reform – unless as part of a general program to move to a non-fault-based compensation system offering wider opportunities for compensation for injured patients on an “avoidable injury” standard less stigmatizing to physicians than the negligence standard. Cost savings from such a program are questionable.

Vidmar: I do not support such legislation and indeed have testified against caps. Other evidence suggests that insurance premiums are a small part of doctor expenses. A few years ago, one of my students whose mother was an ob-gyn conducted interviews with a sample of ob-gyns in Colorado and in North Carolina. Medical malpractice premiums and lawsuits were low on their list of complaints about their medical practice issues.

Segal: Yes, in a qualified way. I’ll explain in a bit. Whether or not immunity would be the holy grail for cost savings – providing such immunity would clearly test the proposition that defensive medicine and its costs can be curtailed.

Brenner: This question demonstrates the inherent conflict of interest in surveying physicians and surgeons on defensive medicine and then publishing those surveys as if they were health science research. Any perceived linkage between defensive medicine and limiting liability will bias all responses. It is impossible to predict how immunizing physicians and surgeons from professional liability will impact their practice patterns.

Teuscher: Yes, they worked in my state, and like in California, they need to be instituted nationally. In order to realize cost savings, we need to institutionalize safe harbors to ensure the behavior ceases.

Bal: Assuming the legislative environment was conducive, what specific reforms should the federal government implement to address the allegedly high incidence of defensive medicine?

Jimenez: I strongly believe that the federal government should enact specific tort reforms, such as a cap on pain and suffering awards. Such a measure would be effective in restraining the trial lawyers from filing or taking on non-meritorious lawsuits. A testimony to that opinion is the continuous efforts by the trial lawyers lobby to overturn the MICRA law in California. On the other hand, any broader measures that would give physicians the feeling of immunity from malpractice litigation would not be good. Physicians, like other professionals who service the public, must be held accountable for their actions or lack of action. Unfortunately, we cannot rely simply on their innate integrity and responsibility.

Choma: I would suggest serious caps on jury awards for pain and suffering, and overall physician liability caps. I would also seriously consider provisions, such as those in Texas that treat academic medical centers that serve a societal safety net function in a separate and more protected category. These centers are typically relied upon to care for the most complex and sickest patients, and it seems to me that a healthy societal contract with them would account for this and shield them from the costs of frivolous lawsuits.

Archdeacon: In my opinion, reform with an emphasis on controlling or capping damage awards as well as controlling attorney fees are more reasonable measures to control costs. Health care providers’ fees are regulated at every level, so it seems reasonable that attorney fees associated with medical cases should be regulated as well.

Sohn: I would support caps on noneconomic damages as this is a form of tort reform which has consistently proven effective. A recent New England Journal of Medicine paper by Kachalia and Mello looked at various forms of tort reform from pretrial screening panels to certificate of merit requirements, and found the most consistent benefits for caps on noneconomic damages. Although various states enact different types of caps, it is safe to conclude to that caps in general lead to substantial savings in indemnity cost, modest constraint of growth of malpractice premiums, reduction in at least some defensive practices, modest improvement of physician supply and perhaps even improved quality of care.

Weinstein: While most solutions at the federal level have been modeled after California’s MICRA legislation in the 1970s or the 2003 Texas legislation, these “cap on non-economic damages” plans are essentially a “non-starter” for opponents in Congress. Achieving meaningful federal medical liability reform in any form will require a bipartisan solution. The trial bar is very well organized and 90%+ of their members support their political action committee (PAC). While the American Academy of Orthopaedic Surgeons (AAOS) is the leader in PAC support in organized medicine, including the American Medical Association, only 28% of our members recognize the importance of contributing to the PAC. If every member supported our PAC, we would be in a stronger position.

Leflar: Looking at the long term, a more promising solution may be a no-fault compensation system employing an “avoidable harm” standard rather than a negligence standard, as I mentioned earlier. However, it should probably be undertaken first on an experimental basis in one or more states rather than by the federal government.

Vidmar: Again, the issue comes back to Studdert and Mello’s study. What kind of defensive medicine?

Segal: I believe doctors who can demonstrate they followed evidence-based guidelines should be immune from litigation. Those doctors who can document why they consciously deviated from such guidelines for a specific and reasonable reason should receive qualified immunity.

Brenner: None.

Teuscher: Hard cap on non-economic damages, federal rules, and safe harbors for practicing within evidence-based guidelines.

Bal: Much of our awareness of what constitutes defensive medicine is from surveys of physicians asking if they practice defensive medicine out of fear of litigation. Recognizing the inherent bias in such surveys, how would one design a scientifically valid study that addresses whether or not U.S. physicians practice costly defensive medicine? How would you factor in the consideration of different practice environments, i.e., practices exposed to malpractice lawsuits vs. a protected environment where litigation is a non-issue?

Jimenez: It is my opinion that the best and most accurate method or survey one could utilize in determining if a physician would react or treat a patient in a defensive medicine manner is in the following manner. The test would be made up of five clinical scenarios representing patients of different gradations of potentially litigious overtones. The responses of the physicians would be recorded, not so much on the accuracy, but on the quality of the communication skills manifested. It has been shown that there is a direct correlation between effective communication skills and reduction of malpractice claims.

Choma: I suspect that given how insidious the practice of defensive medicine can be, it will be impossible to accurately quantify the scope of this issue. I don’t, however, think that this makes current survey information without value.

Archdeacon: A rigorous scientific study that assesses defensive medicine would be difficult to design and implement. It seems that such a study should focus on a universally agreeable negative outcome that physicians are concerned with both from a patient care standpoint as well as a litigation standpoint. Perhaps, the workup and diagnosis of infection associated with total knee or total hip arthroplasty, or deep vein thrombosis after hip fracture. Prior to engaging in such a study, an adjudication panel should come up with a set of expected clinical and diagnostic tests. This would be followed by a prospective analysis of practice patterns. This type of investigation begins to mirror evidence-based medicine approaches, which are difficult to agree upon even without the concern for litigation.

Sohn: I think the only way to see whether physicians practice defensive medicine is to compare physician behavior before and after significant tort reform. Say physicians in a litigious environment order 10 tests per patient. If the same group is then guaranteed immunity and only order six tests per patient, it is reasonable to conclude that the additional four tests were ordered solely out of defensive posture.

Such a test is obviously difficult to administer, but there are studies which look at physician behavior before and after the 1975 California MICRA laws. One study by Stanford economists Kessler and McClellan found that physicians utilized between 5% to 9% less medicine after laws which placed hard caps on noneconomic damages. I think this is good evidence that physicians do practice defensive medicine and that they practice less defensive medicine under the umbrella of tort reform.

Weinstein: This is a very complex issue. The best solution here is not related to spending time on surveys but to devote resources to developing appropriateness criteria and guidelines when possible. Unfortunately orthopedic surgery, not unlike most surgical disciplines, is not an evidence-based discipline but an expert-based discipline. It is very hard and prohibitively expensive to do randomized clinical trials on the multitude of conditions that we treat. The variables are so great and the numbers often small for the conditions we treat.

We definitely need to do good clinical research but the AAOS and our specialty societies need to be working in concert to develop appropriateness criteria which apply across all practice environments. If we don’t do this, then someone external to the profession will. With these in place, we will not only help the medical liability problem but begin to do our part in lowering health care costs and improving quality.

Leflar: Choose a limited number of expensive diagnostic procedures for which indications for their performance are clearly defined. A multicenter trial would be needed so that practice environments could be compared – low litigation risk, maybe veterans administration, vs. high litigation risk; and profit potential present, vs. no profit potential present. Obtain rates of performing each procedure at each center. Ideally, include a risk adjustment mechanism so that patient mixes could be standardized. Ideally, do an independent chart review of all or a randomized sample of cases, for an additional perspective on whether performance of the procedures was less frequently justified in some practice environments than in others.

Vidmar: In my answer above about the survey of ob-gyns, I coached the student to be neutral and not ask leading questions. In this vein, Mello conducted a survey of ob-gyns in Pennsylvania and found many saying they would leave the state because of high malpractice premiums. But she later found data that contradicted that finding — and being an honest and unbiased researcher, she reported the latter finding admitting error. I would love to conduct a much larger study along the lines of the one conducted by my student.

Segal: We already have studies which look at defensive practices in other countries. Such doctors are not even aware of what the term defensive medicine even means – as they have no such need to practice defensively. Further, doctors in more “protected” environments in the United States, such as federal employees, have been shown to practice less defensively, again because they have less need to practice defensively. I am not sure designing a study to “look for” defensive medicine would be a good use of dollars. Defensive medicine is pervasive.

Brenner: In order to validly study defensive medicine research scientists would need to have physicians and surgeons identify the charts of patients where they claim unnecessary procedures were performed to reduce liability exposure. The researchers would have to verify that the procedures were unnecessary. Finally, the researchers would have to verify the motivation for ordering medically unnecessary tests. There are many motivations for doing so including financial gain and, lack of diagnostic self confidence. It would likely be impossible to demonstrate the validity of any study of defensive medicine because the results would always be dependent on subjective factors.

Teuscher: Fear of lawsuits is not measured objectively if one practices in a litigation rich environment. How you measure that will always be biased, based upon the perceived and/or real incidence of lawsuits and the severity of damage that they cause to the practice and psyche of the participants.

Bal: In your opinion, is the ordering of otherwise unnecessary tests a worthwhile strategy to shield against medical liability or do such tests merely serve to relieve physician anxiety?

Jimenez: It is my opinion that simply ordering a test as a form of defensive medicine is not very effective. Usually the test is not necessary to provide a good diagnosis or treatment. If there is a problem associated with the test, such as an untoward side effect, or a significant copayment or cost that the patient has to pay, the patient will be unhappy.

If the patient senses or feels that the test was unnecessary, a litigious result may occur anyway. The physician needs to gain the confidence and trust of the patient by using good communication skills, such as empathy, engagement, education and enlistment. A good shared decision between physician and patient will result and the potential for a malpractice claim will be less.

Choma: I suspect, that like most practices in medicine, there is a spectrum here. At times, I truly feel that some consultations are more to address treating – physician anxiety rather than that of the patient. Again, that does not completely nullify the value of such consultations. As long as medicine is practiced by humans and not computers, it will be subject to the all of the frailties of those humans.

Archdeacon: In my opinion, unnecessary tests serve more to relieve physician anxiety than actually reduce malpractice risk. The majority of physicians are 95% comfortable with a diagnosis based on patient history and physical exam. With few exceptions, imaging studies and tests serve as confirmatory aides more that diagnostic aides.

Sohn: This is a controversial topic. There are some physicians who believe that ordering extra tests is irrational, and that physicians actually make things worse for themselves by ordering more tests. However, there are also closed claim studies which show that a commonly asserted element of plaintiffs’ complaints is failure to order tests. I think this actually would be a worthy study.

Weinstein: In the current climate of fear, defensive medicine is becoming the norm. The fear of a lawsuit drives physicians to assure themselves that they are not “missing something” and hence, they order a lot of tests, images and studies for they cannot personally afford to miss any diagnosis regardless of how rare. Instead of following a more strategic, almost algorithmic order of progression to diagnosis, physicians because of fear of liability feel the need to “cover the waterfront” to avoid missing anything regardless of how rare.

In addition, a better educated public is also more demanding of wanting expensive studies, imaging studies in particular, for diagnosis of their problem. Avoidance behavior is purely defensive on the physicians’ part; this unfortunately profoundly affects patient access to care. This inadequate specialty physician coverage is one of the main drivers for closing of emergency rooms.

Leflar: It is not a worthwhile strategy and is a significant contributor to the inefficiency of U.S. medical practice.

Vidmar: Probably the latter. Also, I am not confident that the anxiety is that high – except when it is triggered by physicians’ professional associations. The real issue is whether doctors and especially hospitals gain financially from these extra tests. I know of anecdotal evidence that the hospitals gain financially from unnecessary tests.

Segal: It is a strategy that is more likely to be effective in warding off meritless suits than hoping for the best. A more cost effective alternative might be to document the tests you would have done defensively. Then include in the documentation the literature explaining why such tests are not appropriate. Such a strategy might still land you in court.

Brenner: I am not aware of any scientifically valid studies that establish the presence or absence of defensive medicine.

Teuscher: After a reasonable informed conversation with the patient and their family, if their needs and willingness to fund are to test to make sure there is a negative result and establish peace of mind, then ordering a test with informed shared decision making with a reasonable expectation of the result is not defensive medicine.

Bal: Are you aware of any scientifically valid studies have shown the existence of high costs related to defensive medicine? Or is the evidence in support of the ubiquitous incidence of defensive medicine largely anecdotal and based on common sense (in addition to survey data)?

JimenezThe Wall Street Journal reported in September 2010 that the latest estimate was (from an analysis published in Health Affairs) $45.6 billion annually (in 2008 dollars), accounting for more than 80% of the$55.6 billion total yearly cost of the medical liability system, according to the authors — from Harvard University and the University of Melbourne.

I do not believe that the numbers are anecdotal but I must admit that they are difficult to exactly pinpoint. Some have also estimated that the costs are about 2.4% of the total health care costs. Even though these figures are difficult to document and verify, it is safe to make the assumption that a significant percentage of the health care dollar is spent trying to avoid lawsuits.

Choma: This is such an emotional issue for physicians that anecdote has a very large affect on our perception of the matter.

Archdeacon: I am not aware of any such studies.

Sohn: California realized a reduction of medical costs from 5% to 9% after enacting caps on noneconomic damages. This seems small, but studies extrapolating these savings to the nation as a whole if there were similar federal tort reform (such as H.R. 5, “The Health Act”) place savings at up to $122 billion per year. That is real savings. Weinstein: The costs of defensive medicine vary considerably and the methodology of determining costs varied. But many credible sources and references do indeed exist. With that said, opponents will always be able to find what they determine to be critical flaws in the methodology. A 2006 study done by PricewaterhouseCoopers estimated costs upwards of$210 billion a year. The respected research firm found, “While the bulk of the premium dollar pays for medical services, those medical services include the cost of medical liability and defensive medicine … Defensive tests and treatment can pose unnecessary medical risks and add unnecessary costs to health care.”

A more recent Gallup survey of American physicians found the fear of lawsuits was the driver behind 21% of all the tests and treatments ordered by doctors, which equates to 26% of all health care dollars spent. That comes to a staggering $650 billion. According to a study of medical liability costs and the practice of medicine in Health Affairs, overuse of imaging services alone, driven by fear of lawsuits, costs as much as$170 billion a year nationally.

Looking at state data, a study by the Massachusetts Medical Society revealed that 83% of the physicians surveyed reported practicing defensive medicine and that an average of 18% to 28% of tests, procedures, referrals and consultations and 13% of hospitalizations were ordered for defensive reasons. Estimates are that assurance behavior costs Massachusetts a staggering $1.4 billion annually. Leflar: The evidence is largely anecdotal. However, it is widespread enough to be believable. Vidmar: I suspect there are no studies that are valid. Segal: Studies by Kessler, McClellan and Baicker suggest that the harsher the medico-legal environment, the more expensive the practice of medicine. Brenner: It only reduces anxieties. Most diagnostic related malpractice claims (and the court decisions that support liability) result from inaccurate histories and incomplete physicals. Teuscher: More importantly, are there any scientifically valid studies that show that defensive medicine and our broken medical liability system are not costing us more in medical expenditures and unnecessary medical tests through defensive medical ordering practices. Bal: To the extent that defensive medicine exists, is it not a beneficial result of our civil liability system that holds individuals accountable for their conduct? In other words, are we not better off because of defensive medicine? Jimenez: I must respectfully disagree with your conclusion that defensive medicine is in itself good or yields a beneficial result. I believe that the feeling of accountability must be inherent in the person of the physician and not the result of society’s demands. In other words, we as physicians must hold ourselves accountable and do the best we can for each and every patient. If every physician had this mindset and practiced these principles, then there would not be any need for the practice of defensive medicine. Choma: I’m afraid that I cannot agree with that. From my view, a large contributor to the emotion of the issue is that physicians inherently resent that there exists this barrier between doctor and patient. We know in our hearts that true confidence in this relationship can improve our quality of medicine. This is the confidence that allows us to skip the next test of dubious value when one of our patients is experiencing a suboptimal outcome. This is the confidence that allows us to skip the next diagnostic MRI when we know that it won’t change the next treatment recommendation. In addition, patients must be brought into the daily conversation with their physicians that we are dealing in uncertainties most of the time. To the extent that the additional diagnostic maneuvers purred by defensive medicine continue to supplant that discussion with our patients, we will continue to be dissatisfied. Archdeacon: Again, I believe most physicians are comfortable with their diagnosis and treatment plans prior to any tests or studies. A small percentage of cases probably really benefit from further investigations. However, there are obvious exceptions, like presurgical imaging studies that assist in developing the surgical plan. So, in my opinion, a small percentage of patients probably benefit from the practice of defensive medicine, but it is unlikely that the majority receive any tangible benefits. Sohn: To some degree, there is a need for the tort system in general. Civil litigation acts as a sort of “private attorney general” that discourages negligence and improves public safety. For example, we don’t want companies making shoddy tiger cages, or cars with gas tanks placed in precarious positions. However, medicine is ill-adapted to the tort system for at least three significant reasons. First, most medical errors are not the result of negligence. They are the result of system errors. According to the groundbreaking 1997 Institute of Medicine report, “To Err is Human,” most errors made are not negligence but unavoidable human error that can only be minimized by investment in systems of checks and verifications to catch such errors. They cannot be avoided by frightening physicians and threatening them with lawsuits. Second, plaintiffs in medical malpractice sue due to complications, not due to negligence. One closed claim study out of Harvard found that only one in seven lawsuits filed actually contained evidence of negligence. In medicine, however, there is always the risk of complications because medicine and human biology is an inexact science. It would be nice to somehow compensate patients who are injured, but trying to assert negligence for unavoidable complications likely will have either a chilling effect on riskier services, an increase in defensive medicine, or both. Third, using the tort system to improve the quality of medicine is no longer a luxury we can afford. We have reached a crisis in the costs of medical care, and even if there were some marginal improvement of quality due to the threat of litigation, it is not justified by the increase in defensive medicine costs. We spend$100 billion per year on radiology costs, 30% of which the radiologists estimate is not necessary. We are at a point where politicians have talked of instituting review panels for rationing of medicine, and where every year there is the threat of 10% to 20% cuts in Medicare reimbursements for physicians. The “private attorney general role,” ill-suited to begin with to the medical field, is a luxury we just cannot afford.

Weinstein: Defensive medicine is a reality. It is costly and interferes with access to care. Defensive practices will slowly become the standard of care leading to permanent costly inappropriate poor quality care. Defensive medicine does not improve patient outcomes nor make the health care delivery system safer. But the current climate of fear among physicians will lead to continued costly defensive medicine practices and lack of system transparency necessary to make the system safer.

With medical liability reform a wedge issue between Republicans and Democrats, the federal government will continue to be impotent in developing a federal solution and hence, we will continue to operate under a patchwork quilt of ineffective state programs that are continually under attack by the trial bar. Until reasonable members of both parties are willing to develop a bipartisan solution, the prognosis for ending defensive medicine practices and reforming the current medical liability system is guarded.

Leflar: No, not if one accepts my two-fold definition of defensive medicine.

Vidmar: Again I go back to the Studdert and Mello study – good or bad defensive medicine?

Segal: No. First, some defensive practices harm patients – causing worry, morbidity, sometimes mortality. Next, defensive medicine makes health care more expensive and decreases access to care for many Americans. Even if select patients benefit, patients in the aggregate do not.

Brenner: I believe that the purpose of our professional liability system is to produce fair and just results. The unending, ideological debate on whether our liability system leads to increased costs or improved patient care quality is a partisan debate unrelated to achieving fair verdicts.

This question demonstrates why the issue of defensive medicine creates an unacceptable choice for organized medicine. If you accept my definition, then performing procedures without any expected benefit to patients is unethical and potentially illegal. On the other hand, if you allow that the definition of defensive medicine includes clinical benefits to patients then you also have to allow that malpractice litigation has increased patient safety and improved patient quality.

Teuscher: Our broken civil liability system does not act swiftly nor justly, let alone predictably as promised. It fails miserably to hold anyone accountable for their misconduct. Why promote spending more money on tests defensively that do not give patients a true benefit? Litigation is not the answer, but merely a symptom of the disease that ails American medicine.

• Michael T. Archdeacon, MD, MSE, can be reached at Department of Orthopaedic Surgery, University Hospital University of Cincinnati Academic Health Center, P.O. Box 670212, Cincinnati, OH 45267-0212; 513-558-2978; email: michael.archdeacon@uc.edu.
• B. Sonny Bal, MD, JD, MBA, can be reached at Missouri Orthopaedic Institute, 1100 Virginia Ave., Columbia, MO 65212; 573-882-6762; email:BalB@health.missouri.edu.
• Lawrence H. Brenner, JD, can be reached at P.O. Box 787, Carrboro, NC 27510; 919-929-5597; email: lb@lawrencebrennerlaw.com
• Theodore J. Choma, MD, can be reached at Department of Orthopaedic Surgery, University of Missouri, 1100 Virginia Ave., DC 000530, Columbia, MO 65212; 573-882-1440; email:chomat@health.missouri.edu.
• Ramon L. Jimenez, MD, can be reached at Monterey Peninsula Orthopaedic and Sports Medicine Institute, 10 Harris Ct. Bldg. A, Suite A, Monterey, CA 93940; 831-643-9788; email: ramon@jimenez.net.
• Robert B Leflar, JD, MPH, can be reached at Arkansas Bar Foundation Professor of Law, University of Arkansas School of Law, 1045 W. Maple St., Fayetteville AR 72701; 479- 575-2709; email: rbleflar@uark.edu.
• Jeffrey Segal, MD, JD, can be reached at Medical Justice, P.O. Box 49669, Greensboro, NC 27419; 336-691-1286; email:jsegal@medicaljustice.com.
• David H. Sohn, JD, MD, can be reached at Department of Orthopaedic Surgery, Division of Sports Medicine, University of Toledo Medical Center, 3000 Arlington Ave., Toledo, OH 43614; 419- 383-3761; email:david.sohn@utoledo.edu.
• David Teuscher, MD, can be reached at Beaumont Bone & Joint Institute, 3650 Laurel Ave., Beaumont, TX 77707; 409-838-0346; email:sportdoctor@gt.rr.com.
• Neil Vidmar, PhD, can be reached at Duke University School of Law, Room 3183, Box 90360, Durham, NC 27708-0360; 919-613-7090; email:vidmar@law.duke.edu.
• Stuart L. Weinstein, MD, can be reached at Department of Orthopaedic Surgery, 01026 JPP University of Iowa Hospitals and Clinics, Iowa City IA 52242; 319-356-1872; fax: 319-353-7919; email: stuart-weinstein@uiowa.edu.
• Disclosures: Archdeacon, Bal, Brenner, Choma, Jimenez, Leflar, Sohn, Teuscher, Vidmar and Weinstein have no relevant financial disclosures; Segal is a shareholder in Medical Justice.

 Keyword(s): Defensive Medicine

### La medicina defensiva: cómo los médicos evitan las demandas

Ana I. Gracia

No hay nada que más alarme a un médico que la citación a un juzgado por la demanda de un paciente. Las demandas por mala praxis a los médicos se han multiplicado por cuatro en la última década. El paciente ya es consciente de que puede denunciar si no está contento con el resultado. Es ése el momento en el que la práctica médica se altera. El médico, para defenderse, ha optado por ejercer una medicina defensiva: ésa que protege ante un eventual reclamo futuro del paciente.

Los enfermos reclaman una atención más humanizada y los especialistas se quejan de falta de tiempo y recursos. Cuando un resultado no es el esperado, la gente siente la necesidad y el derecho de reclamar. La ‘Industria del Juicio’ en el campo sanitario, lejos de disminuir, avanza a un ritmo vertiginoso que no sirve para nada más que para asfixiar la moral y la economía del sistema de salud del país.

En España se contabilizan 50.000 denuncias por negligencias médicas al año, según los datos que maneja la Defensoría del Paciente. Un 60% más que hace 10 años. Carmen Flores, su presidenta, asegura que este aluvión de denuncias llega una vez que el paciente ha tomado conciencia de que, por derecho, puede reclamar en el ámbito sanitario, un asunto antes impensable. “Falta mucha comunicación y que asuman su responsabilidad cuando ocurre un error. Todos sabemos que la medicina no es una ciencia exacta, pero no hay dinero que pague una negligencia que, muchas veces, resulta ser mortal”, explica Flores.

Una vez puesta la demanda, se inicia una lucha entre el médico en cuestión, el paciente, las circunstancias que dieron lugar a la queja y los documentos que apoyan las pretensiones de quien las presenta. Un duro camino que los profesionales intentan evitar a través de la medicina defensiva. Si pierde la demanda, se cuestiona la propia capacidad profesional y la integridad personal del especialista se destroza.

Es complicado evaluar la extensión de la medicina defensiva y sus costes agregados. Aunque no haya datos, los médicos aseguran que se ven obligados a hacer seguimientos innecesariamente al paciente e inician estudios complementarios no justificados para enfrentarse a un supuesto futuro juicio. Ya ven a sus pacientes como enemigos, y son los propios médicos los que alertan del abuso de la medicina defensiva precisamente para evitar potenciales conflictos.

La medicina defensiva dista todavía más al médico del paciente. Por eso JerónimoFernández Torrente, vicesecretario de la Organización Médico Colegial (OMC) propone que los médicos lleven al a práctica acciones que permitan renovar en sus consultas la esencia de la medicina humanista y restaure la relación con el paciente. Es lo que se denomina “medicina asertiva”, donde la comunicación entre paciente y médico sea el epicentro entre ambos. “Supone reconocer el derecho de todos los involucrados, así como las asimetrías diversas entre los actores”.

Falta comunicación entre médico y paciente

El reconocimiento y el respeto de los derechos de os pacientes es un componente obligado de una medicina asertiva. Sólo en este marco (de respeto y ejercicio de los derechos) se podrá realizar el principio de autonomía, bajo el cual el paciente asume la toma de decisiones de acuerdo a sus propios intereses y valores. “Porque deben entender que los médicos no hacen milagros y que también se equivocan, aunque no quieran”, explica Marciano Sánchez-Baile, portavoz de la Federación de asociaciones para la defensa de la sanidad pública.

Fernández Torrente explica que la medicina asertiva exige prestar la debida atención a los aspectos verbales y no verbales, conscientes y no conscientes, explícitos e implícitos, que conforman el entramado de la comunicación entre las dos personas. “Todos somos responsables de este tipo de prácticas, y cada uno debe asumir su parte de culpa, incluida la administración pública, que deja que los médicos ejerzan sin los recursos suficientes su trabajo”.

Tampoco existe medicina asertiva al margen del reconocimiento y respeto de los derechos del médico por parte de los usuarios, instituciones y autoridades sanitarias. Por eso los expertos coinciden en que no sólo hay que educar a médicos y pacientes, sino que es necesario reflexionar “acerca de una nueva deontología médica en el marco de las actuales condiciones de avance científico-tecnológico, organización de los servicios asistenciales y modalidades del trabajo médico”, concluye el vicepresidente de la OMC.

Todos se ponen de acuerdo: el abuso de la medicina defensiva debe ser discutida urgentemente por todas las entidades que agrupan a los profesionales de la salud (incluida administración) para que, de una vez por todas, se salga de esta encrucijada que asfixia tanto a médicos como a pacientes.

### Ética y Medicina Defensiva

Dr. Raymundo Paredes

Introducción

En múltiples artículos, textos y conferencias de los últimos años en varias partes del mundo, se menciona el incremento en las quejas por mala práctica médica, las que han dado lugar a demandas con la consecuencia moral y económica al implicado, quien ha visto disminuido su prestigio e ingresos y en no pocas ocasiones lo orillan a retirarse del ejercicio de la profesión.1, 2, 3
Como resultado el médico selecciona sus casos y rechaza o refiere a los que considera de riesgo, solicita múltiples estudios, -frecuentemente innecesarios- para evitar reclamos por omisión o falta de evidencias para su diagnóstico y tratamiento; realiza intervenciones quirúrgicas innecesarias o deja de hacer otras que si lo son, para evitar quejas de sus pacientes y no verse involucrado en una demanda. Demandas y juicios que son la principal causa del proceder defensivo del médico, de hecho podría considerarse que de no existir estas, no habría medicina defensiva. Las compañías de seguros crearon los seguros de protección médica –responsabilidad profesional- con aumentos progresivos en la prima. Todo esto ha ocasionado el encarecimiento de la medicina y forma parte de lo que se ha llamado Medicina Defensiva. 4,5

Tancredi en 1978 hace referencia a la Medicina Defensiva como el empleo de procedimientos diagnóstico-terapéuticos con el propósito explícito de evitar demandas por mala práctica. En una publicación previa la definimos como: “Cambios en la práctica del médico para defenderse de controversias y demandas por juicios en su ejercicio profesional”. 1,6

En este concepto esta implícita la ética médica; el médico o la institución que actúa de manera defensiva, en contra de los intereses de sus enfermos o limitando sus derechos, esta faltando a la ética.

Las causas del proceder defensivo del médico son múltiples, analizare algunas de ellas, su efecto sobre la ética del ejercicio médico y al final propondré alternativas y recomendaciones para evitarlo.

Causas

• Falta de responsabilidad del médico.
• Proliferación de escuelas y facultades de medicina.
• Avances en tecnología, comunicación e informática.
• Situación económica.

Ante la posibilidad de queja o demanda por parte del paciente, el médico evita tomar la decisión de ciertos tratamientos médicos o procedimientos quirúrgicos, en el mejor de los casos consulta otros médicos, o si trabaja en un hospital somete el caso al comité correspondiente, en ocasiones lo deriva o rechaza. Esta actitud, algunos médicos la justifican por el progreso de la medicina en los últimos 50 años, que los ha rebasado1 , otros a la presión del paciente y sus familiares que exigen o rechazan tratamientos en base a información y la apreciación que tienen del médico como prestador de servicios -a su servicio- mas que como un aliado en la búsqueda de la salud y bienestar del enfermo. 7

En esta situación el médico puede adoptar conductas defensivas anti-éticas por falta de responsabilidad (negligancia), de capacidad y conocimientos (impericia), falta de habilidad para establecer empatía y una buena relación médico-paciente que le permitan lograr la participación de su enfermo y compartir con el las decisiones. Desde luego esto no justifica el proceder defensivo, pero ante la mala preparación con que egresa de la licenciatura, las pocas oportunidades y el poco interés de actualizarse, su desempeño es inadecuado, con aplicación superficial de procedimientos clínicos y en ocasiones exceso de confianza, que lo hace invadir campos de la medicina que no domina (imprudencia).

Proliferación de escuelas y facultades de medicina.

Avances en tecnología, comunicación e informática.

Otro aspecto a considerar, es el desarrollo de la tecnología médica, la electrónica y las comunicaciones, que permiten a los enfermos y sus familiares tener acceso a la información rápida y actualizada de su padecimiento, que pudiera ser en ocasiones más reciente que la de su médico, - si bien, superficial y en algunos casos con sesgo -, situación que ha modificado la relación médico-paciente3 al permitirle no solo participar sino también presionar en las decisiones diagnóstico-terapéuticas, cuestionarlas, aceptarlas o rechazarlas. El paciente demanda, atención y resultados favorables inmediatos y no acepta dudas o errores, exige ciertos estudios y tratamientos, si el médico no accede, busca quien se los proporcione, actitud que de alguna manera, contribuye al comportamiento inadecuado del médico, ya que cuando éste no tiene preparación sólida y principios éticos firmes depende y emplea los recursos tecnológicos con mayor frecuencia de lo necesario, aun sin conocer la indicación precisa y los riesgos. Utiliza poco la clínica y el trabajo intelectual para elaborar diagnósticos y prescripciones. 12,13,14

Situación económica.

La medicina administrada (HMO’s en USA e ISES en México), tiene aspectos que no se apegan a la ética: seleccionan afiliados y rechazan enfermos portadores de padecimientos crónico-degenerativos o de edad avanzada; también imponen condiciones que “obligan” a sus médicos contratados a actuar fuera de los principios de la ética; a saber: limitación para interconsultas, exámenes de laboratorio y gabinete e internamientos, todo esto en detrimento de los derechos de los pacientes y del propio médico.15.16,17

El médico que oculta al paciente la necesidad de un medicamento, la opinión del especialista o de una intervención quirúrgica por la presión del empleador y la necesidad de conservar su trabajo, se cubre tanto de su patrón como del paciente y cae en actitudes ambigüas no éticas y defensivas.

Algo semejante ocurre en las instituciones del sector salud, los hospitales, (sus directivos, administradores y en ocasiones el personal médico y paramédico) faltan a la ética cuando difieren la consulta o la intervención quirúrgica que el paciente requiere por carencia de medicamentos, material, equipo o personal, ocultan la indicación minimizando el problema, lo que ocasiona malestar, inconformidad y queja o demanda (daño moral). Cuando el médico es involucrado por una situación de este tipo, cae en actitudes anti-éticas y defensivas para preservar su trabajo y en ocasiones su prestigio.

Medicina Defensiva y Ética del Ejercicio médico.

Ante esta situación que modifica la práctica médica, es necesario plantearnos la pregunta.
¿Es ética la Medicina Defensiva?.
La respuesta inmediata es no

La medicina defensiva es destructiva

Deteriora la relación médico-paciente, propicia la pérdida de la confianza entre ellos y si llega a queja formal o demanda, ocasiona pérdida de la confianza del médico en sí mismo y favorece posteriormente su proceder defensivo. 18

La medicina defensiva no es ética, ni es sólo el médico el único responsable de su existencia; si consideramos que el médico se auto-protege al solicitar exámenes, prescribir medicamentos o realizar procedimientos quirúrgicos para evitarse problemas, concluimos que se trata de un proceder inadecuado y es consecuencia de su historia personal, tanto de su preparación deficiente o no actualizada como de su inadecuada formación ética y moral en el seno familiar, su medio social y en la escuela.

Si durante el estudio del enfermo el médico recurre a exámenes de laboratorio y gabinete en exceso, invasivos o costosos, para evitarse quejas o demandas, incurre en actitudes defensivas que dañan a la persona y a su economía (gastos de bolsillo –en ocasiones catastróficos- no contemplados). Si indica o realiza intervenciones quirúrgicas no justificadas y lo que es peor, si las realiza con fines de lucro, y sin fundamento, constituyen no sólo faltas a la ética médica, sino verdaderos actos criminales. 19

El médico no es el único culpable, si tomamos en cuenta que son las escuelas de medicina, sus programas, los profesores y las instituciones de salud los primeros implicados en la preparación del médico, tanto en su formación básica como en el posgrado, ahí podríamos ubicar el primer co-responsable de esta forma de actuar del médico.

En la consulta de pacientes ambulatorios son poco frecuentes las quejas tanto a nivel público como privado, si acaso el enfermo reclama falta de efectividad en la prescripción o algún resultado indeseable, directamente al médico y que se resuelve fácilmente entre ellos o con la participación de la CONAMED sin pasar a mayores; en estos casos el médico falta a los principios de lo que podríamos llamar ética de la prescripción, ya que no conoce los efectos indeseables inmediatos o a largo plazo de los fármacos que indica. De conocerlos y si no existe alternativa, debería informar a su paciente y en función del riesgo beneficio juntos decidir si lo prescribe o no. En estos casos más que medicina defensiva, hay falta de preparación y por tanto de principios éticos. La prescripción de medicamentos nuevos para tratar algún padecimiento basándose en la información del laboratorio sin conocer la farmacología del mismo y hacerlo sólo por la novedad, es irresponsable, anti- ético y pone en evidencia la falta de conocimientos.

El médico asume actitudes defensivas y falta a la ética médica cuando oculta información de exámenes de laboratorio y de gabinete o de intervenciones quirúrgicas que solicitó o realizó y cuyos resultados hacen evidente que se equivocó al solicitarlos o que el diagnóstico preoperatorio no se confirma con los hallazgos quirúrgicos, con mayor razón si lo hace para evitarse reclamos o demandas.

En algunas circunstancias, sobre todo cuando el médico trabaja para alguna institución del sector salud, y ante el temor a la crítica o la reclamación de su paciente o los familiares, oculta información; en el caso del pronóstico, lo externa objetivamente, en ocasiones cruda y cruel pero verdadera y si es desfavorable o contrario a lo que el paciente esperaba, ocasiona serio impacto afectivo. Ante esta situación, el médico debe informar a su paciente con frecuencia y de la manera más comedida y menos agresiva posible, sin faltar a la verdad y a la ética médica. Es importante en situaciones como la antes referida tener en mente siempre, que habitualmente los pacientes no demandan cuando les va mal, sino cuando están enojados por mal trato o información inadecuada.

En cuanto a la atención y tratamiento de personas con bajos recursos económicos y deficiente educación, -tan frecuente en nuestro país- estas condiciones no deben ser factor significativo en las decisiones médicas ya que si bien de acuerdo a lo referido en la literatura al respecto, son los “pobres” los que menos demandan al médico, a estas personas como a cualquier otra que se brinde atención médica, ésta debe ser de la mejor calidad y con responsabilidad.20,21

Alternativas

El interés primordial del médico debe centrase en demostrar sus conocimientos habilidades y actitudes que den como resultado el respeto del paciente y su familia aun frente a un mal resultado, esta es la mejor protección ante las actitudes defensivas y las demandas. 22

El manejo hábil -con conocimientos y destrezas actualizados y apegados a las normas y guías de la especialidad- y humano de la práctica médica es la mejor forma de manejar el riesgo implícito en el ejercicio de la profesión.

El médico responsable, se compromete con su capacitación y con la toma de decisiones justas para sus enfermos y para el mismo.

Cuando los pacientes y sus familiares están molestos por el resultado, pero satisfechos con el trato del médico, son incapaces de poner siquiera un pie en la CONAMED, en el ministerio público o en la oficina de un abogado. Actuar con temor y preocupación exagerada en detrimento del paciente degrada la práctica (el ejercicio) de la medicina. Hay cada vez más literatura en relación al beneficio de aceptar los errores ante el paciente y la comunidad médica. El médico debe actuar de manera honesta para evitar daño al paciente y por lo tanto verse sujeto a una demanda. 23,24

Conclusiones:

Algunas prácticas defensivas son adecuadas (¿?) otras modifican la atención del paciente e incrementan los costos a niveles que son éticamente cuestionables. 13,19,25

Las prácticas defensivas pudieran ser benéficas para la atención del paciente cuando el médico es consciente de sus fallas y riesgos y busca corregirlas mediante:

• Capacitación y actualización continua.
• Mejor relación médico-paciente.
• Tratamientos médico-quirúrgicos con indicación precisa.

Las que pueden modificar la atención del paciente y elevar los costos al enfermo o la institución y volverse éticamente sospechosas son:

• Mayor referencia de pacientes.
• Múltiples interconsultas.
• Uso excesivo de laboratorio y gabinete
• Cirugías no necesarias
• Contratación de seguros por mala práctica

Recomendaciones

El médico debe aprender a valorar realistamente el riesgo legal de su desempeño profesional y tomar en cuenta el costo emocional, físico y financiero al paciente, antes de emplear medidas defensivas.23,24

La mejor manera de actuar éticamente y evitar riesgos por el desempeño profesional es ejercer una Medicina Centrada en el Paciente. El ejercer este tipo de medicina resulta complejo y al mismo tiempo sencillo.

Complejo porque involucra la formación del médico desde su origen familiar y social, en la preparación básica, en la universidad, en su paso por los hospitales, durante su licenciatura o en el posgrado y finalmente en el ejercicio cotidiano de su profesión. Esto quiere decir, que los principios morales y éticos los adquiere durante toda su vida y que la ética médica la aprenderá y aplicará cuando estudie y ejerza la medicina.

Sencillo porque el actuar éticamente sólo exige honestidad y seriedad, consigo mismo y con su paciente. Para actuar honestamente se requiere tener una preparación básica sólida, actualizarse, capacitarse continuamente y anteponer los derechos y el bienestar del paciente al afán de lucro y frecuentemente al bienestar personal. Actuar siempre con la verdad, aunque esto implique reconocer errores y el riesgo que conlleva. Mantener altos estándares de desempeño, a nivel de médicos generales o especialistas calificados y de las guías o manuales de procedimientos. 26,27,28

Para terminar, es importante al emitir juicios sobre la actuación del médico, considerarlo como ser humano, que su labor se desarrolla en gran medida en un ámbito de incertidumbre y que la posibilidad de cometer un error no es totalmente evitable.

Finalmente, tener presentes durante el ejercicio profesional las cartas de los derechos de los pacientes y de los derechos generales de los médicos como lineamientos oficiales propuestos por la Comisión Nacional de Arbitraje Médico: 29

Decálogo de los Derechos Generales de los Pacientes.

2. Recibir trato digno y respetuoso
3. Recibir información suficiente, clara, oportuna y veraz
4. Decidir libremente sobre su atención
5. Otorgar o no su consentimiento válidamente informado
7. Contar con facilidades para obtener una segunda opinión
8. Recibir atención médica en caso de urgencia
9. Contar con un expediente clínico
10. Ser atendido cuando se inconforme por la atención médica recibida

Decálogo de los Derechos Generales de los Médicos

1. Ejercer la profesión en forma libre sin presiones de cualquier naturaleza
2. Laborar en instalaciones apropiadas y seguras que garanticen su práctica profesional
3. Tener a su disposición los recursos que requiere su práctica profesional
4. Abstenerse de garantizar resultados en la atención médica
5. Recibir trato respetuoso por parte de los pacientes y sus familiares, así como del personal relacionado con su trabajo profesional
6. Tener acceso a educación médica continua y ser considerado en igualdad de oportunidades para su desarrollo profesional
7. Tener acceso a actividades de investigación y docencia en el campo de su profesión
8. Asociarse para promover sus intereses profesionales
9. Salvaguardar su prestigio profesional
10.Percibir remuneración por los servicios prestados.

BIBLIOGRAFÍA

1. Trancredi LR. The problem of defensive medicine. Science 1978; 200(4344):879-82
2. Charles SC. Sued and nonsued physician’s self-reported reactions to malpractice litigation. American Journal of Psychiatry 1985; 142(4): 437-40
3. Zuckerman S. Medical malpractice: claims, legal costs, and the practice of defensive medicine. Health Affairs 1984; 3(3): 128-33.
4. Weisman CS. Practice changes in response to the malpractice litigation climate. Results of a Maryland physician survery. Medical Care 1989; 27(1): 16-24.
5. Guarner V. Las operaciones innecesarias en el ejercicio de la cirugía. Un tema de nuestro tiempo con graves implicaciones en la ética médica. Gac Med Mex 2000; 136(2): 183-8
6. Paredes-Sierra R, Rivero S.O. Medicina Defensiva. En : Arbitraje Médico. Análisis de 100 casos . JGH Editores. México, 2000. pp. 89-91
7. Summerton N. Trends in negative defensive medicine within general practice. Br J Gen Pract 2000; 50(456): 565-6
8. http://amfem.edu.mex/sept 2002
9. José MV Transición demográfica y epidemiológica Problemas para la Investigación. Salud Pública Mex. 1989; 31: 196-205
11. Urbina FM. Población y Salud: en El Ejercicio Actual de la Medicina. Ed. Siglo XXI Mex. Oct 2000 isbn 968-36-81-409.
12. Lifshitz A. El médico ante los avances de la comunicación. En El Ejercicio Actual de la Medicina. Ed. Siglo XXI. Mex. Oct 2000. isbn 968-36-81-40-9.
13. Decaí ML. Is the defensive use of diagnostic tests good for patients, or bad? Med Decis Making 1998; 18(1): 19-28
14. Vilar PP. Tenorio F. Impacto de la tecnología en el ejercicio de la Medicina moderna. En: El Ejercicio Actual de la Medicina. Ed. Siglo XXI Mex. Oct 2000. isbn 968-36-81-40-9.
15. Feldman DS. Effects of Managed Care on Physician-Patient Relationships, Quality of Care, and the Ethical Practice of Medicine: A Physician Survery. American Medical Association 1998; 158(15): 1626-1632.
16. Bursztajin HJ. A New Resource for Managing Malpractice Risks in Managed Care. American Medical Association 1996; 156(18): 2057-2063.
17. Hall RC. Ethical and legal implications of managed care. Gen Hosp Psychiarty 1997; 19(3): 200-8.
18. Erder EL. Reviews and Notes: Ethics: Standard of Care: The Law of American Bioethics. Ann Interm Med 1994; 120(5): 448.
19. De Ville K. Act first look up the law afterward?: medical malpractice and the ethics of defensive medicine. Theor Med Bioeth 1998; 19(6): 569-89.
20. Vincent C. Why do people sue doctors? A study of patients and relatives taking legal action. Lancet 1994; 343(8913): 1609-13.
21. Burstin HR. Do the poor sue more? A case-control study of malpractice claims and socioeconomic status. JAMA 1993; 270(14): 1697-701.
22. Secker-Walker J. Risk in clinical care. Nurs Manage 1997; 3(9): 22-23.
23. Kraman SS. Risk Management: Extreme Honesty May Be the Best Policy. Ann Intern Med 1999; 13(12): 963-967.
24. Rosner FMD. Disclosure and Prevention of Medical Errors. Arch Intern Med 2000; 160(14): 2089-2092.
25. Summerton N. Positive and Negative Factors in Defensive Medicine: A Questionnaire Study of General Practitioners. BMJ 1995; 310(6971): 27-29.
26. Smith DH. How to be a Good Doctor in the 1990s: Stand and Deliver. Am J Obstet Gynecol 1994; 170(6): 1724-1728.
27. McQuade JS. The medical malpractice crisis-reflections on the alleged causes and proposed cures: discussion paper. Journal of the Royal Society of Med 1991; 84(7): 408-11
28. Reducing Legal Risk by Practicing Patient-Centered Medicine. Arch Intern Med 2002; 162: 1217-1219.
29. http://www.conamed.gob.mx/enero 2003

* Profesor de Asignatura Definitivo Facultad de Medicina FES Iztacala UNAM

• 1.- Progreso, que ha tenido efectos favorables y desfavorables: entre los primeros está, por una parte, la mejoría en la calidad y oportunidad de la atención médica, derivada de la disponibilidad de procedimientos diagnóstico-terapéuticos más exactos y menos invasivos; entre los segundos -desfavorables- podríamos citar el distanciamiento entre el médico y su enfermo, la fragmentación en super-especialidades y el encarecimiento de la medicina. 7
• 2.- A la fecha son aproximadamente 80 en el país, de las cuales 62 están afiliadas a la Asociación Mexicana de Facultades y Escuelas de Medicina (AMFEM), 25 han sido acreditadas por 5 años, 11 están en proceso de dictamen, 24 en autoevaluación y 2 están en trámites de afiliación, esto hace un total de 62, lo que deja alrededor de 20 trabajando en la “ilegalidad” (¿antiética?) Fuente: AMFEM Septiembre 2002 Ref. 8
• 3.- Relación que se vuelve perversa cuando intervienen terceros ajenos que hacen pensar al paciente que el resultado desfavorable se debe a mala práctica y no a la evolución natural de la enfermedad; se enrarece aún mas cuando este tercero es un abogado que aconseja exigir indemnización.
• 4.- En 1999 la DGP tenía registrados 208,765 médicos y la ANUIES publicó en su anuario estadístico de 1998 que egresaban 7,597 médicos de las escuelas y facultades del país cada año, de los cuales se titulan 5,107. Ref.10

 Keyword(s): Medicina Defensiva

### 5 Must-Track Metrics for Practice Profitability

Discover the five key data metrics that will help power your practice's financial success.
In this free whitepaper you'll learn how to:

• Gauge the success of your revenue cycle management processes
• Uncover factors hurting your practice's finances
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• Identify missed revenue opportunities, and more.

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### Patient Portals: A Win-Win for Practice and Patient

Patient portals not only help physicians comply with the Stage 2 rules of meaningful use, but can also build stronger ties with patients. Here’s how your practice can select the right portal and get both staff and patients on-board with using this emerging technology to its fullest potential.

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#### Secondary Storage

Secondary storage, sometimes called auxiliary or external storage, is non-volatile storage that is not under the direct control of a computer's central processing unit (CPU) or does not directly interact with an application.

Typically, secondary storage is used to back up primary storage through replication, which involves holding a secondary copy of the data. To choose an effective secondary storage media, one must first understand the data's value, how often it's used and how it will be accessed. External hard drives, portable flash drives, CDs, DVDs and cloud backup are often used for secondary storage.

In a business environment, an older network-attached storage (NAS) box, SAN array or tape may be used for secondary storage. Object storage systems can also be used as an inexpensive way to implement secondary storage and lessen the demand on primary storage arrays. The growth of corporate data has prompted many storage managers to move data to secondary storage to ease the strain on primary storage systems, reclaim more expensive storage arrays and maintain older data in an easily accessible form to satisfy business and regulatory requirements.

Secondary storage is usually asynchronous; as a result, the data in secondary storage may not be as current as the data in primary storage, especially when backups are not policy-driven and automated. Generally, secondary storage devices perform at a lower level than secondary storage and are less expensive. For many companies, placing a second class of storage between their primary storage and archived storage is the first step toward a tiered storage environment.

• Bit rot is the slow deterioration in the performance and integrity of data stored on storage media. It is also known by the names bit decay, data rot, data decay and silent corruption.

Bit rot is the slow deterioration in the performance and integrity of data stored on storage media. It is also known by the names bit decay, data rot, data decay and silent corruption. Storage array vendors are aware of bit rot and build their products to identify flaws in disks before they place them in arrays, and then monitor disks in production to detect rot before it becomes a problem. While the frequency of bit rot in data is typically low, it can be increased by wear, dust or other contaminants, background radiation and instances of high heat. To guard against bit rot, administrators should periodically go through stored data and compare it to a known copy.

• ##### LUN management is the process of assigning, provisioning and overseeing logical unit numbers (LUNs) across a storage environment.

LUN management is the process of assigning, provisioning and overseeing logical unit numbers (LUNs) across a storage environment. LUN management is a standard feature in storage management software. Since an enterprise storage array may host more than 10,000 LUNs, it is important for administrators to be able to efficiently create and manipulate LUNs.  Masking and zoning, are key features of logical unit number management. LUN management tools can bevendor- or product-specific, orheterogeneous, allowing LUNs to be managed across all storageplatforms. Some  LUN management tools are able to reclaim storage that is no longer needed and provide administrators with reporting capabilities.

#### Glossary

"Secondary Storage" is part of the:

 Keyword(s): SecondaryStorage

### IDC Whitepaper: The Role of Linux in Datacenter Modernization

Industry changes, technology advancements, and changing applications - these are all factors that have made the datacenter an IT investment that is always evolving. And as the IT environment becomes more complex, datacenters will require intensive modernization strategies that go beyond simply expanding floor space. This IDC whitepaper examines how today's datacenters are adapting to and leveraging changing technologies and how Linux can act as an enabler for this evolution. Read on and learn more about Linux's evolving role in the datacenter now and in the future.

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### The role of mobile tech in treating mental health issues

Studies back its efficacy

As we mentioned last month, most smartphone users want to interact with their physician using a mobile device or smartphone. Given the potential for the mishandling of sensitive information, there are a few privacy obstacles to overcome before such a thing becomes common practice, but consumer interest is there.

Arranging a doctor appointment or checking insurance benefits are a couple of low-risk ways patients can engage with the healthcare supply chain via mobile without putting too much of their personal data at risk. Now, the Guardian's Conor Farrington wonders if mobile technology can also be used to offer people better access to mental health treatment.

"[M]any existing capacities of tablets, smartphones and even 'dumbphones' can be repurposed to serve diagnostic, monitoring, and therapeutic functions," explains Farrington. "At the lower end of the scale, researchers at Oxford and elsewhere have shown that SMS and voice-calls can be used to assess mental health status, deliver talking therapies (eg cognitive behavioural therapy) and stimulate behavioural change."

Farrington notes that tablets and smartphones on the higher end of the technology spectrum are even better equipped to assist in the diagnosis and treatment of mental health issues--"for instance through multimedia apps, [that] draw on a wider range of sensors and capacities--eg accelerometers, GPS and camera--to generate richer data and smarter interventions," he says.

study published last year in the Journal of Medical Internet Research reviewed a series of mobile apps aimed at people struggling with depression, anxiety and substance abuse. Researchers found a "significant reduction" in the symptoms of people who used the apps, concluding that "mental health apps have the potential to be effective and may significantly improve treatment accessibility. However, the majority of apps that are currently available lack scientific evidence about their efficacy."

The idea is not without hurdles that, again, relate back to privacy issues. Of equal importance is ensuring that the use of mobile apps, smartphones and tablets don't remove the human element from mental health treatment plans.

For more:
- read the study about the use of mobile apps to treat mental health issues
- get statistics about the prevalence of mental health issues in the U.S.

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#### 2014 Insider Threat

The 2014 Vormetric Insider Threat Report - European Edition represents the result of analysis of interviews with 537 IT and Security managers in major European enterprises around the question of insider threats. Insider threats have expanded from the traditional insiders to privileged users of systems and the compromise of internal accounts by the latest malware attacks. This report captures the key findings, focusing on comparisons critical results around organizations insecurities, concerns, technology investments as well as comparisons against their US counterpart's responses.

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#### Best Practices for Managing Archive Migrations

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### Three Tips to More Effective and Efficient Use of Your EHR

By Avery Hurt

Choosing, buying, and installing EHR software is hard enough. Then there's training staff and making sure patient data is secure. And for practices that choose to take part in CMS' meaningful use program, learning to use the EHR as efficiently and effectively as possible is crucial.

"This is not an easy task," Steven Waldren, director of the American Academy of Family Physicians' Alliance for eHealth Innovation told Physicians Practice. "We've struggled to help our members with this." Nonetheless, he has some practical advice. "Keep in mind that the goal is not just to automate your practice, but to make it work better. In order to do this, you have to think outside the box."

Here are some ideas to get you started to get the most of your EHR to meet those meaningful use requirements:

• Examine work flow.
In order to best use your EHR, you may need to step back and get your nose away from the computer screen, so to speak. Waldren suggests doing a very basic analysis of your practice, looking closely at work flow. Ask yourself: Where are people stumbling? Who is struggling to get work done and who has extra time? Waldren gives an example from the early days of electronic records: "Back when e-prescribing first came along, if a doctor decided to prescribe a new drug for a patient, the doctor then had to figure out what pharmacy the patients used, which location, and so on. It quickly became clear that things went much more smoothly if all this information were gathered at intake. By studying work flow and observing how patients are moving through the system, you can find ways to make the process go more smoothly."

• Have a practice powwow.
Don't try to figure this out all on your own. Brainstorm with everyone in your office. Your staff will often have good ideas. They know what's slowing them down and very often have good ideas about what can be done to fix the problem.

• Reach out to peers.
Brainstorm with other doctors as well. "We're trying to pull together innovators and disseminate information about what they are doing," said Waldren. Meanwhile, ask other doctors you know what has worked for them and let them know what's working for you.

Don't be overwhelmed by the challenges of integrating this technology into your practice. "Little steps make a big difference," said Waldren, "and you'll have more success in the long run if you consider this another quality improvement practice."

 Keyword(s): EHR

### Key Risk Indicator (KRI)

Posted by Margaret Rouse

A key risk indicator (KRI) is a metric for measuring the likelihood that the combined probability of an event and its consequence will exceed the organization's risk appetite and have a profoundly negative impact on an organization's ability to be successful.

If an organization specializes in retail sales, for example, a key risk indicator might be the number of customer complaints because increase in this KRI could be an early indication that an operational problem needs to be addressed. The challenge for an organization is not only to identify which risk indicators should be identified as being key (most important) but also to communicate that information in such a way that everyone in the organization clearly understands its significance.

Identifying key risk indicators requires an understanding of the organization's goals. Each KRI should be able to be measured and accurately reflect the negative impact it would have on the organization's key performance indicators (KPIs).  Key performance indicators, which are often confused with key risk indicators, are metrics that help an organization assess progress towards declared goals.

### PPT

 Keyword(s): KRIKey Risk Indicator

### New Health App to Link Patient Data with Physician EHRs

By Beth A. Balen

There are all kinds of health apps that track blood pressure, medications, nutrition, exercise, you name it. WebMD has one. Weight Watchers, Nike, FitBit, and CVS pharmacy and Walgreens pharmacy do too. A huge new player coming to the market in the fall of 2014 is Apple's "Health" app, which will be a standard feature of the new iOS8. Health will provide users an easy-to-read dashboard that integrates all their fitness and health data into one convenient place.

The Health app will gather data from many fitness and health apps, giving easy to access information on exercise, lab results, medications, food, sleep, and vitals, such as blood pressure.

Health also includes a new tool called "HealthKit" that will allow outside developers to give their own apps access to your health data, even giving you the ability to share that data with your doctor's EHR.

The connections between EHRs and Apple's Health app don't exist yet, but they may be active as soon as this fall. I question whether doctors would be interested in such a gadget, as it could potentially provide a lot of irrelevant data. But, a feature of Health gives patients the ability to choose which data they wish to share with health providers, so perhaps the doctor would just want to receive daily blood pressure or weight measurements.

Apple worked with the Mayo Clinic for the past five years to develop HealthKit. They have also been working with UCLA and Stanford Hospitals, Cambridge University Hospitals, Nike, and Epic.

Mayo Clinic's marketing medical director, John Wald, says they want to use their own health app to communicate with the HealthKit's cloud information repository, using it to access personal health information and develop relationships with their patients, before they get sick. They are already using their app with HealthKit to monitor specific vital signs such as blood pressure, and to alert the doctor if readings are out of normal ranges.

Wald says he is convinced that physicians will use this new technology, since their lives can be made easier by keeping patients healthy. It also could help physicians earn some extra money if they are taking advantage of payer incentives that reward them for keeping their patients out of the hospital. Physicians can be slow adopters of new technology, so it remains to be seen whether this will pan out.

Here's what I see as practical user benefits and adoption tips:

• HealthKit-type programs could help with compliance. The second stage of the government's meaningful use requirements includes patient engagement through electronic tools. Most often this happens through either a secure Web portal or secure messaging between patient and physician. Since one of the requirements is that at least 10 percent of patients actually use that system, geeky people like me might gravitate toward it more, if apps are available for health interaction.

• Medical data sharing and monitoring may help physician offices get some of those insurance bonuses for keeping their patients healthy. And wearable devices that communicate the data directly will be more accurate than the patient's self-report, for instance, of how much the patient exercised this week.

• If using an EHR giant like Epic, the technology may be closer to going live than you might think. If you use Epic, start talking with your vendor now to start planning for this future functionality.

• Patients will have to be aware of the Health app. Once the new technology is available it could be communicated to patients in the same way you communicate about your patient portal. Some offices give every patient a handout on the portal and how to access it. Include the apps you communicate with, and the data you would like them to report.

• Choose specific information to have the patient share so the data is not overwhelming and potentially ignored due to sheer volume. This new digital functionality may just be the next version of disruptive technology in the healthcare world.

### 93% believe EHR-connected mHealth apps benefit patient care

Author Name Jennifer Bresnick

Physicians want patients to use mHealth apps as much as patients themselves do, a new survey by EHR vendor eClinicalWorks says.  From scheduling appointments and emailing nurses to receiving follow-up reminders and accessing their own EHR data, mobile smartphone apps have numerous uses before, during, and after a clinical visit, and an overwhelming majority of physicians are eager to embrace the technology.

More than ninety percent of the 650 physicians polled believe that mHealth apps have the potential to improve patient outcomes, and an equal amount would like to see apps give patients the ability to upload data into their personal EHR file. Eighty-nine percent would recommend an app to a patient in the future.

The ability to send patients reminders and alerts topped the mHealth wish list for respondents, followed by allowing patients to access their PHI from mobile devices, making it easier for patients to conduct administrative tasks like appointment scheduling, and getting more accurate self-reported data from patients on a regular basis.  Preventative care, diabetes monitoring, weight management, and medication adherence were all areas of opportunity for mHealth apps to address.

The mHealth market is expanding rapidly, and is expected to reach 1.7 billion usersworldwide by 2017, according to a recent prediction.  Patients are beginning to trustdownloadable apps as much as a live clinician even as physicians are starting to accept the idea of patient-reported data being useful for diagnosis, monitoring, and treatment.  With mHealth tools projected to save more than $500 billion in productivity, travel, and administrative costs over the next ten years, both consumers and providers are taking notice of the market’s potential. “In order to transform healthcare, patients need to be engaged,” said Girish Kumar Navani, CEO and co-founder of eClinicalWorks. “People are invested in and want to be engaged in their health as long as they trust the source of the information.” Apps provided by or otherwise linked to their trusted providers may help drive patient engagement ahead of Stage 2 meaningful use, which requires 5% of patients to access or download their health information online through a portal. With more than half of the survey’s participants representing primary care, the pervasive willingness to adopt mHealth seems to bode well for the Stage 2 requirement and the future of mobile healthcare. Related White Papers: Related Articles:  Keyword(s): Health AppLink Patient DataPhysician EHRs #### New Hospital CEOs Tend to Be Outsiders, Were Rarely CIOs Credit: Getty Images ### New Hospital CEOs Tend to Be Outsiders, Were Rarely CIOs #### Look at the hospital C-suite moves made so far in 2014 and you'll see that facilities tend to hire outside candidates for CEO and promote the COO if they do look internally. They all but ignore the CIO when filling the corner office -- but that might actually be a sign of respect. Earlier this year, the American College of Healthcare Executives released its annual report on hospital CEO turnover rates. At 20 percent, the rate is the highest it's been since the organization started analyzing those numbers in 1981. (ACHE gets its data from the American Hospital Association.) ACHE attributes this to a combination of factors – retiring Baby Boomers, hospital consolidation and increasing complexity. In addition, healthcare is struggling with meaningful use and other technology initiatives, preparing for ICD-10 and adapting to rapidly changing business models. Such high hospital CEO turnover, then, shouldn't be too surprising. It does raise a question, though: Who's replacing the departing CEOs? To answer that, Billian's HealthDATA and Porter Research looked at announcements of executive moves tracked in the first seven months of 2014. The resulting study examined more general hospital C-suite trends, as CEO moves accounted for only 53 percent of the 384 personnel announcements. Several points stand out: • Sixty percent of C-level executives came from outside the organization. For CEOs specifically, the figure was 58 percent. • A "good portion" of the placements came with "interim" tag, says Jessica Clifton, marketing director at Billian's. This reflects the transition in the market as, for example, facilities merge and consolidate roles. • New COOs came from outside the organization 27 percent of the time. In addition, COOs were the most likely internal candidates for a move to CEO, receiving that promotion 44 percent of the time. Clifton says this could be because COOs take a multifaceted approach to their work, building relationships with "multiple wings of the hospital." • Chief nursing officers (CNOs) were the most likely executives within an organization to be promoted to COO. This occurred in 17 percent of cases. • In all, women comprised 28 percent of new C-suite or director-level hires. CEOs made up the plurality, at 38 percent, followed by CNOs (26 percent) and COOs (13 percent). #### Healthcare CIOs, CEOs From Other Industries Rarely Get Hospital Corner Office The research is also notable for what it didn't find. For starters, only 3 percent of hospital C-suite hires came from outside the hospital or health system environment. Clifton expects this number to increase. Market forces leave today's hospitals to compete for patients – who, when comparing rising healthcare costs to declining travel costs, can be more discerning consumers than they have been. "Patients have so much more flexibility than they used to," she says. This should drive innovation in areas such as patient engagement; here, Clifton says, hospitals that bring in executives with hospitality and customer service experience will be at an advantage. In addition, only one of the 384 personnel moves thus far in 2014 involved the promotion of a CIO to the role of CEO. This isn't necessarily because CIOs can't handle the top job but, rather, because of the importance in building healthcare IT infrastructure, Clifton says. The CIO is "a key role to have in place." Finally, Billian's saw little activity regarding healthcare CISOs and CSOs, though Clifton says this will likely change as hospitals segment their technology roles. The same was true for clinical informatics roles, she adds, but that's due in part to the multitude of titles used to describe that particular role. Brian Eastwood — Senior Editor | Senior editor for CIO.com covering healthcare IT. Link: http://www.cio.com  Keyword(s): New Hospital CEOs #### Missteps to Avoid When Communicating Electronically with Patients ### Five Missteps to Avoid When Communicating Electronically with Patients By Aubrey Westgate Communicating electronically with patients is fast and easy, but it comes with some big risks. Here, Robin Diamond, MSN, JD, RN, senior vice president and chief patient safety officer for medical malpractice insurer The Doctors Company, identifies five things physicians should not do when communicating to patients using electronic communications. Please view the slides in PDF format (attached whitepaper).  Keyword(s): MisstepsAvoidCommunicatingElectronicallyPatients #### Six Phrases to Avoid When Talking with Patients ### Six Phrases to Avoid When Talking with Patients By Aubrey Westgate Robin Diamond, chief patient safety officer at medical malpractice insurer The Doctors Company, identifies six common communication missteps physicians make. Please view the slides on the attached whitepaper.  Keyword(s): Six PhrasesAvoidTalking with Patients #### Breakthrough Technologies in Surgery ### Breakthroughs Technologies in Surgery Dr. Catherine Mohr, VP of Medical Research at Intuitive Surgical, speaking about breakthrough technologies in surgery. #### View Catherine Mohr’s full talk here.  Keyword(s): BreakthroughTechnologiesSurgery #### Utilization of open source electronic health record around the world: A systematic review ### Utilization of open source electronic health record around the world: A systematic review #### Abstract #### Many projects on developing Electronic Health Record (EHR) systems have been carried out in many countries. The current study was conducted to review the published data on the utilization of open source EHR systems in different countries all over the world. Using free text and keyword search techniques, six bibliographic databases were searched for related articles. The identified papers were screened and reviewed during a string of stages for the irrelevancy and validity. The findings showed that open source EHRs have been wildly used by source limited regions in all continents, especially in Sub-Saharan Africa and South America. It would create opportunities to improve national healthcare level especially in developing countries with minimal financial resources. Open source technology is a solution to overcome the problems of high-costs and inflexibility associated with the proprietary health information systems. Keywords: Electronic health record, electronic medical record, healthcare, health information system, open source software INTRODUCTION Today with the vast development of technology in the world responding to the variable and complex needs for interchanging clinical information among health-care providers to improve the quality of health-care services seems more practical than any time before. Efficacy of healthcare services and medical interventions are highly dependent on a trust worthy and integrated history of individual medical and health status. Electronic health record (EHR) is one such response that covers the need of all engaged parties including patients, doctors, clinical staff, insurance companies, health care providers and policy makers. It provides a platform on which individual health information is stored and accessed only by authorized people. EHR is defined as digitally stored health-care information about an individual's life with the purpose of supporting continuity of care, education and research. Lack of the required health information causes a lot of delay and expenses in health-care delivery.[1] EHR is a new way of storing and processing health information. A wide range of terms and phrases have been used to describe health and medical records. Health Insurance Portability and Accountability Act (HIPAA) defines EHR as “an electronic record of health-related information on an individual that is created, gathered, managed and consulted by authorized health-care clinicians and staff.”[2] The terms “Electronic Medical Record,” (EMR) Computer-based Patient Record (CPR), Electronic Patient Record (EPR), Personal Health Record (PHR), Computerized Medical Record (CMR) may also be treated synonymously with EHR. #### OPEN SOURCE SOFTWARE (OSS) In terms of software development and licensing, OSS and proprietary software are two main categories of software.[3] “The promise of opensource is better quality, higher reliability, more flexibility, lower cost and an end to predatory vendor lock-in.”[4] OSS encourages having access to the source code — the code computer programmers write-with the freedom of usage, modification and redistribution. On the contrary, he source code in proprietary software is confidential. The end user of such products can access and execute only the machine code.[3] The source code of proprietary software is closed and belongs only to the developer. The intention of developing this kind of software is to make a profit from licensing, rental or sale of the software and maintain full control of the product.[5] Although OSS and “free software” describe almost the same category of software, they stand for views based on different values. Free software respects freedom to run the software to study and change it and also to redistribute copies with or without changes. The free software movement begins in 1983. In 1984, the free operating system GNU was developed.[6] GNU General Public License (GPL) is a free, copy left license for software, which is intended to guarantee the freedom to share and change all versions of software to make sure it remains free for all its users.[7] As some of the users and developers of free software were not agreed with the goals of the free software movement, a part of the free software community separated in 1998 and began to campaign in the name of “open source” afterward. Open source is based only on practical values, such as making or having powerful and reliable software.[6] Open Source Software (OSS), Free and Open Source Software (FOSS) and Free, Libre and Open Source Software (FLOSS)- although are not exactly the same- are alternative terms for free software. In the health sector, open source products have been designed to improve health-care while reducing the cost of similar proprietary products. According to Reynolds and Wyatt, it creates “a key opportunity for the promotion of effective systems by enhancing clinical engagement in software development, fostering innovation, improving system usability and reducing costs and should therefore be central to a rational HIS [Healthcare Information System] procurement strategy.”[3] A handful of projects on developing EHR systems have been carried out in many countries. #### EHR in USA In the United States of America, approximately 23.9% of physicians used EHR in the ambulatory setting and only 5%of hospitals used Computerized Physician Order Entry (CPOE) through 2005.[8] A study on the levels of EHR adoption in USA revealed that only few US hospitals had a comprehensive electronic clinical information system and many others only had parts of an electronic records system. It seems that financial support, interoperability and training of information technology support staff by policy makers is necessary for increasing the application of EHR in US hospitals.[9] Since the late 1970s, U.S. Department of Veterans Affairs (VA) as a governmental sector advanced their efforts to develop an extensive organizational health information system named veterans’ health information systems and technology architecture (VistA). VistA uses Massachusetts general hospital utility multi-programming system (MUMPS) a program that can be used for disease case registries.[10] Only a few major organizations in the private sector worked on the implementation of EHRs in USA.[11] #### EHR in Canada Canada is another country, which seeks technological solutions to expand high quality health-care services across the country. These solutions also create new challenges, especially in acceptable standards, choice of technologies, overcoming traditional jurisdictional boundaries, privacy and confidentiality.[12] Many projects were planned to develop an efficient EHR in Canada. Health Infoway is among such efforts. Canada Health Infoway is a non-profit corporation founded by the federal government of Canadian 2000. The initial aim of this organization was to accelerate the development of EHR on a pan-Canadian basis by 2007. It tries to connect organizations, which are working on EHR projects and encourage them to produce and share “knowledge objects,” which can be reused by other organizations. Canada Health Infoway is a major investment for Canadians with 1.1 billion dollar budget.[13] This would support more efficient health-care delivery, patient confidentiality, immediate access to complete and accurate patient information while enabling better decisions about diagnosis and treatment. The final result would be a sustainable health-care system with higher quality, accessibility, productivity and cost savings.[6] #### EHR in England In England, National Program for Information Technology, which is directed by the National Health Service (NHS) is responsible for delivering England's EHR.[14] NHS established an EHR system in 2005. The aim was to provide all 50 million NHS patients with an individual electronic NHS Care Record Service (NHSCRS) by 2010. The NHSCRS would securely share the detailed records of each person between different parts of the local NHS sites. The system uses a unique identifier for each patient. Patients would be able to have a summary of their important health information, known as their Summary Care Record (SCR), available to authorized NHS staff anywhere in the NHS in England. They also would access their SCR using a secure website named as “HealthSpace.” The budget of this project was estimated 12.6 billion Pounds in 2006. This was almost 2 times more than what was estimated since the project was first launched. It was assumed that the project may finally cost more than 20 billion pounds.[15] #### EHR in Australia Many regional and national EHR projects and systems have been developed in the Asia-Pacific region.[16] In Australia as the pioneer of EHRs, Health Information Technology (HIT) is considered the basis for improving the quality of healthcare, safety and efficiency by the government. General practices were encouraged to install clinical software packages for prescribing and transmission of clinical data in the late 1990s.[17] HealthConnect is a joint Australian, State and Territory Governments’ initiative for revolving paper-based health records to EHRs for the benefit of consumers and also health-care providers. Through which, health information would be more quickly available and transferred among healthcare professionals under more secure condition. The main aims of this program was the accessibility of life-saving information in emergencies and also the improvement of safety and quality of health information through a shared electronic health record (SEHR).[18] The National E-Health Transition Authority (NEHTA) is responsible for developing a design for SEHR. NEHTA was funded jointly by the Australian, state and territory governments in 2005 to develop national standards and infrastructure for EHR across Australia.[19] Many studies focused on the benefits of using the OSS in the health sector.[20,21,22,23,24,25,26,27,28,29,30] In a number of researches, the characteristics of OSS systems have been compared with each other.[31,32] During the recent years, utilization of OSS in national health systems has been welcomed by many countries to respond to the necessity of EHR systems for improving the health-care services and the problems of implementing proprietary EHR systems. The present study was conducted to review the published data on the utilization of open source EHR systems in different countries all over the world and the primary reasons for utilization of those systems highlighted by published studies. #### METHODS A systematic review of studies on the utilization of open source EHR was developed through the following stages: #### Eligibility criteria All indexed original and review articles, short communications, case reports and scientific letters by selected bibliographic databases on the utilization of open source EHR in any country were eligible in this study. #### Data sources Six bibliographic databases including Ovid Medline, ISI Web of Science, Scopus, Excerpta Medica Database (EMBASE), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Library Information Science and Technology Abstracts (LISTA) were searched for relevant articles. #### Search strategy We searched all six databases using free-text and subject-keyword search techniques for relevant studies according to the search tools of each database. The selected keywords were “electronic health record,” “electronic medical record,” “computerized medical record”,” “computer based medical record,” “computerized patient record” “computer based patient record,” “electronic patient record,” “personal health record” and “open source.” We limited the search results to original and review articles, short communications, case reports and scientific letters published from 1990 up to 2012. #### Screening and selection Primary selection of studies was based on the inclusion criteria, which were original and review articles, short communications, case reports and scientific letters on the utilization of open source EHR in any country. The duplicated publications were excluded. At the first screening stage, two reviewers (FA andFS) independently screened title and abstract of retrieved documents to determine those which met the eligibility criteria. Full citations of those documents considered eligible at least by one reviewer were imported into an EndNote database. In the next stage, the full text of the imported papers were provided and reviewed for subject relevancy individually by each of the two reviewers. A critical appraisal check list was used to evaluate the validity of the selected studies and to criticize them.[33] Finally, the two reviewers made a face-to-face meeting, discussing on papers selections. Discrepancies were resolved through discussion. In the cases, which consensus did not happen, a third reviewer (MA) made the final decision on the eligibility of a particular paper. Consequently, those papers, which have been considered as valid by both reviewers, selected for data extraction. #### Data extraction A list of eligible studies was produced. Also, a specific questionnaire for data extraction was designed for recording data from the selected studies. The extracted data were the authors name, year of publication, the source title, the open source EHR system/systems, country/countries of utilization and the primary reasons for open source EHR utilization in selected studies. #### RESULTS A total of 183 papers were identified by searching six bibliographic databases. The 99 duplicated publications were excluded. After screening, the title and abstract of the retrieved documents, 51 irrelevant papers were excluded and 33 studies were considered for full text evaluation. Then the full texts of selected papers were obtained and evaluated from which 17 papers were selected for inclusion in the review.[32,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49] The flow chart of the process of study selection is shown in Figure 1. Flow chart of study selection The excluded studies were not original article, review, case report or scientific letter or did not related to the utilization of a specific open source EHR in a specific country. The included studies are introduced in Table 1. Included studies The Academic Model Providing Access to Healthcare (AMPATH) Medical Record System (AMRS), Androbase, HospitalOS, iSante, iTrust, OpenEHR, OpenMRS, OpenVistA, Oopen Source Cluster Application Resources (OSCAR), One Stop Crisis Centre (OSCC) portal, Personal Internetworked Notary and Guardian (PING), PropeRWeb and WorldVistA. Table 2 shows the characteristics of the 13 identified open source EHRs. It represents the country/countries of utilization and the primary reason/reasons for utilization of systems identified by reviewing the selected documents. Characteristics of identified open source electronic health record systems #### AMRS AMRS is an implementation of Open MRS. AMRS is an open source medical record system developed by the AMPATH informatics team at the AMPATH center in Eldoret, to manage clinical care of human immunodeficiency virus (HIV) infected patients. AMRS is composed of paper-based records as well as EMRs because most clinicians in resource limited settings cannot use computers directly during patient visits. The system collects discrete data from clinical encounters at AMPATH including demographic data, symptoms, vital signs, physical exam findings, test results, diagnoses and treatments. All data are stored as coded concepts to allow easy retrieval and analysis. The system strongly emphasizes on data reuses to support patient care. AMRS is securely accessible via the internet with proper authorization #### Androbase Androbase is a new EPR and database based on open source technology (MySQL database and PHP language), which is established in a university clinic in Germany. Androbase was developed mainly because the lack of adaptability and extensibility of the previous commercially protected system to specific needs and its poor response times during daily work made it unacceptable by users. Utilization of Androbase reduced workload and increased performance through eliminating transcription steps and decreasing time for data entry. #### Hospital OS Hospital OS is an open source EMR system developed by Open Source Technology Co., Ltd. located in Phuket, Thailand. Hospital OS is user-friendly software released under a GNU GPL in 2001. The system developed by a team of programmers, software engineers, healthcare professionals and hospital experts to improve the quality of healthcare services in Thailands hospitals at no cost. Hospitals can use and customize the software to suit their particular needs and also share the software to other hospitals. Hospital data reporting and filing is streamlined in Hospital OS. It can save time and cost in health-care management. Nowadays, the system is demanded by many countries around the world. #### iSante iSanté is free open source EMR system developed to improve clinical care of HIV-infected patients in Haiti. The system is available in French and English. iSanté can provide and send aggregated data for national reporting. #### iTrust iTrust is an open source EHR system, which was founded as a project in a software engineering course at North Carolina State University to teach various automatic testing techniques. The system enjoyed the consultation of a practicing physician and a professional from the North Carolina Healthcare Information and Communications Alliance (NCHICA). iTrust is a patient-centered system. Patients can login to the system and do a variety of tasks. It allows patients to access to their own medical records, select their care giver and also communicate with their doctors. Any access and change into a specific medical record can be reported to patient through e-mail alerts. Some of functionalities of iTrust include appointment scheduling, physician order entry, prescribing medication, billing, ordering laboratory tests and viewing lab results. #### OpenEHR OpenEHR is founded by the OpenEHR Foundation, which is a not-for-profit company. It is initiated as a mutual project by University College London, UK and Ocean Informatics Pty Ltd, Australia. The main focus of the openEHR Foundation is EPRs. OpenEHR is about life-long interoperable EHRs to improve the quality of health-care and research. One of the features of openEHR is developing publicly available structures and terminologies in a repository known as the Clinical Knowledge Manager (CKM). As an online clinical knowledge resource, the OpenEHR CKM allows users to participate in the creation an international set of archetypes, which could enhance interoperability of the whole system. OpenEHR enables clinicians to manage clinical content separately from the software through the archetype formalism. Now, it is used in a number of countries around the world. #### OpenMRS OpenMRS is an open source EMR system developed by a large network of open source developers coordinated by the Regenstrief Institutein 2004. The system was implemented initially in Kenya and then was rapidly adopted by health-care organizations in resource poor countries. OpenMRS has a concept dictionary in its core, which stores total diagnosis, tests, drugs and also general questions and potential answers. It has been used in several African countries including South Africa, Ethiopia, Mali, Ghana, Nigeria, Kenya, Rwanda, Malawi, Senegal, Tanzania, Uganda, Lesotho, Zimbabwe, Mozambique, Sierra Leone and Haiti. Nowadays, it is wildly used throughout the world. #### OpenVistA OpenVistA is a non-proprietary, open source EHR system based on the VA VistA software. OpenVistA reduces the expenses by allowing VistA to run on the Linux operating system, which is open source and free. It also enables the client organizations to run the system also on Windows. They can choose either InterSystems Caché or Fidelity GT.Ml. OpenVistA allows multiple clinicians to simultaneously access to various patient data in real-time. The system provides progress note, various templates, ordering and reporting tools, audit capabilities, electronic signature. Document management, data integration tools and CPOE are among other features of OpenVistA. #### OSCAR OSCAR is an open source EHR system developed by Department of Family Medicine at McMaster University, Canada. OSCAR is based on Linux and MySQL database and uses the GPL. The system allows users to install a high performance computing cluster. Multiple message passing interface implementations could be install on one cluster. OSCAR`s functionalities include various services such as registration, scheduling, medical record and billing. Moreover, it includes a powerful testing architecture for ensuring the readiness of the cluster set up for production. #### OSCC Portal The OSCC Portal is an open source web-based EPR system, which is developed for OSCC, Hospital University Sains Malaysia (HUSM) in Kelantan, Malaysia. Utilization of OSCC Portal improved data confidentiality; data integration; communication, coordination between disciplines; standardization of data; quality assessment; and research in HUSM, which are all necessary for quality of care. #### PING PING is a free and open source health information system. It is designed and implemented as an interoperable, personally controlled health record, which enables patients to have control accessibility to their medical information by others. PING architecture is based on replaceable modular pieces so that collaborators can add to or substitute in PING components. PING compiles lifelong patient history and allows patients to store encrypted copies of their records in selective storage sites. PING is adopted by the Canadian National Research as a model for regional, provincial and national personally controlled health records. #### PropeRWeb PropeRWeb is a multidisciplinary EHR system, which is built based on open standards in Netherlands. As a web based application, the system uses servlets and Java Server Pages with CORBA connection to the database servers. In PropeRWeb, patients and care givers are separated into two different Person Identification Specification (PIDS) servers to enhance security and privacy. Auditing as a functionality that provides info at a specific moment is implemented in PropeRWeb by distinguishing between versions of archetypes and forms. Although some aspects such as user friendliness need more improvements; however, the system is flexible enough to be readily customized for use in a variety of clinical domains. #### WorldVistA WorldVistA is an open source EHR system that evolved from VistA project to make it widely available outside of its original setting within the United States and around the world. The system developed additional modules such as pediatrics, obstetrics and patient billing not normally used in the veteran's health-care setting. WorldVistA is able to run on proprietary intersystem cache database. Web-based and client-server configurations can be established on the system depending on the environment. Although it is a primary care system, but other templates for specialties can be created by users. WorldVistA has various functionalities including patient registration, drug allergy and interaction checking, creating health maintenance remainders, clinical order entry, templates for obstetrics/gynecology and pediatrics care, viewing lab and imaging results and generating reports of demographics, medications and problems. DISCUSSION EHR provides brilliant chance of readily retrieving the required information for conducting a faster and a much more accurate decision for action. Decline in medical errors is another important advantage of applying EHR that should seriously be taken into account.[1] Open source EHRs have been designed to improve health-care while reducing the cost of similar proprietary systems. Those who developed OSS actually encourage it and rely on this philosophy to see the software spread and grow beyond its original creators.[4] According to the findings, open source EHR systems have been wildly welcomed by source limited regions around the world, especially in Sub-Saharan Africa and South America. Argentina, Australia, Chile, Ecuador, Ethiopia, Germany, Ghana, Haiti, Jordan, Kenya, Lesotho, Malawi, Malaysia, Mali, Mexico, Mozambique, Netherlands, Nigeria, Pakistan, Peru, Rwanda, Senegal, Sierra Leone, South Africa, Sweden, Tanzania, Thailand, Turkey, Uganda, USA and Zimbabwe are among countries, which used open source EHRs to enhance the health care quality. The results indicated that many countries especially developing countries- demand to use an interoperable and cost-efficient EHR system, which is flexible enough to modify and improve. Commercial software companies and some people claim that open source systems cannot fulfil medicolegal and security requirements required for a health-care system and may allow hackers to know the software bugs more easily than proprietary software.[50] However, some experts believe that open source systems are more secure from external attack than closed source systems because the independent assessment of system security, which happens in OSS “makes bug patching easier and more likely and forces developers to spend more effort on the quality of their code.”[49] Active assessment of software codes by their users makes them more stable than proprietary systems. On the other hand, because of commercial pressures customers’ requirements are more important for proprietary software developers than security requirements, which are invisible to customers.[51] Open source systems make opportunities for advanced innovation in the health information sector of low income countries.[49] However, cost- efficiency seems to be the most important reason for utilization of open source systems in many countries. Despite the enormous financial investment to Canada Health Infoway, some believes that the reduction in duplicated efforts will reduce the total expenses of a pan-Canadian EHR.[13] Some critics said that spending billions of dollars in purchasing health software would lead to enormous overpayments to technology companies and consultants. Such a huge investment on a national health information structure encourages a competition between companies for profitable deals to sell their electronic health systems promising to connect patients, doctors and hospitals. They believe that OSS would be a better solution instead of spending too much money on expensive proprietary products.[52] The open three (O3) consortium project launched in 2004 is an example of utilization of OSS, which was based on the agreements on the impact of open solutions in facilitating fast integration of health systems in Europe and the world.[22] Even, in the USA some of the current EHR systems are not fully desirable because of being expensive and inflexible and proprietary. Open source systems with the potentiality for local customization could be a possible solution to solve these problems and to improve health-care services in the United States as they have done in many other countries around the world.[28] The evidences indicated that utilization of OSS in the health sector is more welcomed in developing countries with financial limitations. Although various open source EHR programs may not fully encompass the functionality requirements for an ideal EHR system, they create opportunities to improve national health-care level in countries with minimal financial resources.[31] Developing countries use open source EHRs to lower cost and to improve the efficiency and quality of health-care services. The overall results indicated that open source EHR is a solution to overcome the problems of high costs and inflexibility associated with proprietary systems. CONCLUSION Several projects on utilizing open source EHR in the world, especially in developing countries confirm the effective role of open source EHR systems in improving the healthcare level in countries with minimal financial resources. ACKNOWLEDGMENT This study was part of a PhD thesis supported by Iran University of Medical Sciences. Footnotes • Source of Support: Iran university of medical sciences • Conflict of Interest: None declared REFERENCES • 1. Rezae P, Ahmadi M, Sadughi F. Comparative study on EHR content, structure, and terminology standards in selected organizations and design a model for Iran. J Health Adm. 2007;10:55–64. • 2. HIPPA. The Definition of Electronic Health Record. [Accessed on 2012 Sep 20]. Available from:http://www.hipaa.com/2009/05/the-definition-of-electronic-health-record . • 3. Reynolds CJ, Wyatt JC. Open source, open standards, and healthcare information systems. J Med Internet Res. 2011;13:e24. [PubMed] • 4. Open Source initiatives. [Accessed on 2012 Dec 6]. Available from: http://www.Opensource.org/docs/osd . • 5. Khelifi Adel AT, editor. Abu Dhabi, UAE: European and Mediterranean Conference on Information Systems (EMCIS2010); 2010 April 12-13; A preliminary open source software infrastructure for the health sector in the UAE. • 6. Stallman R. Why open source misses the point of free software. [Accessed on 2012 Sep 20]. Available from:http://www.gnu.org/philosophy/open-source-misses-the-point.html . • 7. GNU General Public License. [Accessed on 2012 Sep 20]. Available from:http://www.gnu.org/licenses/gpl.html . • 8. Jha AK, Ferris TG, Donelan K, DesRoches C, Shields A, Rosenbaum S, et al. How common are electronic health records in the United States? A summary of the evidence. Health Aff (Millwood) 2006;25:w496–507.[PubMed] • 9. Jha AK, DesRoches CM, Campbell EG, Donelan K, Rao SR, Ferris TG, et al. Use of electronic health records in U.S. hospitals. N Engl J Med. 2009;360:1628–38. [PubMed] • 10. Greenbaum D, Sboner A, Mu XJ, Gerstein M. Genomics and privacy: Implications of the new reality of closed data for the field. PLoS Comput Biol. 2011;7:e1002278. [PubMed] • 11. Berner ES, Detmer DE, Simborg D. Will the wave finally break? A brief view of the adoption of electronic medical records in the United States. J Am Med Inform Assoc. 2005;12:3–7. [PubMed] • 12. Alvarez RC. The promise of e-health – A Canadian perspective. World Hosp Health Serv. 2004;40:31–5.[PubMed] • 13. Catz M, Bayne J. Canada health infoway – A pan-Canadian approach. AMIA Annu Symp Proc. 2003:807. [PubMed] • 14. Huston JL. EHR in the UK: Shedding some light from a manager's perspective. Health Care Manag (Frederick) 2006;25:335–40. [PubMed] • 15. Nicholson L. Amsterdam: EHR Conference; 2008. Electronic Health Records in the United Kingdom of Great Britain Northern Ireland. • 16. Kimura M, Croll P, Li B, Wong CP, Gogia S, Faud A, et al. Survey on medical records and EHR in Asia-Pacific region: Languages, purposes, IDs and regulations. Methods Inf Med. 2011;50:386–91. [PubMed] • 17. McInnes DK, Saltman DC, Kidd MR. General practitioners’ use of computers for prescribing and electronic health records: Results from a national survey. Med J Aust. 2006;185:88–91. [PubMed] • 18. Health Connect. [Cited on 2012 Sep 09]. Available from: http://www.health.gov.au/healthconnect . • 19. NEHTA- National E-Health Transition Authority. [Accessed on 2012 Sep 20]. Available from:http://www.nehta.gov.au . • 20. Bush J. Open-source software: Just what the doctor ordered? Fam Pract Manag. 2003;10:65. 69. [PubMed] • 21. De Lusignan S, Kumarapeli P, Debar S, Kushniruk AW, Pearce C. Using an open source observational tool to measure the influence of the doctor's consulting style and the computer system on the outcomes of the clinical consultation. Stud Health Technol Inform. 2009;150:1017–21. [PubMed] • 22. Dinevski D, Poli A, Krajnc I, Sustersic O, Arh T. E-health integration and interoperability based on open-source information technology. Wien Klin Wochenschr. 2010;122(Suppl2):3–10. [PubMed] • 23. Dove ES, Ozdemir V, Joly Y. Harnessing omics sciences, population databases, and open innovation models for theranostics-guided drug discovery and development. Drug Dev Res. 2012;73:439–46. • 24. Gatta R, Abeni F, Buglione M, Peveri A, Barbera F, Tonoli S, et al. Open-source, low-cost, high-reliability solutions for digital imaging systems: Example of a “dicom router” Radiol Med. 2007;112:1252–9. [PubMed] • 25. Good T, DiTommaso M. SQL Clinic: The open-source alternative for electronic medical records. Psychiatr Serv. 2005;56:269–71. [PubMed] • 26. Lee YH. Efficient radiologic reading environment by using an open-source macro programas connection software. Eur J Radiol. 2012;81:100–3. [PubMed] • 27. Marques ET, Jr, Maciel FilhoR, August PN. Overcoming health inequity: Potential benefits of apatient-centered open-source public health infostructure. Cad Saude Publica. 2008;24:547–57. [PubMed] • 28. Yellowlees PM, Marks SL, Hogarth M, Turner S. Standards-based, open source electronic health record systems: A desirable future for the U.S. health industry. Telemed J E Health. 2008;14:284–8. [PubMed] • 29. Kantor GS, Wilson WD, Midgley A. Open-source software and the primary care EMR. J Am Med Inform Assoc. 2003;10:616–7. [PubMed] • 30. Los RK, vanGinneken AM, svanderLei J. Open SDE: Astrategy for expressive and flexible structured data entry. Int J Med Inform. 2005;74:481–90. [PubMed] • 31. Flores Zuniga AE, Win KT, Susilo W. Functionalities of free and open electronic health record systems. Int J Technol Assess Health Care. 2010;26:382–9. [PubMed] • 32. Millard PS, Bru J, Berger CA. Open-source point-of-care electronic medical records foruse inresource-limited settings: Systematic review and questionnaire surveys. BMJ Open. 2012;2:e000690. [PubMed] • 33. Critical Appraisal Skills Programme (CASP) [Accessed on 2012 Dec 21]. Available from: http://www.casp-uk.net . • 34. Seebregts CJ, Mamlin BW, Biondich PG, Fraser HS, Wolfe BA, Jazayeri D, et al. The OpenMRS implementers network. Int J Med Inform. 2009;78:711–20. [PubMed] • 35. Noormohammad SF, Mamlin BW, Biondich PG, McKown B, Kimaiyo SN, Were MC. Changing course to make clinical decision support work in an HIV clinic in Kenya. Int J Med Inform. 2010;79:204–10. [PubMed] • 36. Tüttelmann F, Luetjens CM, Nieschlag E. Optimising workflow in andrology: A new electronic patient record and database. Asian J Androl. 2006;8:235–41. [PubMed] • 37. Ohemeng-Dapaah S, Pronyk P, Akosa E, Nemser B, Kanter AS. Combining vital events registration, verbal autopsy and electronic medical records in rural Ghana for improved health services delivery. Stud Health Technol Inform. 2010;160:416–20. [PubMed] • 38. Massey AK, Otto PN, Hayward LJ, Antón AI. Evaluating existing security and privacy requirements for legal compliance. Requir Eng. 2010;15:119–37. • 39. Waters E, Rafter J, Douglas GP, Bwanali M, Jazayeri D, Fraser HS. Experience implementing a point-of-care electronic medical record system for primary care in Malawi. Stud Health Technol Inform. 2010;160:96–100.[PubMed] • 40. Syed-Mohamad SM, Ali SH, Mat-Husin MN. The development and design of an electronic patient record using opens ource web-based technology. HIMJ. 2010;39:30–5. [PubMed] • 41. Van der Linden H, Tange H, Talmon J. PropeR and archetypes. Stud Health Technol Inform. 2004;110:49–53. [PubMed] • 42. Van der Linden H, Talmon J, Tange H, Grimson J, Hasman A. PropeRrevisited. Int J Med Inform.2005;74:235–44. [PubMed] • 43. Kanter AS, Negin J, Olayo B, Bukachi F, Johnson E, Sachs SE. Millennium global village-net: Bringing together millennium villages throughout sub-Saharan Africa. Int J Med Inform. 2009;78:802–7. [PubMed] • 44. Fraser HS, Thomas D, Tomaylla J, Garcia N, Lecca L, Murray M, et al. Adaptation of a web-based, open source electronic medical record system platform to support a large study of tuberculosis epidemiology. BMC Med Inform Decis Mak. 2012;12:125. [PubMed] • 45. Kouematchoua Tchuitcheu G, Rienhoff O. Options for diabetes management in sub-Saharan Africa with an electronic medical record system. Methods Inf Med. 2011;50:11–22. [PubMed] • 46. Chen R, Klein G. The openEHR Java reference implementation project. Stud Health Technol Inform.2007;129:58–62. [PubMed] • 47. Yusuf EM. Implementation of OpenVistA in hospitals in Turkey. J Inf Technol Healthc. 2008;6:212–20. • 48. Simons WW, Mandl KD, Kohane IS. The PING personally controlled electronic medical record system: Technical architecture. J Am Med Inform Assoc. 2005;12:47–54. [PubMed] • 49. Webster PC. The rise of open-source electronic health records. Lancet. 2011;377:1641–2. [PubMed] • 50. Gallivan MJ. Striking a balance between trust and control in a virtual organization: A content analysis of open source software case studies. Inf Syst J. 2001;11:277–304. 51. Payne C. On the security of open source software. Inf Syst J. 2002;12:61–78. 52. Webster PC. Canada's ehealth software “Tower of Babel” CMAJ. 2010;182:1945–6. [PubMed] Articles from Journal of Research in Medical Sciences : The Official Journal of Isfahan University of Medical Sciences are provided here courtesy of Medknow Publications  Keyword(s): Utilizationopen sourceelectronic health recordaround the worldA systematic review #### Resolving Conflict among Medical Practice Staff ### Resolving Conflict among Medical Practice Staff By Keith L. Martin ### Video Consultant and coach Charlie Hauck of Growth Dynamics provides five key components every practice should implement to reduce conflict and provide prescriptions for resolution when conflict does occur. For more on settling staff disputes at your medical practice, see the October 2014 Cover Story.  Keyword(s): Resolving ConflictMedical Practice Staff #### Boost patient experience at first point of contact: The call center ### Boost patient experience at first point of contact: The call center I recently worked with a hospital improve its cancer program. It had wonderful doctors and an up-to-date facility. Nurses were very patient-focused and the staff smiled a lot. What could be better? Yet new patient volumes were sluggish and growth elusive. The hospital found the highly competitive local market very challenging, especially because differentiation--a meaningful point of difference--was pretty much non-existent. In truth, the area hospitals were all pretty much the same. How could it compete? Most of the ideas focused on the patient experience inside the hospital. So instead, we decided to see what it was like as an outsider trying to find out more about the hospital options if we were diagnosed with cancer. We began our inquiry, with observational research and shopping the experience. We called hospitals in the region, as well as some nationally recognized leaders in cancer care, hoping to learn something of value. We contacted 20 hospitals and quickly realized something was clearly missing: The basics of a good (let alone great) customer experience. I invite you to call your own call center and see how it presents your excellent services to your consumer. The typical call experience went something like this: • After waiting multiple rings, an operator finally answered the call. We said: "My father has just had a positive diagnosis for prostate (or lung) cancer and we are evaluating his options. Could you please connect me with someone who could tell me more about how you treat prostate cancer?" • The responses: "What is the name of the patient?" (us) "No, my father is not at (name of hospital). I would like to learn more about your hospital's cancer services and how you would evaluate his prostate cancer." "What is his doctor's name?" (us) "He doesn't see one of your doctors." "Where did he get his diagnosis? He should go back there." Hang up! • We got passed along to another call center for oncology physicians and had to go through its prompts, none of which would connect us to anyone who could answer questions. • They referred us to their website. • They referred us to surgery department, which then referred us to a surgeon's office, but we had to call the office back directly at another number. We experienced 18 of these types of encounters. Then we called Cancer Treatment Centers of America, Dana Farber Cancer Institute, Johns Hopkins Medicine and Massachusetts General Hospital. While each was different, they at least had an approach to cancer inquiries and cancer care that demonstrated they might actually care about a caller requesting information. Of these national brands, Cancer Treatment Centers of America, was clearly in another space. The operator was immediately engaged, showed empathy towards me and expressed concern for my "father." She knew whom to connect me with--their cancer advocate, who introduced herself, expressed her concern for my father and explained how the Centers deliver care for cancer patients. Their well-thought-out call center process was all about making both the patient and the family feel important, cared about and listened to. The process was also easy to understand and made sense. What startled us, was the sorry state of the rest of the call centers. The basic caring of the other healthcare organizations was totally missing in action at the first point of contact. Any effort to understand the needs of a cancer patient at that crucial point was back in the dark ages. The operators, supposedly, are there to answer a call in three rings and direct the caller to where he/she needs to go. For us, we would have been happy if they had, at the very least, answered the phone in less than 10 rings and greeted us with kindness. True, most calls to a hospital's central number are from people wanting to be connected to a patient, seeking a physician or looking for an administrative department--billing or admissions. We clearly threw them a curve ball asking for information about their cancer protocols. But was that enough of an excuse not to: 1. Answer the call promptly? 2. Reflect the brand of the hospital in their voice? 3. Utilize their communication skills? 4. Demonstrate a willingness to try and find a solution to our inquiry? Which led us to wonder: Why? With all the innovative work going on these days to respond to healthcare reform, almost everyone, it seems, forgets the telephone center--a necessary evil. From our perspective, the call center seems an easy point of differentiation. How can a healthcare institution make a person's overall experience satisfyingly patient-focused and person-centered if they canâ€™t even answer the phones well? And conversely, if they could create an amazing experience at that first touch point, maybe they could do the same throughout the entire patient and family experience. Overwhelmingly, this whole experience felt like a time to pause and focus on the basics. While not innovative or sexy, the call center is essential. It must reflect well on you and add value to your organization, not dysfunction. Remember: you don't get a second chance to make a first impression. Your call center is the first contact someone has with you. You certainly don't want to go to a hospital that cannot even get the phones answered satisfactorily nor provide an operator who can genuinely engage with you with emotion and empathy. It may seem small, but really, it is huge. And healthcare organizations better start paying attention, soon. Andrea J. Simon, Ph.D., is a former marketing, branding and culture change senior vice president at Hurley Medical Center in Flint, Michigan. She also is president and CEO of Simon Associates Management Consultants. Link: http://www.hospitalimpact.org  Keyword(s): Boostpatient experiencefirst point of contactcall center #### El brote de Ébola Todo lo que hay que saber ### El brote de Ébola día a día Ante la emergencia internacional se requiere que todo el personal sanitario conozca los fundamentos de la enfermedad y de las medidas preventivas. IntraMed actualiza la información diariamente. #### ¿Qué es? Enfermedad por el virus del Ebola • El virus del Ebola causa en el ser humano la enfermedad homónima (antes conocida como fiebre hemorrágica del Ebola). Los brotes de enfermedad por el virus del Ebola (EVE) tienen una tasa de letalidad que puede llegar al 90%. • Los brotes de EVE se producen principalmente en aldeas remotas de África central y occidental, cerca de la selva tropical. • El virus es transmitido al ser humano por animales salvajes y se propaga en las poblaciones humanas por transmisión de persona a persona. • Se considera que los huéspedes naturales del virus son los murciélagos frugívoros de la familia Pteropodidae. • No hay tratamiento específico ni vacuna para las personas ni los animales. • El virus del Ebola causa en el ser humano la EVE, cuya tasa de letalidad puede llegar al 90%. El virus se detectó por vez primera en 1976 en dos brotes simultáneos ocurridos en Nzara (Sudán) y Yambuku (República Democrática del Congo). La aldea en que se produjo el segundo de ellos está situada cerca del río Ebola, que da nombre al virus. El género Ebolavirus es, junto con los géneros Marburgvirus y Cuevavirus, uno de los tres miembros de la familia Filoviridae (filovirus). El género Ebolavirus comprende cinco especies distintas: • ebolavirus Bundibugyo (BDBV); • ebolavirus Zaire (EBOV); • ebolavirus Reston (RESTV); • ebolavirus Sudan (SUDV), y • ebolavirus Taï Forest (TAFV). Las especies BDBV, EBOV y SUDV se han asociado a grandes brotes de EVE en Africa, al contrario de las especies RESTV y TAFV. La especie RESTV, encontrada en Filipinas y China, puede infectar al ser humano, pero hasta ahora no se han comunicado casos de enfermedad humana ni de muerte debidos a ella. Transmisión El virus del Ebola se introduce en la población humana por contacto estrecho con órganos, sangre, secreciones u otros líquidos corporales de animales infectados. En África se han documentado casos de infección asociados a la manipulación de chimpancés, gorilas, murciélagos frugívoros, monos, antílopes y puercoespines infectados que se habían encontrado muertos o enfermos en la selva. Posteriormente, el virus se propaga en la comunidad mediante la transmisión de persona a persona, por contacto directo (a través de las membranas mucosas o de soluciones de continuidad de la piel) con órganos, sangre, secreciones, u otros líquidos corporales de personas infectadas, o por contacto indirecto con materiales contaminados por dichos líquidos. Las ceremonias de inhumación en las cuales los integrantes del cortejo fúnebre tienen contacto directo con el cadáver también pueden ser causa de transmisión. Los hombres pueden seguir transmitiendo el virus por el semen hasta siete semanas después de la recuperación clínica. La infección del personal sanitario al tratar a pacientes con EVE ha sido frecuente cuando ha habido contacto estrecho y no se han observado estrictamente las precauciones para el control de la infección. Entre los trabajadores que han tenido contacto con monos o cerdos infectados por el RESTV se han registrado varios casos de infección asintomática. Por tanto, parece que esta especie tiene menor capacidad que otras de provocar enfermedad en el ser humano. Sin embargo, los datos recopilados al respecto solo se refieren a varones adultos sanos, y sería prematuro extrapolarlos a todos los grupos de población, como los pacientes inmunodeprimidos o con trastornos médicos subyacentes, las embarazadas o los niños. Son necesarios más estudios sobre el RESTV antes de que se puedan sacar conclusiones definitivas sobre su patogenicidad y virulencia en el ser humano. Signos y síntomas La EVE es una enfermedad vírica aguda grave que se suele caracterizar por la aparición súbita de fiebre, debilidad intensa y dolores musculares, de cabeza y de garganta, lo cual va seguido de vómitos, diarrea, erupciones cutáneas, disfunción renal y hepática y, en algunos casos, hemorragias internas y externas. Los resultados de laboratorio muestran disminución del número de leucocitos y plaquetas, así como elevación de las enzimas hepáticas. Los pacientes son contagiosos mientras el virus esté presente en la sangre y las secreciones. El virus del Ebola se ha aislado en el semen hasta 61 días después de la aparición de la enfermedad en un caso de infección contraída en el laboratorio. El periodo de incubación (intervalo desde la infección hasta la aparición de los síntomas) oscila entre 2 y 21 días. Diagnóstico Antes de establecer un diagnóstico de EVE hay que descartar el paludismo, la fiebre tifoidea, la shigelosis, el cólera, la leptospirosis, la peste, las rickettsiosis, la fiebre recurrente, la meningitis, la hepatitis y otras fiebres hemorrágicas víricas. Las infecciones por el virus del Ebola solo pueden diagnosticarse definitivamente mediante distintas pruebas de laboratorio, a saber: • prueba de inmunoadsorción enzimática (ELISA). • pruebas de detección de antígenos. • prueba de seroneutralización. • reacción en cadena de la polimerasa con transcriptasa inversa (RT-PCR). • aislamiento del virus mediante cultivo celular. Las muestras de los pacientes suponen un enorme peligro biológico, y las pruebas tienen que realizarse en condiciones de máxima contención biológica. Prevención y tratamiento No hay vacuna contra la EVE. Se están probando varias, pero ninguna está aún disponible para uso clínico. Los casos graves requieren cuidados intensivos. Los enfermos suelen estar deshidratados y necesitar rehidratación por vía intravenosa u oral con soluciones que contengan electrólitos. Tampoco hay ningún tratamiento específico, aunque se están evaluando nuevos tratamientos farmacológicos. Huésped natural del virus del Ébola Se considera que los murciélagos frugívoros, en particular Hypsignathus monstrosus, Epomops franqueti y Myonycteris torquata, son posiblemente los huéspedes naturales del virus del Ebola en África. Por ello, la distribución geográfica de los Ebolavirus puede coincidir con la de dichos murciélagos. El virus del Ébola en animales Aunque los primates no humanos han sido una fuente de infección para las personas, se cree que no son el reservorio del virus, sino huéspedes accidentales, como los seres humanos. Desde 1994 se han registrado brotes de EVE causada por las especies EBOV y TAFV en chimpancés y gorilas. El virus RESTV ha causado brotes de EVE grave en macacos cangrejeros (Macaca fascicularis) criados en Filipinas, y también se ha detectado en monos importados de Filipinas a los Estados Unidos en 1989, 1990 y 1996, y a Italia en 1992. Desde 2008, el virus RESTV se ha detectado en varios brotes epidémicos de una enfermedad mortal en cerdos en Filipinas y China. También se han notificado casos de infección asintomática en cerdos, pero las inoculaciones experimentales han revelado que este virus no causa enfermedad en el cerdo. #### Prevención Control del virus del Ébola de Reston en animales domésticos No hay ninguna vacuna para animales contra el RESTV. Se considera que la limpieza y desinfección regulares (con hipoclorito sódico u otros detergentes) de las granjas de cerdos y monos es eficaz para inactivar el virus. Si se sospecha que se ha producido un brote, los locales deben ponerse en cuarentena inmediatamente. Para reducir el riesgo de transmisión al ser humano puede ser necesario sacrificar a los animales infectados, supervisando estrechamente la inhumación o incineración de los cadáveres. La restricción o prohibición del movimiento de animales de las granjas infectadas a otras zonas puede reducir la propagación de la enfermedad. Como las infecciones humanas han estado precedidas de brotes por RESTV en cerdos y monos, el establecimiento de un sistema activo de vigilancia de la sanidad animal para detectar casos nuevos es esencial con el fin de alertar de forma temprana a las autoridades veterinarias y de salud pública. Reducción del riesgo de infección humana por el virus del Ébola A falta de un tratamiento eficaz y de una vacuna humana, la concienciación sobre los factores de riesgo de esta infección y sobre las medidas de protección que las personas pueden tomar es la única forma de reducir el número de infecciones y muertes humanas. En África, cuando se produzcan brotes de EVE, los mensajes educativos de salud pública para reducir los riesgos deben centrarse en varios factores. • Reducir el riesgo de transmisión de animales salvajes al ser humano a consecuencia del contacto con murciélagos de la fruta o monos o simios infectados y del consumo de su carne cruda. Deben utilizarse guantes y otras prendas protectoras apropiadas para manipular animales. Sus productos (sangre y carne) deben estar bien cocidos antes de consumirlos. • Reducir el riesgo de transmisión de persona a persona en la comunidad a consecuencia del contacto directo o estrecho con pacientes infectados, especialmente con sus líquidos corporales. Hay que evitar el contacto físico estrecho con pacientes con EVE y utilizar guantes y equipo de protección personal adecuado para atender a los enfermos en el hogar. Es necesario lavarse las manos con regularidad tras visitar a enfermos en el hospital, así como después de cuidar a enfermos en el hogar. • Las comunidades afectadas por la EVE deben informar a la población acerca de la naturaleza de la enfermedad y de las medidas de contención de los brotes, en especial la inhumación de las personas fallecidas. Los enfermos que mueren por esta causa deben ser sepultados rápidamente y en condiciones de seguridad. • En África, las granjas de cerdos pueden participar en la amplificación de la infección debido a la presencia de murciélagos frugívoros. Deben implantarse medidas de bioseguridad para limitar la transmisión. En lo que respecta al RESTV, los mensajes educativos de salud pública deben centrarse en la reducción del riesgo de transmisión del cerdo al ser humano a consecuencia de prácticas poco seguras de cría y sacrificio, así como del consumo de sangre fresca, leche cruda o tejidos animales. • Deben utilizarse guantes y otras prendas protectoras apropiadas al sacrificar o manipular animales enfermos o sus tejidos. En las zonas en las que se han notificado casos de infección por RESTV en cerdos, todos los productos animales (sangre, carne y leche) deben estar bien cocidos antes de su consumo. Control de la infección en centros de atención médica La transmisión del virus del Ebola de persona a persona se asocia principalmente al contacto directo o indirecto con sangre o líquidos corporales. Se han notificado casos de transmisión al personal sanitario en situaciones en las que no se habían adoptado medidas apropiadas de control de la infección. No siempre es posible identificar precozmente a los pacientes con EVE porque los síntomas iniciales pueden ser inespecíficos. Por este motivo, es importante que los profesionales sanitarios observen en todo momento y todos los centros las precauciones habituales en todos los pacientes, independientemente de su diagnóstico. Entre ellas se encuentran la higiene básica de las manos, la higiene respiratoria, el uso de equipos de protección personal (en función del riesgo de salpicaduras u otras formas de contacto con materiales infectados) y prácticas de inyección e inhumación seguras. Los trabajadores sanitarios que atienden a pacientes con infección presunta o confirmada por el virus del Ebola deben aplicar, además de las precauciones generales, otras medidas de control de las infecciones para evitar cualquier exposición a la sangre o líquidos corporales del paciente y el contacto directo sin protección con el entorno posiblemente contaminado. Cuand tengan contacto estrecho (menos de 1 metro) con pacientes con EVE, los profesionales sanitarios deben protegerse la cara (con máscara o mascarilla médica y gafas) y usar bata limpia, aunque no estéril, de mangas largas y guantes (estériles para algunos procedimientos) Quienes trabajan en el laboratorio también corren riesgo. Las muestras tomadas a efectos de diagnóstico de personas o animales con infección presunta o confirmada por el virus del Ebola deben ser manipuladas por personal especializado y procesarse en laboratorios adecuadamente equipados. Respuesta de la OMS La OMS aporta conocimientos especializados y documentación para apoyar la investigación y el control de la enfermedad. La OMS ha elaborado una lista de verificación de las precauciones generales que se han de adoptar en la asistencia médica (en fase de actualización). Esas precauciones están concebidas para reducir el riesgo de transmisión de agentes patógenos, entre ellos los de origen sanguíneo; su aplicación universal ayudará a prevenir la mayoría de las infecciones transmitidas por exposición a sangre o líquidos corporales. Se recomienda aplicar las precauciones generales cuando se atienda y trate a cualquier paciente, independientemente de que sea un caso de infección presunta o confirmada. Estas precauciones representan el nivel básico de control de las infecciones e incluyen la higiene de las manos, el uso de equipo de protección personal para evitar el contacto directo con sangre y líquidos corporales, la prevención de los pinchazos de aguja y las lesiones con otros instrumentos cortopunzantes, y un conjunto de medidas de control ambiental. #### Preguntas frecuentes El virus del Ebola causa en el ser humano la enfermedad homónima (antes conocida como fiebre hemorrágica del Ebola). Los brotes de enfermedad por el virus del Ebola (EVE) tienen una tasa de letalidad que puede llegar al 90%. Los brotes de EVE se producen principalmente en aldeas remotas de África central y occidental, cerca de la selva tropical. El virus es transmitido al ser humano por animales salvajes y se propaga en las poblaciones humanas por transmisión de persona a persona. Se considera que los huéspedes naturales del virus son los murciélagos frugívoros de la familia Pteropodidae. No hay tratamiento específico ni vacuna para las personas ni los animales. ##### Preguntas frecuentes sobre la enfermedad por el virus del Ebola 1. ¿Qué es la enfermedad por el virus del Ebola? La enfermedad por el virus del Ebola (denominada anteriormente fiebre hemorrágica del Ebola) es una enfermedad grave y con frecuencia letal cuya tasa de mortalidad puede llegar al 90%. La enfermedad afecta a personas y a primates no humanos (monos, gorilas y chimpancés). Se detectó por primera vez en 1976 en dos brotes simultáneos, uno en una aldea cercana al río Ebola, en la República Democrática del Congo, y el otro en una zona remota del Sudán. Se desconoce el origen del virus del Ebola, pero las pruebas científicas disponibles apuntan a que los murciélagos frugívoros (familia Pteropodidae) son sus huéspedes más probables. 2. ¿Cómo se infectan las personas con el virus? El virus del Ebola se introduce en la población humana por contacto estrecho con órganos, sangre, secreciones u otros líquidos corporales de animales infectados. En África se han dado casos de infección asociados a la manipulación de chimpancés, gorilas, murciélagos frugívoros, monos, antílopes y puercoespines encontrados muertos o enfermos en la selva. Es importante reducir el contacto con animales de alto riesgo (es decir, murciélagos frugívoros, monos o simios) y no recoger los cadáveres de animales muertos que puedan encontrarse en la selva ni manipular su carne cruda. El virus del Ebola puede propagarse en la comunidad de persona a persona cuando una persona entra en contacto con un animal con el virus. La infección se produce por contacto directo (a través de membranas mucosas o heridas abiertas en la piel) con la sangre u otros líquidos o secreciones corporales (heces, orina, saliva, semen) de personas infectadas. También puede producirse infección cuando las heridas abiertas en la piel o las membranas mucosas de una persona sana entran en contacto con entornos contaminados por los líquidos infecciosos de un paciente con el virus del Ebola, como prendas de vestir o ropa de cama sucias o agujas usadas. El personal de salud se ve con frecuencia expuesto al virus cuando atiende a pacientes enfermos. Existe riesgo si no llevan puesto equipo de protección personal, como guantes, al atender a los pacientes. Los proveedores de atención sanitaria de todos los niveles del sistema de salud –hospitales, dispensarios y centros de salud– deberían recibir información sobre la naturaleza de la enfermedad y su transmisión, y acatar rigurosamente las precauciones recomendadas para el control de la infección. Las ceremonias de inhumación en las cuales los integrantes del cortejo fúnebre tienen contacto directo con el cuerpo del difunto también puede que intervengan en la transmisión del virus del Ebola. Deben utilizarse guantes e indumentaria protectora resistente para manipular a las personas fallecidas por esta enfermedad, que deben ser sepultadas inmediatamente. Existe posibilidad de contagio mientras el virus esté presente en la sangre y las secreciones. Por ello, los profesionales médicos efectúan un estrecho seguimiento de los pacientes infectados y les someten a pruebas de laboratorio para verificar que el virus ya no circula por su organismo antes de regresar a su hogar. Cuando los profesionales médicos determinan que los pacientes pueden regresar a su hogar es porque ya no son infecciosos y no pueden propagar el virus en sus comunidades. Los hombres pueden seguir transmitiendo el virus a su pareja por el semen hasta siete semanas después de la recuperación clínica. Por ello, es importante que eviten mantener relaciones sexuales durante al menos siete semanas o que utilicen preservativos en caso de mantener relaciones sexuales antes de transcurrido ese plazo. 3. ¿Quiénes corren mayor riesgo? Durante un brote, quienes mayor riesgo de infección corren son: • El personal sanitario. • Los familiares u otras personas que hayan estado en contacto estrecho con personas infectadas. • Los integrantes del cortejo fúnebre que hayan tenido contacto directo con el cuerpo del difundo como parte de las ceremonias de inhumación. • Los cazadores que hayan tenido contacto con animales muertos hallados en la selva. • Es necesario seguir investigando para entender si algunos grupos, como las personas inmunodeprimidas o con enfermedades subyacentes, son más susceptibles que otras a contraer la enfermedad. • La exposición al virus puede controlarse mediante el uso de medidas de protección en dispensarios y hospitales, en reuniones comunitarias o en el hogar. 4. ¿Cuáles son los signos y síntomas típicos de la infección? La enfermedad se suele manifestar con la aparición súbita de fiebre, debilidad intensa, dolores musculares, de cabeza y de garganta, síntomas que van seguidos de vómitos, diarrea, erupciones cutáneas, disfunción renal y hepática y, en algunos casos, hemorragias internas y externas. Los resultados de laboratorio muestran disminución del número de leucocitos y plaquetas, así como aumento de las enzimas hepáticas. El periodo de incubación (el intervalo desde la infección a la aparición de los síntomas) oscila entre 2 y 21 días. Los pacientes son contagiosos desde el momento en que empiezan a manifestarse los síntomas. No son contagiosos durante el periodo de incubación. Las infecciones de la enfermedad por el virus del Ebola solamente pueden confirmarse mediante pruebas de laboratorio. 5. ¿Cuándo se debe buscar atención médica? Alguien que haya estado en una zona con casos confirmados de enfermedad por el virus del Ebola o en contacto con una persona presuntamente infectada o cuya infección se haya confirmado debe buscar de inmediato atención médica. Todos los casos de personas presuntamente enfermas deben notificarse sin demora al centro de salud más cercano. La atención médica temprana es esencial para mejorar la tasa de supervivencia a la enfermedad. Es también importante contener la propagación de la enfermedad, para lo cual es necesario iniciar de inmediato los procedimientos de control de la infección. 6. ¿En qué consiste el tratamiento? Los casos graves requieren cuidados intensivos. Los pacientes suelen deshidratarse y necesitan sueros intravenosos o rehidratación por vía oral con soluciones que contengan electrólitos. En la actualidad no se dispone de ningún tratamiento específico que cure la enfermedad. Algunos pacientes se recuperarán con la atención médica adecuada. Para contribuir a contener la propagación del virus, los casos presuntos o confirmados deben aislarse de los otros pacientes y ser tratados por personal de salud que aplique estrictas precauciones para controlar la infección. 7. ¿Qué puedo hacer yo? ¿Puede prevenirse la enfermedad? En la actualidad no existe ninguna vacuna autorizada contra la enfermedad por el virus del Ebola. Hay varias vacunas en fase de pruebas, pero en estos momentos ninguna está disponible para uso clínico. La única forma de reducir los contagios y la muerte es divulgar información sobre los factores de riesgo y las medidas de protección que pueden adoptarse. Formas de evitar la infección • Entender la naturaleza de la enfermedad, cómo se transmite y cómo impedir que siga extendiéndose. • Reducir el contacto con animales con elevado riesgo de estar infectados (es decir, murciélagos frugívoros, monos o simios) en las zonas de la selva afectadas. • Los productos de origen animal (sangre y carne) deben ser bien cocinados antes de su consumo. • Deben utilizarse guantes y equipo protector si se atiende a una persona enferma. • Se recomienda lavarse las manos con regularidad tras visitar a pacientes en el hospital o cuidar a enfermos en el hogar. • Las personas que hayan muerto por esta causa deben ser manipuladas utilizando equipo protector resistente y ser sepultadas de inmediato. 8. ¿Y el personal de salud? ¿Cómo se protege del elevado riesgo que supone atender a los enfermos? El personal de salud que trata a pacientes con infección presunta o confirmada corre un mayor riesgo de infección que otros grupos. • Además de las precauciones generales en la asistencia médica, el personal de salud debe aplicar rigurosamente las medidas recomendadas para el control de la infección con objeto de evitar la exposición a sangre o líquidos infectados o a entornos u objetos contaminados, como la ropa de cama sucia de un paciente o las agujas usadas. • Debe utilizar equipo de protección personal, como batas, guantes, mascarillas y anteojos, o caretas protectoras, todo ello de uso individual. • No debe reutilizar el equipo o la indumentaria de protección a menos que se hayan esterilizado debidamente. • Debe cambiarse de guantes entre pacientes presuntamente infectados por el virus del Ebola. • Los procedimientos invasores que pueden exponer a los médicos, el personal de enfermería y otras personas a una infección deben realizarse en estrictas condiciones de seguridad. • Los pacientes infectados deben mantenerse separados de otros pacientes y de personas sanas, en la medida de lo posible. 9. ¿Y los rumores de que algunos alimentos pueden prevenir o curar la infección? La OMS recomienda encarecidamente que se solicite asesoramiento de salud creíble sobre la enfermedad por el virus del Ebola a las autoridades de salud pública. Si bien no existe ningún fármaco específico contra el virus del Ebola, el mejor tratamiento son los cuidados intensivos prestados en el hospital por el personal de salud que utiliza procedimientos rigurosos de control de la infección, como las medidas de protección recomendadas. 10. ¿Cómo protege la OMS la salud durante los brotes? La OMS facilita asesoramiento técnico a los países y las comunidades con objeto de que se preparen para los brotes de virosis del Ebola y respondan a ellos. Entre las medidas de la OMS cabe mencionar las siguientes: • Vigilancia de la morbilidad e intercambio de información entre las regiones para que estén alerta ante posibles brotes. • Prestación de asistencia técnica en la investigación y contención de las amenazas para la salud cuando ocurran, por ejemplo ayuda in situ para detectar a las personas enfermas y hacer un seguimiento de las características de la morbilidad. • Asesoramiento sobre prevención y opciones de tratamiento. • Despliegue de expertos y distribución de suministros sanitarios (como equipo de protección personal para el personal de salud) cuando el país los solicite. • Comunicaciones para dar a conocer la naturaleza de la enfermedad y las medidas sanitarias de protección para controlar la transmisión del virus. • Activación de redes regionales y mundiales de expertos que proporcionen asistencia, en caso de solicitarse, y mitiguen las posibles repercusiones sanitarias internacionales y las perturbaciones en los viajes y el comercio. 11. Durante un brote, ¿el número de casos notificados por los funcionarios de salud puede aumentar o disminuir? ¿Por qué? Durante un brote de virosis del Ebola, las autoridades de salud pública del país afectado informan del número de casos y muertes provocados por la enfermedad. Las cifras cambian cada día y reflejan los casos sospechosos y los confirmados en laboratorio. A veces las cifras de casos sospechosos y casos confirmados se notifican al mismo tiempo, otras veces por separado. Por ello, los datos pueden variar. Analizar las tendencias de los datos a lo largo del tiempo, y disponer de información adicional, es por lo general más útil para evaluar la situación de salud pública y determinar la respuesta adecuada. 12. ¿Es seguro viajar durante un brote? ¿Qué recomienda la OMS en los viajes? Durante un brote, la OMS examina periódicamente la situación de salud pública y recomienda restricciones de viaje o de comercio, de ser necesario. El riesgo de infección para los viajeros es ínfimo puesto que la transmisión de persona a persona se deriva del contacto directo con los líquidos o secreciones corporales de un paciente infectado. Recomendaciones generales de la OMS en los viajes • Los viajeros deben evitar todo contacto con pacientes infectados. • El personal de salud que viaje a las zonas afectadas debe acatar rigurosamente las orientaciones sobre el control de la infección recomendadas por la OMS. • Las personas que hayan estado en zonas con casos recientemente notificados deben conocer los síntomas de la infección y solicitar atención médica al primer signo de la enfermedad. • Se aconseja a los médicos clínicos que atiendan a viajeros que hayan regresado de zonas afectadas y que presenten síntomas compatibles que consideren la posibilidad de la enfermedad por el virus del Ebola. "Suero secreto" La OMS considera ético el uso del ‘suero secreto’ contra el Ébola La Organización Mundial de la Salud (OMS) ha celebrado una reunión con especialistas en ética médica para valorar si es adecuado usar el fármaco experimental ZMapp, nunca antes probado en humanos, contra la epidemia de ébola. Su respuesta es “sí”, siempre que se respeten criterios de transparencia, dignidad y consentimiento informado. El tratamiento contra el ébola que están recibiendo dos pacientes en EE UU con el fármaco experimental ZMapp, y que ayer empezó a recibir el hoy fallecido Miguel Pajares, ha obligado a la OMS a plantearse dudas éticas. ¿Se pueden utilizar terapias cuya seguridad no está probada y con efectos adversos desconocidos? ¿Quién debe recibir el tratamiento con este ‘suero secreto’, del que se dispone de cantidades limitadas? Por eso, ayer la OMS reunió a un panel de especialistas en ética médica para debatir el uso de estos medicamentos contra el brote de ébola en África occidental, que ya se ha cobrado más de mil vidas, según datos de la organización. Por consenso, el grupo de expertos determinó que teniendo en cuenta las circunstancias de este brote, sí es ético utilizar fármacos experimentales para el tratamiento o la prevención del ébola, aunque su eficacia no esté probada y se desconozcan sus posibles efectos secundarios, siempre que se cumplan ciertas condiciones. En las circunstancias de este brote, la OMS considera ético utilizar fármacos experimentales contra el ébola, aunque su eficacia no esté probada Según informa la OMS en un comunicado, este tipo de intervenciones deben guiarse por criterios éticos estrictos que incluyen la transparencia absoluta, el consentimiento informado, la libertad de elección, la confidencialidad, el respeto a la persona, la preservación de la dignidad y la participación de la comunidad. Contra el ébola no hay medicamentos ni vacunas. Durante la última década, numerosos grupos de investigación han trabajado para desarrollar fármacos. Algunos de ellos han ofrecido resultados prometedores en el laboratorio, pero todavía no se ha evaluado en humanos su eficacia y seguridad, una condición que, en circunstancias normales, es imprescindible para administrar un medicamento a los pacientes. Obligaciones morales El grupo de expertos de la OMS ha concluido que, en este caso extraordinario, es lícito utilizar fármacos experimentales para tratar a los pacientes, y que, con vistas a evaluar la eficacia y seguridad de ZMapp, producido por la empresa Mapp Biopharmaceutical, “existe la obligación moral de recoger y compartir todos los datos generados, incluidos los del uso compasivo de un medicamento no aprobado fuera de un ensayo clínico”. Quedan cuestiones pendientes: ¿qué criterios de prioridad se deben emplear para distribuir estas terapias? Los especialistas se han mostrado unánimes en que es necesario evaluar los resultados del nuevo fármaco con ensayos clínicos diseñados en las mejores condiciones posibles, a pesar de que las circunstancias no sean las idóneas. El panel ha dejado sin resolver otras cuestiones que, según su opinión, necesitan de un análisis más profundo: ¿Cómo recopilar los datos de estos ensayos de manera ética y dar a la vez una atención óptima a los pacientes? ¿Qué criterios de prioridad se deben emplear para la distribución equitativa de estas terapias experimentales en los países afectados? Fuente: Agencia SINC #### OMS respalda uso de medicamentos experimentales contra ébola en África Occidental * Liberia tratará a médicos infectados con medicamento de prueba ZMapp * Sacerdote español que recibió ZMapp muere en Madrid * No existen tratamientos autorizados ni vacunas para el ébola * Virus ha causado la muerte a más de 1.000 personas en África Occidental Por Kate Kelland y Stephanie Nebehay LONDRES/GINEBRA - Las personas infectadas por el brote de ébola en África Occidental pueden acceder a medicamentos no probados, dijo el martes la Organización Mundial de la Salud, pero los escasos suministros plantean interrogantes sobre quién tendrá prioridad para recibirlos durante la epidemia del virus. Liberia dijo que planeaba tratar a dos médicos infectados con un medicamento no probado para el ébola llamado ZMapp. Un sacerdote español que el Ministerio de Salud del país dijo que también había recibido ZMapp falleció. La epidemia del virus ébola en África Occidental -la mayor y más mortífera del mundo hasta el momento- ha causado la muerte de 1.013 personas en Guinea, Liberia, Sierra Leona y Nigeria. La OMS la ha declarado una emergencia internacional de salud y estima que la epidemia continuará durante meses. No existen tratamientos autorizados ni vacunas para el ébola, pero varias empresas de biotecnología y equipos de investigación han estado trabajando en posibles medicamentos. "Hubo un acuerdo unánime entre los expertos respecto a que ante las circunstancias especiales de este brote de ébola es ético ofrecer intervenciones no registradas como posible tratamiento o prevención", dijo la subdirectora general de la OMS, Marie-Paule Kieny, después de que una comisión de ética publicó su orientación. La comisión de especialistas en ética médica convocada por la OMS dijo que varios posibles medicamentos habían pasado las fases de estudio laboratorio y en animales para desarrollo y que ahora deberían pasar en vía rápida a ensayos clínicos y también estar disponibles para el uso compasivo. "Si estos tratamientos pueden salvar vidas, como lo sugieren estudios animales, ¿no deberíamos usarlos para salvar vidas cuando demasiadas vidas se están perdiendo?", afirmó Kieny. ESPERANZAS CON ZMAPP La reunión de la comisión de ética de la OMS fue convocada después de que se administró el medicamento experimental ZMapp para el ébola, elaborado por la empresa estadounidense de biotecnología Mapp Biopharmaceutical, a dos socorristas estadounidenses que contrajeron el virus en Liberia. Ambos han mostrado algunas señales de mejoría desde que recibieron el medicamento y Kieny dijo que ha oído informes de que el tratamiento había tenido un efecto rápido e importante en esos pacientes. Según la OMS, sólo han sido elaboradas entre 10 y 12 dosis de la droga experimental. Liberia se preparaba para tratar a dos médicos locales con ZMapp después de que autoridades estadounidenses aprobaron su exportación. El Ministerio de Salud de España informó que el martes falleció en un hospital de Madrid un sacerdote de 75 años que también había sido tratado con ZMapp. Había contraído el ébola en Liberia mientras trabajaba para una organización no gubernamental. Ben Neuman, un virólogo de la Universidad de Reading en Gran Bretaña, dijo que la decisión de la comisión de la OMS era bienvenida. "El caso humanitario para tratamiento en una enfermedad tan mortal como el ébola es muy claro. Si yo tuviera ébola, estaría buscando cualquier tratamiento disponible, incluso si estuviera sólo en fase experimental", sostuvo. La comisión de ética de la OMS afirmó que era probable que las primeras pruebas de los medicamentos en humanos sean realizadas en los próximos dos a cuatro meses, pero advirtió que incluso entonces, y si las pruebas eran exitosas, los suministros serían limitados. "Es (...) probable que el número de dosis disponibles para nuevos estudios y/o desarrollo desde fines del 2014 hacia adelante siga siendo insuficiente para satisfacer la demanda", dijo la comisión en el comunicado. Entre las empresas con posibles tratamientos figuran Tekmira Pharmaceuticals, Biocryst Pharmaceuticals y Siga Technologies. GlaxoSmithKline y científicos estadounidenses del Instituto Nacional de Alergias y Enfermedades Infecciosas esperan iniciar un ensayo clínico de una vacuna experimental para el ébola tan pronto como el mes próximo, tras prometedores resultados de pruebas en primates. Otra vacuna experimental de la unidad Crucell de Johnson & Johnson debería entrar en ensayos clínicos de fase I a fines del 2015 o inicios del 2016, mientras que Profectus Biosciences también trabaja con científicos estadounidenses en otra vacuna preclínica. (Reporte adicional de Ben Hirschler en Londres, Clair MacDougall en Monrovia, Daniel Flynn en Dakar, Teresa Larraz en Madrid y Jenny Clover en Kigali; escrito por Kate Kelland. Editado en español por Patricio Abusleme). #### Salud Pública Declaración de la OMS sobre la reunión del Comité de Emergencias del Reglamento Sanitario Internacional acerca del brote de enfermedad por el virus del Ebola de 2014 en África Occidental Declaración de la OMS El miércoles 6 de agosto de 2014, de 13.00 a 17.30, y el jueves 7 de agosto de 2014, de 13.00 a 18.30 (hora de Ginebra; CET), se celebró por teleconferencia la primera reunión del Comité de Emergencias, convocada por la Directora General de conformidad con el Reglamento Sanitario Internacional (2005) [RSI (2005)], para tratar del brote de enfermedad por virus del Ebola (EVE) de 2014 en África Occidental. Los miembros y los asesores del Comité de Emergencias se reunieron por teleconferencia ambos días.1 En la sesión informativa de la reunión, celebrada el miércoles 6 de agosto, participaron los siguientes Estados Partes en el RSI (2005): Guinea, Liberia, Nigeria y Sierra Leona. Durante la sesión informativa, la Secretaría de la OMS presentó la información de última hora y una evaluación del brote de EVE en África Occidental. Los mencionados Estados Partes expusieron la evolución reciente en sus países, y las medidas que han adoptado a fin de poner en práctica estrategias para controlar rápidamente el brote, así como las deficiencias y los problemas que plantea la respuesta. Después de debatir y deliberar sobre la información aportada, el Comité consideró: Que el brote de EVE en África Occidental constituye un ‘evento extraordinario’ y supone un riesgo de salud pública para otros estados. Que las posibles consecuencias de una mayor propagación internacional son particularmente graves dada la virulencia del virus, su intensa transmisión tanto en la comunidad como en los centros sanitarios, y la debilidad de los sistemas de salud en los países afectados y en los que corren mayor riesgo de verse afectados. Que es esencial una respuesta internacional coordinada para detener y revertir la propagación internacional del virus. Por unanimidad, el Comité consideró que se han cumplido las condiciones para declarar una emergencia de salud pública de importancia internacional. El actual brote de EVE empezó en Guinea en Diciembre de 2013, y en la actualidad hay transmisión en Guinea, Liberia, Nigeria y Sierra Leona. A fecha de 4 de agosto de 2014, los cuatro países habían notificado 1711 casos (1070 confirmados, 436 probables y 205 posibles), 932 de ellos mortales. Se trata del mayor brote de EVE registrado hasta ahora. Para responder a él, varios países no afectados han emitido una serie de consejos o recomendaciones en relación con los viajes. Las exposiciones hechas por los Estados Partes y los posteriores debates del Comité han permitido identificar varios problemas en los países afectados: Sus sistemas de salud son frágiles y tienen importantes deficiencias en recursos humanos, económicos y materiales que comprometen su capacidad para montar una respuesta que permita controlar el brote adecuadamente. Carecen de experiencia sobre los brotes de EVE; los conceptos erróneos sobre la enfermedad, y en particular sobre su modo de transmisión, son frecuentes y siguen constituyendo un gran obstáculo en algunas comunidades. La población tiene una gran movilidad y ha habido varios casos de desplazamiento transfronterizo de viajeros infectados. Ha habido varias generaciones de transmisión en tres capitales: Conakry (Guinea), Monrovia (Liberia) y Freetown (Sierra Leona). Ha habido un gran número de infecciones en profesionales sanitarios, lo cual indica que las prácticas de control de la infección son inadecuadas en muchos centros. El Comité presentó a la consideración de la Directora General los siguientes consejos para abordar el brote de EVE en conformidad con el RSI (2005). #### Estados donde hay transmisión del virus del Ebola Los Jefes de Estado deberían declarar el estado de emergencia en sus países; dirigirse personalmente a la nación para informar de la situación y las medidas adoptadas para hacer frente al brote, y explicar el papel fundamental de la comunidad para garantizar su control rápido; proporcionar acceso inmediato a financiación de emergencia para iniciar y mantener las operaciones de respuesta; y garantizar que se toman todas las medidas necesarias para movilizar y remunerar al personal sanitario necesario. Los Ministros de Salud y otros líderes del sector de la salud deberían asumir un papel destacado de liderazgo en la coordinación y ejecución de las medidas de emergencia para hacer frente al brote, y en este sentido sería fundamental que periódicamente se reunieran con las comunidades afectadas y visitaran los centros de tratamiento. Los estados deberían activar sus mecanismos de gestión de desastres/emergencias y establecer un centro de operaciones de emergencia bajo la autoridad del Jefe del Estado, a fin de coordinar el apoyo de todos los asociados, así como los sectores de la información, la seguridad, las finanzas y otros, con miras a garantizar una aplicación y supervisión eficiente y eficaz de las medidas integrales de control de la EVE. Dichas medidas deben incluir la prevención y control de la infección, la sensibilización de la comunidad, la vigilancia, la disponibilidad de pruebas diagnósticas de laboratorio exactas, el rastreo y seguimiento de los contactos, la atención clínica a los casos y la comunicación puntual de información exacta entre los países. En todas las zonas infectadas y de alto riesgo deben establecerse mecanismos similares en el ámbito estatal/provincial y local para garantizar la coordinación en todos los niveles. Los estados deberían velar por la existencia de medidas a gran escala y sostenidas para lograr la participación de la población, a través de los líderes locales, religiosos y tradicionales y de los curanderos tradicionales, de modo que las comunidades desempeñen un papel central en la identificación y rastreo de los casos y la información sobre el riesgo; la población debería ser plenamente consciente de los beneficios del tratamiento precoz. Es fundamental que se establezca un sistema de suministro sólido, de modo que haya productos médicos básicos suficientes, en especial equipos de protección personal, para quienes los necesiten, tales como los profesionales sanitarios, los técnicos de laboratorio, el personal de limpieza y mortuorio, y otras personas que puedan entrar en contacto con pacientes infectados o materiales contaminados. En las zonas con transmisión intensa (por ejemplo, la zona fronteriza de Guinea, Liberia y Sierra Leona), la prestación de atención clínica de calidad y de apoyo material y psicosocial a las poblaciones afectadas debería utilizarse como base principal para reducir los movimientos de población, aunque puedan adoptarse medidas complementarias extraordinarias, como la cuarentena, si se consideran necesarias. Los estados deberían velar por que los profesionales sanitarios dispongan de medidas adecuadas para garantizar su seguridad y protección, cobren puntualmente sus salarios, y si procede, primas por peligrosidad, y reciban formación y capacitación adecuadas en materia de prevención y control de la infección, y en particular sobre el uso apropiado del equipo de protección personal. Los estados deberían velar por que: haya centros de tratamiento y laboratorios de diagnóstico fiables tan cerca como sea posible de las zonas de transmisión; que estas instalaciones dispongan de suficiente personal capacitado y de equipos y suministros proporcionales al número de casos que atienden; que se garantice la seguridad del personal y se reduzca al mínimo el riesgo de altas prematuras; y que periódicamente se le recuerden al personal las medidas de prevención y control de la infección y se supervise su cumplimiento. Los estados deberían examinar en los aeropuertos y puertos marítimos internacionales y en los principales pasos fronterizos terrestres a todas las personas que salgan del país, a fin de detectar enfermedades febriles compatibles con una posible infección por el virus del Ebola. Dichos exámenes deberían consistir, como mínimo, en un cuestionario, el registro de la temperatura y, en caso de la persona tenga fiebre, una evaluación del riesgo de que su causa sea la EVE. Se debe impedir el viaje a toda persona con enfermedad compatible con la EVE, a no ser en el contexto de una evacuación médica apropiada. Los casos de EVE y sus contactos no deberían hacer viajes internacionales, a no ser en el contexto de una evacuación médica apropiada. Para reducir al mínimo el riesgo de propagación internacional de la EVE: • Los casos confirmados deberían ser aislados y tratados inmediatamente en centros terapéuticos específicos para la EVE, y se deberían impedir los viajes nacionales o internacionales hasta que se obtengan resultados negativos en dos pruebas diagnósticas específicas realizadas con un intervalo mínimo de 48 horas entre ellas. • Los contactos (no se consideran como tal los profesionales sanitarios protegidos adecuadamente ni el personal de laboratorio que no haya tenido exposición sin protección) deben ser examinados cada día, y se les deben restringir los viajes dentro del país e impedir los viajes internacionales hasta 21 días después de la exposición. • Los casos probables y posibles deberían aislarse inmediatamente, restringiéndose sus viajes en función de su clasificación como casos confirmados o contactos. A fin de reducir el riesgo de infección por el virus del Ebola, los estados deberían velar por que los funerales y entierros sean llevados a cabo por personal bien capacitado, permitiendo la presencia de la familia y las prácticas culturales, y de conformidad con las reglamentaciones sanitarias nacionales. Se debería prohibir el traslado transfronterizo de restos mortales de casos posibles, probables o confirmados de EVE, a no ser que se cumplan las disposiciones de bioseguridad reconocidas internacionalmente. Los estados deberían velar por la disponibilidad de atención médica apropiada para las tripulaciones y el personal de las aerolíneas que operen en el país, y colaborar con estas para facilitar y armonizar las comunicaciones y la gestión de los pasajeros sintomáticos de conformidad con el RSI (2005), los mecanismos de rastreo de los contactos en caso de necesidad, y el uso de registros para localizar a los pasajeros cuando proceda. Los estados donde haya transmisión de la EVE deberían considerar la posibilidad de postergar las concentraciones multitudinarias hasta que se interrumpa dicha transmisión. Estados con algún caso posible o confirmado de EVE y estados no afectados que tengan fronteras terrestres con estados afectados Los estados no afectados que tengan fronteras terrestres con estados en los que haya transmisión del virus del Ebola deberían establecer de forma urgente una vigilancia de los conglomerados de casos de fiebre de origen desconocido o de muertes por enfermedad febril; establecer acceso a un laboratorio cualificado para el diagnóstico de la EVE; velar por que los profesionales sanitarios tengan conocimientos y capacitación en materia de procedimientos adecuados de prevención y control de la infección; y crear equipos de respuesta rápida con capacidad para investigar y atender los casos de EVE y sus contactos. Todo estado en el que se detecte por primera vez un caso confirmado o sospechoso de EVE, un contacto o conglomerados de muertes debidas a enfermedades febriles de origen desconocido debería tratarlos como una emergencia sanitaria y adoptar inmediatamente medidas para investigar y detener en las primeras 24 horas un posible brote de EVE, tratando a los casos, estableciendo un diagnóstico definitivo y procediendo al rastreo y seguimiento de los contactos. Si se confirma que está habiendo transmisión del virus del Ebola en ese estado, se aplicarán las recomendaciones para los Estados donde hay transmisión del virus del Ebola a nivel nacional o subnacional, dependiendo del contexto epidemiológico y del riesgo. #### Todos los estados ##### No deben prohibirse de forma generalizada el comercio ni los viajes internacionales, aunque deberían aplicarse las restricciones definidas en estas recomendaciones con respecto a los viajes de los casos de EVE y sus contactos. Los estados deberían proporcionar a los viajeros a zonas afectadas o de alto riesgo la información pertinente sobre los riesgos, las medidas para minimizarlos y consejos sobre cómo actuar en caso de posible exposición. Los estados deberían estar preparados para detectar, investigar y atender casos de EVE, y ello debería incluir el acceso garantizado a laboratorios cualificados para el diagnóstico de la EVE y, cuando proceda, la capacidad para gestionar los viajeros procedentes de zonas infectadas que lleguen a los aeropuertos internacionales o a los principales pasos fronterizos terrestres con enfermedades febriles de origen desconocido. La población general debería disponer de información exacta y pertinente sobre el brote de EVE y las medidas para reducir el riesgo de exposición. Los estados deberían estar preparados para facilitar la evacuación y repatriación de sus ciudadanos (por ejemplo, profesionales sanitarios) que hayan estado expuestos al virus del Ebola. El Comité hizo hincapié en la importancia del apoyo continuo de la OMS y de otros asociados nacionales e internacionales para lograr la aplicación eficaz de estas recomendaciones y la supervisión de su cumplimiento. Fuente OMS: http://www.who.int #### Guinea declara emergencia sanitaria pública por ébola #### Por Saliou Samb CONAKRY (Reuters) - Guinea declaró una emergencia sanitaria pública por una epidemia de ébola que ha provocado la muerte de más de 1.000 personas en estados de África occidental, y enviará trabajadores del sector de la salud a todos los puntos fronterizos afectados, informó el jueves un funcionario de gobierno. Se calcula que en Guinea han muerto 377 personas desde marzo, cuando estalló el peor brote del ébola a nivel mundial en zonas remotas de la región que limita con Sierra Leona y con Liberia. Guinea asegura que la enfermedad está controlada dentro de su territorio y que el número de nuevos casos está disminuyendo, pero que se necesitan nuevas medidas para evitar más infecciones desde los países que están en el centro de la epidemia. "Se van a destinar camiones llenos de insumos de salud y a personal de seguridad a los puntos fronterizos con Liberia y con Sierra Leona", dijo Aboubacar Sidiki Diakité, presidente de la comisión de ébola de Guinea. Cerca de 3.000 personas están aguardando en 17 puntos fronterizos para que se les permita el ingreso al país, agregó el funcionario. "Cualquier persona que esté enferma será aislada de inmediato. Se les harán seguimientos a las personas. No podemos tomar el riesgo de dejar entrar a todos sin revisiones", agregó. Sierra Leona ha declarado el ébola una emergencia nacional, al igual que Liberia. Nigeria, que también declaró una emergencia nacional el jueves, dijo que registraba 11 casos de ébola luego del contagio de un doctor que trató a un ciudadano liberiano que llevó la enfermedad a Lagos. Número sin precedentes de personal médico infectado con Ébola OMS. Evaluación de la situación - 25 de agosto 2014 El brote de la enfermedad del virus del Ébola en África occidental no tiene precedentes en muchos aspectos, entre ellos la alta proporción de médicos, enfermeras y otros trabajadores de la salud que han sido infectadas. Hasta la fecha, más de 240 trabajadores de la salud han desarrollado la enfermedad en Guinea, Liberia, Nigeria y Sierra Leona, y más de 120 han muerto. El Ébola ha cobrado la vida de médicos prominentes en Sierra Leona y Liberia, privando a estos países, no sólo de la atención médica con experiencia y dedicación, sino también de los héroes nacionales inspiradores. Hay varios factores que ayudan a explicar la alta proporción de personal médico infectado. Entre estos factores incluyen la escasez de equipo de protección personal o su uso inapropiado, demasiado poco personal médico para un brote tan grande, y la compasión que hace que el personal médico trabaje en salas de aislamiento mucho más allá de la cantidad de horas recomendadas como seguras. En el pasado, algunos brotes de Ebola se hicieron visibles sólo después de que la transmisión se amplificó en un entorno de atención de salud y los médicos y enfermeras se enfermaron. Sin embargo, una vez que se identificó el virus de Ebola y se pusieron las medidas de protección adecuadas en el lugar, los casos entre el personal médico se redujeron drásticamente. Por otra parte, muchos de los más recientes brotes de Ébola han ocurrido en zonas remotas, en una parte de Africa que está más familiarizada con esta enfermedad y con las cadenas de transmisión que eran más fáciles de rastrear y romper. El brote actual es diferente. Ciudades capitales, así como áreas rurales remotas se ven afectadas enormemente, aumentado las oportunidades de que los casos no diagnosticados tengan contacto con el personal del hospital. Ni los médicos ni el público están familiarizados con la enfermedad. El miedo intenso gobierna aldeas enteras y ciudades. Varias enfermedades infecciosas endémicas en la región, como la malaria, la fiebre tifoidea y la fiebre de Lassa, imitan los síntomas iniciales de la enfermedad del virus del Ébola. Los pacientes infectados con estas enfermedades a menudo se necesitan atención de emergencia. Sus médicos y enfermeras pueden no ver ninguna razón para sospechar Ebola y no ven la necesidad de tomar medidas de protección. Algunas infecciones documentadas han ocurrido cuando los médicos no protegidos se apresuraron a ayudar a un paciente que estaba visiblemente muy enfermo. Esta es la primera reacción de la mayoría de los médicos y enfermeras: ayudar al enfermo. En muchos casos, el personal médico están en riesgo porque ningún equipo de protección está disponible - ni siquiera guantes y mascarillas. Incluso en las salas dedicadas al Ébola, los equipos de protección personal a menudo son escasos o no se utilizan correctamente. La capacitación en el uso adecuado es absolutamente esencial, como son los estrictos procedimientos para la prevención y el control de infecciones. Además, el equipo de protección personal es caliente y pesado, especialmente en un clima tropical, lo que limita seriamente el tiempo que los médicos y las enfermeras pueden trabajar en una sala de aislamiento. Algunos médicos trabajan más allá de sus límites físicos, tratando de salvar vidas en turnos de 12 horas, todos los días de la semana. El personal que se agota es más propenso a cometer errores. Todo el equipo de protección personal enviado o aprobado por la OMS cumple con los estándares internacionales de seguridad apropiados. La pesada carga sobre los trabajadores de la salud en este brote tiene una serie de consecuencias que impiden aún más los esfuerzos de control. Se agota uno de los activos más importantes durante el control de cualquier brote. La OMS estima que, en los tres países más afectados, únicamente dos médicos están disponibles para tratar a 100.000 personas, y estos médicos se concentran en las zonas urbanas. Esto puede conducir a la clausura de los establecimientos de salud, sobre todo cuando el personal se niega a trabajar, temiendo por sus vidas. Cuando los hospitales se cierran, otras necesidades médicas comunes y urgentes, tales como un parto seguro y el tratamiento de la malaria, se descuidan. El hecho de que gran parte del personal médico haya desarrollado la enfermedad aumenta el nivel de la ansiedad: si los médicos y enfermeras se infectan, ¿qué oportunidad tiene el público en general? En algunas áreas, los hospitales son considerados como incubadoras de la infección y son rechazados por los pacientes con cualquier tipo de dolencia, reduciendo de nuevo el acceso a la atención médica general. La pérdida de tantos médicos y enfermeras ha hecho que sea difícil para la OMS asegurar el apoyo de un número suficiente de personal médico extranjero. La Unión Africana ha puesto en marcha una iniciativa urgente de contratar a más trabajadores de la salud, de entre sus miembros. OMS #### OMS retira personal de laboratorio ébola en Sierra Leona tras contagio de médico Por Umaru Fofana y Media Coulibaly FREETOWN (Reuters) - La Organización Mundial de la Salud (OMS) anunció el martes que cerró un laboratorio en Sierra Leona después de que uno de sus trabajadores se infectó con ébola, una decisión que podría obstaculizar sus esfuerzos para reforzar la respuesta global al peor brote histórico de la enfermedad. Al menos 1.427 personas han muerto y 2.615 han sido infectadas desde que la enfermedad fue detectada en marzo en las selvas del sur de Guinea. La OMS ha destinado casi 400 trabajadores propios y de organizaciones asociadas a la lucha contra la epidemia de la altamente contagiosa fiebre hemorrágica, que ha atacado Sierra Leona, Liberia, Guinea y Nigeria. Un brote separado fue confirmado el domingo en República Democrática del Congo. El ministro de Salud de Nigeria declaró el martes que su país había "contenido hasta ahora" el brote de ébola. Una de las enfermedades más mortíferas conocidas por el hombre, el ébola se transmite por contacto con los fluidos corporales y el brote actual ha provocado la muerte de al menos 120 trabajadores médicos. La OMS dijo que retiró al personal del laboratorio que hacía análisis de ébola en Kailahun -uno de los únicos dos en Sierra Leona- después de que un epidemiólogo senegalés fue infectado con ébola. "Es una medida temporal para cuidar el bienestar del resto de los trabajadores", dijo a Reuters Christy Feig, portavoz de la OMS. La OMS dijo en un comunicado posterior que el personal podría regresar cuando culmine una investigación, y agregó que mientras tanto las pruebas continuarán en el laboratorio Kenema. El médico senegalés -el primer trabajador de la OMS infectado- será evacuado desde Sierra Leona en los próximos días, señaló Feig. El único tratamiento para la enfermedad es un medicamento experimental y hasta ahora su uso ha arrojado resultados dispares. De los seis trabajadores de la salud tratados con el fármaco ZMapp, dos han muerto. En Liberia, el país que ha reportado más muertes por ébola, el Ministerio de Salud ha reportado más de 200 nuevos casos supuestos, probables y confirmados en un periodo de tres días. Muchos de ellos en la capital Monrovia, donde dos barrios están en cuarentena custodiados por el ejército. Algunos funcionarios liberianos han abandonado el país o simplemente no acuden al trabajo por temor a contraer el virus, lo que empujó a la presidenta Ellen Johnson a emitir una orden amenazando a aquellos con rango ministerial con el despido. #### Muere médico liberiano que recibió medicamento experimental ZMapp para el ébola DAKAR (Reuters) - Uno de los tres médicos africanos infectados con el virus de ébola tratados con el medicamento experimental ZMapp murió en Monrovia, dijo el lunes el ministro de Información de Liberia, Lewis Brown. Liberia, el país de África Occidental donde el ébola se está expandiendo más rápidamente, recibió tres dosis del tratamiento el 13 de agosto. Las autoridades dijeron inicialmente que los tres médicos, los liberianos Zukunis Ireland y Abraham Borbor y el nigeriano Aroh Cosmos Izchukwu, estaban respondiendo bien al tratamiento, generando optimismo sobre la terapia experimental. Al pedirle que confirmara la muerte de Borbor, el ministro Brown dijo: "Es correcto. Murió ayer". Dos trabajadores estadounidenses de ayuda que contrajeron ébola en Liberia fueron declarados libres del virus la semana pasada y recibieron el alta tras recibir el mismo tratamiento. Pero un cura español a quien le suministraron ZMapp murió. Mapp Biopharmacutical, el fabricante del medicamento con sede en Estados Unidos, dijo que los limitados suministros se habían acabado y que producir más tomaría tiempo. Hay otros medicamentos en estudio, pero ninguno está probado y aún deben pasar por lo menos la primera etapa de los ensayos clínicos. El ébola provocó la muerte de al menos 1.427 personas en el brote más mortífero de la enfermedad hasta la fecha. En la semana hasta el 22 de agosto fueron reportados 292 nuevos casos sospechados, probables y confirmados de ébola en Liberia, el mayor número semanal desde que la epidemia comenzó en marzo, según un reporte de la agencia para la infancia de Naciones Unidas. El ébola puede provocar la muerte de hasta un 90 por ciento de los infectados aunque la tasa de mortalidad producto de la actual epidemia es de cerca del 60 por ciento. #### La OMS confirma que uno de sus trabajadores ha contraído el ébola en Sierra Leona La Organización Mundial de la Salud (OMS) ha confirmado este domingo que uno de sus trabajadores en Sierra Leona ha contraído el ébola y ha indicado que el enfermo está recibiendo la mejor atención médica posible. La OMS no ha descartado la posibilidad de evacuarle si lo considera necesario. Desde el comienzo del brote de ébola, el pasado mes de diciembre en Guinea, la OMS ha desplegado a casi 400 trabajadores de la organización y de la Red Global de Alerta y Respuesta contra Brotes para lidiar con el ébola que se ha propagado por Liberia, Sierra Leona, Nigeria y República Democrática del Congo. El ébola no se transmite por el aire como otras enfermedades, sino que es necesario un contacto directo con sangre, secreciones, órganos internos o fluidos corporales de personas o animales infectados, vivos o muertos. Los trabajadores sanitarios que atienden a los infectados por el ébola son considerados un grupo de alto riesgo. Entre ellos, la OMS ha reconocido que hay riesgo de que los trabajadores de la organización puedan contraer la enfermedad y ha asegurado que se toman todas las medidas necesarias para asegurar la protección de aquellos que están desplegados sobre el terreno. Una vez que los trabajadores han llegado a las zonas afectadas por el brote, la organización se asegura de que todos los trabajadores cuenten con el apoyo médico apropiado. Europa Press #### Umar Khan, héroe de la lucha contra el Ébola La propia enfermedad que combatía acabó con la vida del médico de Sierra Leona EMILIO DE BENITO Umar Khan, médico fallecido de Ébola, en junio de este año. / UMARU FOFANA (REUTERS) El jeque Umar Khan representa, como pocos, la dureza del brote de ébola que afecta a su país, Sierra Leona, y a los vecinos Guinea y Liberia. Responsable de la lucha contra el virus en el departamento de Kenema (Sierra Leona), ingresó en el Kailahun Ebola Centre, atendido por Médicos sin Fronteras, hace poco más de una semana. Falleció el 29 de julio. El próximo 11 de septiembre habría cumplido 40 años. Khan ha sido considerado un héroe por las autoridades de su país. Dirigía en su hospital el departamento de Lassa, otro virus hemorrágico primo hermano del ébola. Con razón y orgullo presumía de que su centro era el único del África Occidental que estaba preparado para diagnosticar el ébola y otros virus parecidos, y todo gracias al trabajo de su equipo. Antes de ello había que mandar las muestras a Alemania. La importancia de este tipo de avances se ha hecho más evidente que nunca en el actual brote, que según el último recuento va por los 1.323 afectados, de los que han fallecido 729. Tener un diagnóstico rápido del ébola, sobre todo al principio de su manifestación, cuando los síntomas no son concluyentes, es muy importante para proceder al aislamiento de los enfermos e intentar, así, romper la cadena de transmisión. Organizaciones como el Instituto Pasteur francés o el CDC estadounidense, aparte de la Organización Mundial para la Salud, han desplazado laboratorios a la zona para agilizar este paso fundamental. El médico también había ayudado a combatir el estigma de la enfermedad, y, por su afición a la genómica —una de las ramas que él consideraba con mayor futuro— había concluido que el ébola no era tan extraño a Guinea como se creía, y que el virus no había llegado a la región desde otros países, sino que ya estaba en ella, aunque no se hubiera manifestado. Khan había estudiado en el College of Medicine and Allied Health Sciences (COMAHS) de Sierra Leona, donde se graduó en 2001 en Cirugía y Medicina Tropical. Tras ocupar varios puestos oficiales, en 2005 llegó al hospital de Kenema. Se da la trágica coincidencia de que su predecesor como responsable de la lucha contra las hemorragias víricas, Aniru Conteh, había muerto de otro de estos patógenos, el virus de Lassa. Khan ha sido quizá el más destacado de los médicos y profesionales sanitarios que, en su intento por ayudar a los afectados por esta enfermedad, que puede tener tasas de mortalidad cercanas al 90% (aunque, de momento, este brote ronda el 60%) han resultado infectados. En algunos momentos se ha calculado que hasta un 30% de las víctimas pertenecen a los servicios sanitarios. Esto es una muestra de la extrema peligrosidad de su trabajo. Khan estaba considerado como uno de los mayores expertos mundiales en el tratamiento de estos enfermos, por lo que, para él, las medidas de prevención no eran en absoluto desconocidas. Esa experiencia no fue suficiente, lo que demuestra la gravedad del reto al que se enfrentan los sanitarios de los países afectados. Fuente: El País, Madrid #### Muere sacerdote español contagiado con ébola tras ser repatriado desde Liberia MADRID (Reuters) - El sacerdote español Miguel Pajares, repatriado la semana pasada desde Liberia tras enfermar de ébola durante el peor brote de la enfermedad, murió en un hospital de Madrid, dijo a Reuters una funcionaria local de salud. Pajares, de 75 años, fue ingresado en el Hospital Carlos III después de llegar a Madrid en un avión medicalizado el jueves y había empezado a ser atendido con un medicamento experimental. Una portavoz de la Consejería de Sanidad de la Comunidad de Madrid no pudo ofrecer más detalles y no fue posible contactar con la ONG San Juan de Dios, para la que trabajaba el religioso, que fue el primer europeo enfermo de ébola en ser repatriado desde Africa. Pajares trabajaba en un hospital del país de África Occidental, donde el brote de ébola ha causado más de 1.000 muertos, de acuerdo con los datos entregados el lunes por la Organización Mundial de la Salud (OMS). Varios compañeros suyos, entre ellos la hermana Chantal Pascaline Mutwamene, fallecieron también tras contagiarse por estar atendiendo a enfermos en el Hospital San José de Monrovia. Se trata del peor brote del letal virus en la historia, y la OMS dijo el viernes que representa una urgencia de salud internacional que seguirá extendiéndose durante meses. A los fallecidos se suman más de 1.800 enfermos por una enfermedad que no tiene vacuna o cura conocidas. El Ministerio español de Sanidad informó el lunes que Pajares sería atendido con el fármaco experimental bautizado ZMapp, con el que se está tratando a dos estadounidenses repatriados a su país. Junto con Pajares fue repatriada a España otra religiosa, Juliana Bohí, quien permanece ingresada en el mismo hospital como medida de precaución tras no mostrar síntomas de la enfermedad por el momento. (Reporte de Teresa Larraz Mora. Editado en español por Marion Giraldo y Rodrigo De Miguel). #### Fallece por ébola en Liberia el religioso Combey, compañero de Pajares El religioso George Combey, compañero del sacerdote Miguel Pajares, ha fallecido este lunes en el Hospital ELWA, en Monrovia (Liberia) a causa del virus del Ébola, ha informado la Orden Hospitalaria de San Juan de Dios. Esta organización también ha señalado en un comunicado que el estado de salud de los religiosos Miguel Pajares y Juliana Bonoha sigue "sin cambios" desde la última información que ofrecieron este domingo, aunque han recordado que los dos pacientes no quieren que se hagan públicos los detalles sobre su estado de salud. MSN Argentina #### Ante el alerta de la Organización Mundial de la SaludArgentina se prepara para detectar eventual introducción de casos de ébola en el país Siguiendo los lineamientos recomendados por la Organización Panamericana de la Salud (OPS) y la Organización Mundial de la Salud (OMS), el Ministerio de Salud de la Nación extremó la vigilancia ante la potencial recepción de casos. Atento al brote de ébola que afecta a África occidental y que motivó hoy a la Organización Mundial de la Salud (OMS) a declararlo "como una emergencia pública sanitaria internacional" el Ministerio de Salud de la Nación, a cargo de Juan Manzur, distribuyó ayer información técnica a todas las Direcciones de Epidemiología del país y a la Red de Laboratorios y las medidas previstas a nivel nacional para dar respuesta ante la potencial aparición de casos en Argentina. "Estamos ante el brote más severo y complejo en cuatro décadas de historia de esta enfermedad", afirmó la directora de la OMS Margaret Chan al tiempo que el organismo internacional estableció una serie de recomendaciones. Para todos los países, la OMS determinó que no debería existir una prohibición general para los viajes y el comercio internacional salvo de que se trate de casos con ébola o personas que estuvieron en contacto con algún infectado. Quienes viajen a las zonas afectadas y con riesgo deben contar con información sobre los riesgos, las medidas de prevención y de manejo ante una posible exposición al virus. Anticipándose a la declaración de la OMS, la cartera sanitaria nacional había instado ayer a las autoridades de Salud de las provincias a fortalecer la vigilancia epidemiológica y a adoptar las medidas necesarias en el nivel local y provincial para enfrentar la eventual presentación de casos en su jurisdicción. Se considera caso sospechoso a toda persona que haya tenido fiebre (mayor a 38°); contacto con algún caso confirmado de ébola en los 21 días anteriores a la aparición de síntomas y que haya viajado a regiones con circulación confirmada del virus. Otros síntomas de la enfermedad son dolor muscular, de cabeza y garganta y debilidad. La enfermedad evoluciona con vómitos, diarrea, rash, fallo renal y hepático y hemorragia masiva interna y externa. En el estadio final, los pacientes desarrollan un fallo multiorgánico. Desde marzo pasado autoridades sanitarias internacionales notificaron la propagación de un brote epidémico de ébola en Guinea, que luego se extendió a Liberia, Sierra Leona y Nigeria, países que tienen una alta circulación fronteriza, lo que dificultó la contención del brote, entre otros factores. Si bien el movimiento de personas entre Argentina y los países donde se ha documentado la transmisión de la enfermedad no es frecuente, la potencial vía de introducción del virus del ébola (EVE) en el territorio argentino es el ingreso de viajeros afectados desde zonas con transmisión activa, aunque el país no dispone de vuelos directos con los países donde se registra el brote. Ante el eventual arribo al país de casos sospechosos, estos serán aislados, evaluados y eventualmente trasladados cumpliendo con las medidas de protección al Hospital de Alta Complejidad "Néstor Carlos Kirchner" (de la localidad de Florencio Varela) o al Hospital de Pediatría "Juan P. Garrahan", establecimientos designados para la atención de estos casos. El laboratorio nacional de referencia que se ocupará de analizar las muestras y confirmar los casos, en caso de ser necesario, es el INEI-ANLIS "Carlos Malbrán". El Ministerio de Salud también instó a extremar la vigilancia epidemiológica con el objetivo de captar y notificar oportunamente los casos sospechosos para así minimizar los efectos de la posible introducción del virus del ébola y disminuir el riesgo de diseminación posterior. #### Otras características del ébola El virus del Ébola produce una enfermedad hemorrágica febril. Es considerada una patología severa con una alta tasa de letalidad que va del 50 al 90 por ciento y afecta a personas de todas las edades. Como no existe vacuna, ni tratamiento específico probado resulta fundamental adoptar medidas de prevención y control de los posibles casos. El virus se propaga en la comunidad mediante la transmisión de persona a persona, por contacto directo (a través de las membranas mucosas o de soluciones de continuidad de la piel) con órganos, sangre, secreciones, u otros líquidos corporales de personas infectadas, o por contacto indirecto con materiales contaminados por dichos líquidos. No está demostrada la transmisión aérea. En África se han documentado casos de infección asociados al contacto con chimpancés, gorilas, murciélagos frugívoros, monos, antílopes y puercoespines infectados. Fuente: Ministerio de Salud Argentina #### FDA advierte contra fraude La FDA advierte acerca de productos fraudulentos para el Ébola La Food and Drug Administration de Estados Unidos recomienda a los consumidores ser conscientes de los productos que se venden on line que dicen prevenir o tratar el virus del Ébola. Desde el brote del virus Ébola en África Occidental, la FDA ha visto y recibido quejas de los consumidores acerca de una variedad de productos que dicen ser efectivos ya sea para prevenir el virus del Ébola o para tratar la infección. Actualmente no hay vacunas o medicamentos aprobados por la FDA para prevenir o tratar el ébola. Aunque existen vacunas y tratamientos experimentales en fase de desarrollo, estos productos en investigación se encuentran en las primeras etapas de desarrollo del producto, aún no han sido plenamente probados acerca de su seguridad o eficacia, y la oferta es muy limitada. Hay vacunas no aprobadas, drogas y productos en investigación para el Ébola disponibles para su compra en Internet. Por ley, los suplementos dietéticos no se pueden anunciar para prevenir o curar la enfermedad. La FDA monitorea estos productos fraudulentos y falsos anuncios Las personas que promueven estos productos no aprobados y fraudulentos deben tomar medidas inmediatas para corregir o eliminar estas reclamaciones o enfrentar una potencial de acción de la FDA. Es importante tener en cuenta que de acuerdo con los Centros para el Control y la Prevención de Enfermedades (CDC), el Ébola no plantea un riesgo significativo para el público estadounidense. Por desgracia, durante situaciones de brote, los productos fraudulentos que pretenden prevenir, tratar o curar una enfermedad con demasiada frecuencia aparecen en el mercado. La FDA monitorea estos productos fraudulentos y falsos anuncios y toma las medidas adecuadas para proteger a los consumidores. El virus Ébola es la causa de una enfermedad, la fiebre hemorrágica viral. Los síntomas incluyen fiebre, dolor de cabeza, dolores articulares y musculares, debilidad, diarrea, vómitos, dolor de estómago, falta de apetito, y sangrado anormal. Los síntomas del virus pueden aparecer en cualquier lugar de 2 a 21 días después de la exposición, pero es más frecuente en los días 8 a10. En Estados Unidos, el Ébola no es una enfermedad transmitida por el agua o por los alimentos y no se transmite a través del aire. El virus Ébola se transmite por contacto directo con los fluidos corporales de una persona infectada o con objetos como agujas que han sido contaminados con el virus. Las personas que no presentan síntomas no son contagiosas. Se anima a los consumidores que han visto estos productos fraudulentos o falsos reclamos a informar de inmediato sobre ellos a la FDA. La FDA, la agencia dentro del Departamento de Salud y Servicios Humanos de Estados Unidos, protege la salud pública asegurando la seguridad, la eficacia y la seguridad de los medicamentos humanos y veterinarios, vacunas y otros productos biológicos para uso humano y dispositivos médicos. La agencia también es responsable de la seguridad y la seguridad del suministro de alimentos en los EE.UU. así como de los cosméticos, suplementos dietéticos, productos que emiten radiación electrónica, y de regular los productos de tabaco. Noticias día a día #### OMS advierte de "zonas grises" y casos ocultos en brote de ébola GINEBRA (Reuters) - La escala del peor brote mundial de ébola no se ha podido apreciar en su totalidad debido a los casos de familias que ocultaron en sus casas a personas infectadas y la existencia de "zonas grises" donde los médicos no pueden ingresar, dijo el viernes la Organización Mundial de la Salud (OMS). La agencia de la ONU emitió un comunicado detallando por qué el brote en África Occidental fue subestimado, luego de recibir críticas de que había sido demasiado lento en contener el virus mortal, que ahora está fuera de control. Expertos independientes plantearon preocupaciones similares hace un mes sobre que el virus contagioso podría ser peor de lo reportado debido a que pobladores desconfiados han expulsado a los trabajadores sanitarios y rechazado el tratamiento. La OMS dijo el viernes que 1.427 personas murieron por la enfermedad, en 2.615 casos registrados, y muchos expertos no esperan que la epidemia pueda controlarse este año. Los casos no reportados son un problema especialmente en Liberia y Sierra Leona. La OMS dijo que estaba trabajando con Médicos Sin Fronteras (MSF) y con los Centros para el Control y la Prevención de Enfermedades de Estados Unidos para producir "estimaciones más realistas". La titular de MSF, quien ha instado a la OMS a hacer más, dijo a Reuters en una entrevista el jueves que la lucha contra el ébola estaba siendo subestimada por la falta de liderazgo internacional y habilidades del manejo de emergencias. El estigma que rodea al ébola representa un grave obstáculo en los esfuerzos para estimar el brote en Liberia, Sierra Leona, Guinea y Nigeria, que se ha cobrado más víctimas que cualquier otro episodio de la enfermedad, descubierta por primera vez hace unos 40 años en los bosques de África Central. "Como el ébola no tiene cura, algunos creen que sus seres queridos infectados estarán más cómodos muriendo en sus casas", dijo el comunicado de la OMS. "Otros niegan que un paciente tenga ébola y creen que el cuidado en una sala aislada, vista como una incubadora de la enfermedad, llevará a una infección y a la muerte segura. La mayoría teme el estigma y el rechazo social que padecen las familias cuando un diagnóstico de ébola es confirmado", agregó. Los cuerpos son usualmente enterrados sin notificación oficial, dijo la OMS, mientras otro problema es la existencia de numerosas "zonas grises", o pueblos rurales donde hay rumores de casos y muertes que no pueden ser investigados debido a la resistencia de la comunidad o la falta de personal y transporte. En otros casos, donde el tratamiento está disponible, los centros de salud están sobrepoblados de pacientes, lo que sugiere que hay muchos posibles infectados que no están en el radar de los sistemas oficiales de vigilancia. #### PLAN ESTRATÉGICO La OMS dijo el viernes que había diseñado el borrador de un plan estratégico para combatir el ébola en África Occidental en los próximos seis a nueve meses, lo que implica que el organismo no espera que la epidemia cese este año. "La OMS está trabajando en un documento con una hoja de ruta para el ébola, que es en realidad un documento operativo sobre cómo combatir el ébola", dijo la portavoz de la OMS, Fadela Chaib, en una rueda de prensa en Ginebra. "(El documento) detalla la estrategia de la OMS y sus socios para los próximos seis a nueve meses", agregó. Consultada sobre si este marco temporal significaba que la OMS esperaba que la epidemia que ahora se propaga con fuerza en Guinea, Liberia y Sierra Leona seguirá en 2015, la portavoz dijo: "Francamente, nadie sabe cuándo terminará este brote". Se declarará terminado al brote de ébola en un país cuando haya dos períodos seguidos de incubación -42 días en total- sin un nuevo caso confirmado, explicó. #### Epidemia de ébola en África Occidental ha causado 1.427 muertos: OMS GINEBRA (Reuters) - La epidemia de ébola en África Occidental ha causado 1.427 muertos en 2.615 casos registrados, dijo el viernes la Organización Mundial de la Salud (OMS). En su última actualización, la OMS informó de 142 nuevos casos confirmados, probables o sospechosos de ébola y 77 muertos más en cuatro países afectados: Guinea, Liberia, Nigeria y Sierra Leona. Anteriormente en el día, la OMS dijo que la magnitud del peor brote de ébola no se puede apreciar en su totalidad debido a que muchas familias escondieron a sus seres queridos en sus hogares y a la existencia de "zonas grises" donde los médicos no pueden ingresar. La agencia de la ONU planea divulgar un plan estratégico global hacia fines de la próxima semana en Ginebra. #### Liberia crea "pueblos de la plaga" en epicentro del brote de ébola Por Eric Telmor y Emma Farge BOYA, Liberia/DAKAR (Reuters) - Para intentar controlar la epidemia de ébola que se extiende por África Occidental, Liberia puso en cuarentena remotas aldeas en el epicentro del virus, una medida que recuerda a los "pueblos de la plaga" de la Europa medieval. Con escaso acceso a alimentos y medicinas, muchos habitantes enfrentan una cruda opción: quedarse donde están y arriesgarse a morir o abandonar la cuarentena, extendiendo la infección en un país mal equipado para contenerla. En Boya, en el norteño distrito liberiano de Lofa, Joseph Gbembo, que se contagió de ébola pero sobrevivió, dice que está intentando criar a 10 niños menores de cinco años y mantener a cinco viudas luego de que nueve miembros de su familia murieran por culpa del virus. Por temor a contagiarse, los vecinos del hombre de 30 años se niegan a hablarle y le culpan por haber traído la enfermedad al pueblo. "Estoy solo", dijo. "Nadie me habla y la gente corre cuando me ve". Gbembo dijo que no había recibido alimentos ni cuidados médicos para los niños, ni tampoco ayuda de autoridades. Trabajadores de ayuda dicen que si el apoyo no llega pronto, los habitantes de pueblos como Boya, donde la maleza ya comenzó a crecer entre las viviendas, simplemente desaparecerán por los senderos de la selva. "Si no llegan medicamentos, alimentos y agua suficientes la comunidad buscará comida por sus medios, y eso podría llevar a una mayor propagación del virus", dijo Tarnue Karbbar, un trabajador de la organización benéfica Plan International basado en Lofa. El ébola ha causado la muerte de al menos 1.145 personas en cuatro países africanos. En la semana terminada el 13 de agosto, el condado de Lofa registró más nuevos casos que cualquier otra parte del continente: 124 infectados y 60 muertes. ##### La Organización Mundial de la Salud (OMS) y las autoridades liberianas advirtieron que, debido al escaso acceso a regiones remotas de la selva, los números deben de ser mucho más altos. #### ESCUDO BLANCO En Monrovia, la capital que aún muestra las cicatrices de la brutal guerra civil de 14 años terminada en el 2003, autoridades dicen que controlar la situación en Lofa es clave para superar la crisis más grave desde el fin del conflicto. Con su país amenazado, la presidenta Ellen Johnson Sirleaf impuso medidas de emergencia como las comunidades en cuarentena y un "cordón sanitario", un sistema de controles médicos en las carreteras para evitar que la infección llegue a las ciudades, parecido al usado durante la Edad Media durante la Peste Negra. La operación "Escudo Blanco" incluyó el despliegue de tropas para evitar que las personas abandonen sus hogares e infecten a otros, en un país donde la mayoría de los casos permanecen sin atención porque las clínicas están llenas o porque las personas tienen miedo a los hospitales, que consideran "poco seguros". "Debería preocupar que las personas en áreas en cuarentena estén abandonadas a su suerte", dijo Mike Noyes, el director de respuesta humanitaria de la organización ActionAid UK. "¿Qué oficial de policía irá a esos lugares? Existe el riesgo de que esos lugares se conviertan en pueblos de la plaga", agregó. Trabajadores de ayuda dicen que el virus les recuerda a las fuerzas que azotaron Liberia durante la guerra civil, volviendo a la nación africana un sinónimo de brutalidad. "Era como la guerra. Tan desolado", dijo Adolphus Scott, un trabajador de UNICEF al describir Zango, un pueblo en la jungla del norte de Liberia donde la mayoría de sus 2.000 habitantes murieron por culpa del ébola o huyeron. Los ancianos se sentaban en la puerta de sus casas, mirando una calle de tierra vacía salvo por algunas cabras o gallinas, comentó. "El ébola es como una guerrilla saqueando el país", agregó. #### PERSONAS SALUDABLES EN RIESGO El virus del ébola, nunca antes detectado en la empobrecida África occidental, es portado por algunos mamíferos de la selva como murciélagos de la fruta. Se cree que fue contagiado a los humanos a través de carne de animales salvajes aproximadamente en diciembre en el remoto sureste de Guinea. Los síntomas iniciales como fiebre o dolores musculares son difíciles de distinguir de otras enfermedades tropicales como la malaria, lo que explica porqué el brote no fue detectado hasta marzo. En las últimas etapas de la enfermedad, las víctimas están en el punto de mayor contagio, sangrando a través de los ojos y los oídos. Países como Uganda, en África oriental, contuvieron brotes previos en zonas rurales mediante sistemas de reporte online y una rigurosa vigilancia, dijo Anthony Mbonye, el director de servicios comunitarios y clínicos en Uganda. Pero en la zona occidental, los débiles sistemas de salud no estaban preparados. Liberia, uno de los países menos desarrollados del mundo, tiene una pobre red de internet y de telecomunicaciones, y sólo unos 50 médicos para una población de más de 4 millones. Los funerales tradicionales, en los que los familiares bañan y visten los cuerpos a pesar del enorme riesgo de contagio, han acelerado la propagación del ébola a nueve de los 15 condados del país. A principios de agosto, la Organización Mundial de la Salud (OMS) declaró al ébola como emergencia internacional de salud. Es la tercera vez en sus 66 años de historia que ha tomado esa medida. Países vecinos como Guinea y Sierra Leona instalaron puestos de control en Gueckedou y Kenema, creando una zona fronteriza de cuarentena de unos 20.000 kilómetros cuadrados, aproximadamente del tamaño de Gales, llamada "sector unificado". Dentro de esta área, el ministro de Información Lewis Brown describió medidas de cuarentena más intensas en Lofa, en donde hasta un 70 por ciento de las personas están infectadas. "El acceso a estos lugares está ahora suspendido excepto para trabajadores médicos", dijo en una entrevista. Llegar a los enfermos en poblados aislados es clave, porque el principal centro de salud de Foya está repleto. El sitio era dirigido por la organización benéfica estadounidense Samaritan's Purse hasta que se retiró luego de que dos empleados contrajeron el virus en Monrovia. Médicos Sin Fronteras, que se hizo cargo de lugar, dice que 137 pacientes están amontonados en un centro que cuenta con sólo 40 camas. Los trabajadores de salud esperan capacitar a locales para crear unidades de aislamiento en escuelas e iglesias dentro de sus propias comunidades. "La cuarentena expone a personas saludables al riesgo. Por eso es tan importante la efectividad de los Estados en apoyar medidas preventivas que minimicen ese riesgo", dijo Robert Dingwall, un especialista en políticas de respuesta sanitaria a enfermedades infecciones de la Universidad de Nottingham Trent. Esas medidas incluyen educación para la prevención, además de crematorios y equipos de protección, explicó. AISLAMIENTO Pero el equipo de respuesta de Liberia tiene dificultades para hacer frente al problema. El principal centro de salud en Lofa está "superado" por el ingreso de nuevos pacientes, según un reporte del Ministerio de Salud. Un total de 13 trabajadores de la salud ya han muerto en el condado por el ébola, y a la oficina de vigilancia le hacen falta computadores para administrar los casos. Brown, el ministro de Información, reconoce el riesgo. "Podemos establecer tantos puestos de control como queramos, pero si no podemos llevar los alimentos y suministros médicos a las comunidades afectadas (las personas) se irán", dijo. Y aún si los recursos llegan, la ayuda podría ser alejada. A diferencia de otras áreas en el país donde las campañas de concientización sobre el ébola están ayudando a las personas a no esconderse, en esta aislada zona fronteriza, alejada de los omnipresentes carteles puestos por el Gobierno que dicen "el ébola es real", la negación sigue siendo fuerte. Según rumores, personas disfrazados como trabajadores de salud secuestran a las personas para vender sus órganos, lo que provocó reacciones violentas entre los locales, señala Karbarr. A fines de julio una ambulancia fue apedreada en el distrito de Kolahun cuando intentaba llevarse un cuerpo para sepultarlo. Residentes ahuyentaron a un grupo de trabajadores de la salud, amenazándolos con quemar su vehículo. CORTES DE SUMINISTROS Brown dijo que las personas en condados no afectados en el este de Liberia han recibido bien la cuarentena. Sin embargo, advirtió el ministro, el sentimiento podría cambiar si los suministros empiezan a escasear. La raíz italiana de la palabra cuarentena, o "40 días", se refiere al período de aislamiento para las tripulaciones de los barcos que llegaban a Venecia procedentes de las regiones de la plaga. Pero en Liberia el aislamiento podría continuar por tres meses o más, por lo que se necesita elaborar un plan a largo plazo. Junto a una mayor sensación de aislamiento y criminalización de quienes están en cuarentena, la duración del encierro amenaza con interrumpir el flujo de suministros. Los precios del petróleo y el aceite ya se duplicaron, según los residentes. Aunque Lofa está dentro del cinturón productor de boniatos y dátiles, los condados del este que no fueron afectados hasta el momento no pueden abastecerse a sí mismos. El Programa Mundial de Alimentos de la ONU busca distribuir alimentos a más de 1 millón de personas en la zona de cuarentena en la frontera, pero hasta ahora no hay planes para los condados no afectados. "Mi preocupación ahora es cómo el sudeste conseguirá comida. Se podría comerciar con la costa de Costa de Marfil, pero ellos podrían no estar dispuestos por miedo al virus", dijo Scott, de la UNICEF, sobre los condados de River Gee y de Maryland. Hay indicios de que eso ya estaría ocurriendo. Aboubacar Barry, que vende arroz y azúcar en el pueblo marfileño de Danane, dice que su negocio se redujo a un quinto de lo que era antes del cierre de facto de frontera con Liberia. Y Yacouba Sylla, un conductor de mototaxi en la frontera, también se queja de una caída en su negocio. "El ébola no ha llegado aquí, pero va a matarnos de todos modos antes de llegar", dijo, "porque vamos a morir de hambre". #### Hospital de EEUU dará de alta a médico tratado con fármaco experimental contra el ébola Por Joe Bavier ABIYÁN (Reuters) - Un médico estadounidense que contrajo el ébola cuando atendía a víctimas del mortífero virus en Liberia se ha recuperado y será dado de alta el jueves del hospital donde fue tratado con un fármaco experimental, dijo la organización de caridad a la que pertenece. Kent Brantly recibió ZMapp, un fármaco experimental empleado en unos pocos pacientes en el brote de la enfermedad en África Occidental y producido por Mapp Biopharmaceutical, con sede en Estados Unidos. El Hospital de le Universidad de Emory en Atlanta, Georgia, dijo que realizaría una conferencia de prensa para comentar el caso de Brantly y el de otra estadounidense, Nancy Writebol, que está siendo tratada en ese centro con ZMapp. Mapp afirma que sus suministros del fármaco se han agotado. Brantly saldrá del hospital de Emory después de la conferencia de prensa, afirmó un portavoz de la organización Samaritan's Purse. "Me he maravillado con el espíritu valiente del Dr. Brantly. Él ha combatido este horrible virus con la ayuda del personal altamente competente y dedicado del Hospital de la Universidad de Emory", dijo a través de un comunicado el presidente de Samaritan's Purse, Franklin Graham. La Organización Mundial de la Salud dijo el miércoles que 2.473 personas han sido infectadas y que 1.350 han muerto desde que se identificó en marzo el brote de ébola en el remoto sudeste de Guinea. La OMS afirmó que no se han confirmado casos de infectados con la enfermedad fuera de Guinea, Sierra Leona, Liberia y Nigeria, los países afectados por el ébola, pese a que ha habido casos sospechosos en otros países. Un alto funcionario de salud en Togo dijo que dos casos sospechosos, incluyendo el de un marino de Filipinas, estaban siendo examinados para constatar la presencia del virus. Tres médicos africanos, también tratados con ZMapp en Liberia, han mostrado notables señales de mejoría, declaró a Reuters el martes el Ministro de Información de ese país, Lewis Brown. #### Reino Unido y organización benéfica ofrecen 10 mln dlr para investigación sobre ébola LONDRES (Reuters) - El Gobierno británico y la organización benéfica Wellcome Trust se comprometieron a aportar 6,5 millones de libras esterlinas (10,8 millones de dólares) en conjunto para financiar una investigación de emergencia solicitada para luchar contra el brote de ébola en África Occidental. Equipos de expertos de todo el mundo están siendo invitados a presentar propuestas de investigación hasta el 8 de septiembre para crear iniciativas que puedan explorar rápidamente nuevos enfoques para tratar, prevenir y contener la enfermedad. "La gravedad de la epidemia de ébola en África Occidental exige una respuesta urgente, y creemos que una rápida investigación de intervenciones humanitarias y terapéuticas puede tener un impacto sobre el tratamiento y la contención del presente brote", dijo en un comunicado Jeremy Farrar, director de Wellcome Trust. Wellcome, la segunda fundación benéfica de mayor gasto a nivel mundial, también anunció el jueves una inversión de largo plazo de 40 millones de libras esterlinas en el sector científico de África. No hay tratamientos probados o vacunas para el ébola, pero la Organización Mundial de la Salud ha apoyado el uso de productos no examinados y espera mejores suministros de medicamentos experimentales para fin de año. Científicos británicos dijeron previamente que hasta el momento habría hasta 30.000 personas con la necesidad de tratamientos o vacunas como parte del brote actual del virus, que ya ha provocado la muerte de 1.350 personas. (1 dólar = 0,6008 libras esterlinas) #### Policía liberiana dispara a manifestantes, muertes por ébola llegan a 1.350 Por Clair MacDougall y James Harding Giahyue MONROVIA (Reuters) - La policía disparó y arrojó gases lacrimógenos el miércoles en la capital de Liberia para dispersar a una multitud que arrojaba piedras e intentaba salir de un barrio que quedó bajo cuarentena por causa del virus del ébola, en una jornada en la que la cantidad de muertos por el brote llegó a 1.350. En el superpoblado barrio de West Point en Monrovia, al menos cuatro personas resultaron heridas en enfrentamientos con las fuerzas de seguridad, dijeron testigos. No estaba claro si alguno había sido herido por los disparos. Las autoridades de Liberia impusieron un toque de queda a nivel nacional el martes y dejaron a West Point bajo cuarentena para limitar la propagación de la enfermedad. "Los soldados están usando munición real", dijo el portavoz del Ejército Dessaline Allison, quien agregó: "Los soldados aplicaron las reglas de combate. No dispararon contra ciudadanos pacíficos. Habrá reportes médicos si hay heridos de bala". Varios testigos dijeron que los enfrentamientos en West Point comenzaron después de que las fuerzas de seguridad bloquearon desde temprano los caminos hacia el barrio con mesas, sillas y alambres de púas. Los intentos por aislar las zonas más afectadas del país y la vecina Sierra Leona han hecho surgir temores de agitación civil en una de las regiones más pobres del mundo si en las comunidades comienzan a escasear los alimentos y los suministros médicos. La Organización Mundial de la Salud dijo que los países golpeados por el mayor brote histórico del mortal virus estaban comenzando a sufrir escasez de combustible, alimentos y productos básicos debido a que compañías navieras y aerolíneas suspendieron los servicios hacia la región. La epidemia de ébola, un virus que puede matar hasta al 90 por ciento de aquellos a quienes infecta, está arrasando a los pequeños países de Liberia, Sierra Leona y Guinea. También se han reportado casos en Nigeria, la mayor economía africana y el país más poblado del continente. Liberia -donde la cantidad de muertes crece más rápido- dijo que en los depósitos del Ministerio de Salud ya no quedaban botas de goma ni botellas de desinfectante para manos, artículos esenciales para prevenir la propagación de la enfermedad. Todavía en plena recuperación de una devastadora guerra civil entre 1989 y 2003, Liberia registró 95 muertes en los dos días previos al 18 de agosto, según informó la OMS. Desde que el brote fue descubierto en marzo en la remota región sudeste de Guinea, la cifra de muertos ha alcanzado a 1.350 sobre un total de 2.473 casos. El brote de ébola está aplazando los viajes de miles de turistas que habían planeado visitar África este año, especialmente asiáticos, incluso destinos ubicados a miles de kilómetros de la comunidad infectada más cercana, como Kenia y Sudáfrica. Contener el brote requiere de un gran número de personal especializado para hacer un mapa de la epidemia, seguir a personas que han tenido contacto con enfermos, y trabajar en centros de aislamiento y tratamiento. La OMS ha prometido reforzar la ayuda humanitaria internacional, pero hasta ahora sólo ha habido trabajadores sanitarios extranjeros adicionales destinados a los países afectados. En tanto, República Democrática del Congo envió a su ministro de Salud y a un equipo de expertos a la remota provincia norteña de Equateur, luego de que varias personas murieron en la zona por una enfermedad cuyos síntomas son similares a los del ébola, dijeron el miércoles un funcionario local y un maestro. No quedó claro inmediatamente si había alguna conexión con el ébola. #### Enfermedad con síntomas similares a los de ébola provoca varias muertes en el Congo KINSHASA (Reuters) - La República Democrática del Congo envió a su ministro de Salud y a un equipo de expertos a la remota provincia norteña de Equateur, luego de que varias personas murieron en la zona por una enfermedad cuyos síntomas son similares a los del ébola, dijeron un funcionario local y un maestro. No quedó claro inmediatamente si había alguna conexión con el ébola. Una epidemia de la enfermedad ha provocado la muerte de más de 1.200 personas en Guinea, Liberia, Sierra Leona y Nigeria. "Una enfermedad se está propagando en Boende pero no conocemos su origen", dijo Michel Wangi, portavoz de la oficina del Gobierno. "El Gobierno ha enviado un equipo de expertos del INRB (Instituto Nacional de Investigación Biomédica) está mañana, encabezado por el ministro de Salud (Felix) Kabange Numbi y por el gobernador interino Sebastian Impeto". Un profesor que acompaña a la delegación en el avión presidencial confirmó que esta mañana estaba viajando para descubrir "la naturaleza exacta de la enfermedad que causó las muertes en Boende". Un residente de Equateur, que pidió reserva de su identidad, dijo que unas diez personas habían muerto, entre ellas cuatro trabajadores de salud, tras sufrir fiebres, diarrea y hemorragia por los oídos y la nariz, todos síntomas del ébola. (Reporte de Bienvenu Bakumanya; Escrito por Emma Farge; Editado en español por Janisse Huambachano/Marion Giraldo) #### El británico afectado por el ébola empieza su tratamiento en el Reino Unido Royal Free Hospital en Londres, donde ha sido ingresado el paciente aquejado de ébola. / Efe El primer británico afectado por el virus del Ébola en Sierra Leona ha comenzado su tratamiento en una unidad especialmente aislada de un hospital del noroeste de Londres tras haber sido evacuado al Reino Unido desde ese país africano, informa hoy la BBC. El enfermo ha sido identificado por un científico estadounidense que trabajaba con él como William Pooley, un enfermero voluntario de 29 años que residía en Sierra Leona, según esta cadena pública de televisión. El británico fue repatriado ayer al Reino Unido en un avión medicalizado de las Fuerzas Aéreas Británicas (RAF) hasta la base militar aérea de Northolt, desde donde se le trasladó, escoltado por la policía, hasta el Royal Free Hospital, en el norte de la capital. Fuente: Agencia SINC Día a día Secuencian 99 genomas del Ébola Pardis C. Sabeti "Cinco de los autores del estudio contrajeron la enfermedad y están muertos" El combate contra el ébola continúa, y un equipo internacional de científicos acaba de comunicar lo que en términos bélicos sería un éxito de los servicios de inteligencia. Más de 50 profesionales de cuatro países han ayudado a analizar secuencias genéticas del virus recogidas durante los primeros 24 días del brote en Sierra Leona. Ese trabajo ha permitido obtener 99 genomas del patógeno, una información que ayudará a trazar su origen, mejorar los diagnósticos y a diseñar tratamientos. El precio de este conocimiento parece propio de tiempos de guerra: cinco de los autores del estudio contrajeron la enfermedad y están muertos. El actual brote de ébola no tiene precedentes, por su tamaño, pero sobre todo, por haberse extendido a varias zonas muy pobladas. El virus se detectó por primera vez en 1976 en dos brotes simultáneos, en Sudán y la República Democrática del Congo. Desde entonces, los brotes se han producido en regiones poco pobladas del centro de África, pero ahora, por primera vez, ha llegado a la región occidental del continente, con una densidad de población mucho mayor. En aquella primera ocasión, el virus infectó a 318 personas. Ahora, desde que el virus se encontró por primera vez en Guinea en marzo de este año, ya se han detectado más de 3.069 casos y han muerto 1.552 personas según la Organización Mundial de la Salud. La cifra es mayor que la suma de todas las víctimas de anteriores brotes y el actual continúa acelerando su expansión. Más del 40% de los casos registrados se han producido en los últimos 21 días y la OMS estima que este brote podría llegar a afectar a más de 20.000 personas. La OMS ya ha elaborado una hoja de ruta para acabar con el brote de ébola en menos de nueve meses, por 490 millones de dólares El análisis de las muestras del ébola, que ahora se publica en la revista Science, permitió encontrar más de 300 cambios genéticos que diferencian a esta variante de otras aparecidas durante las últimas décadas. Estas mutaciones que alteran las secuencias de proteínas del virus y cambian su comportamiento o la manera en que daña a sus víctimas, pueden convertirse en dianas sobre las que disparar fármacos, una herramienta para diagnosticar mejor o una base sobre la que crear una vacuna. En el caso del diagnóstico, por ejemplo, los investigadores observaron que el genoma del virus está cambiando a gran velocidad, en particular en regiones que son importantes para que los tests sean precisos, por lo que es necesario vigilar estos cambios. Carne de mono o murciélago Los autores del estudio consideran que, aunque no saben si estas diferencias en la secuencia genética tienen alguna relación con la virulencia de esta versión del ébola, compartir la información obtenida durante sus pesquisas con otros investigadores ayudará a acelerar la comprensión de esta epidemia y dará herramientas para contenerla. Además de conocer el comportamiento actual del virus, el análisis de estos 99 genomas está permitiendo trazar su origen. En este caso, parece que el patógeno se introdujo en un solo humano (posiblemente a partir del consumo o manipulación de carne cruda de murciélago o mono) y a partir de ahí se fue extendiendo. La OMS ya ha propuesto una hoja de ruta para contener la epidemia en alrededor de nueve meses. El plan, que tendría un coste de unos 490 millones de dólares, tiene mucho de estrategia frente a una catástrofe humanitaria. El suministro de equipamiento de protección para los médicos, desinfectantes o bolsas para los cadáveres aparecen como elementos claves para contener la enfermedad. REFERENCIA 'Gire, SK, Goba, A et al. Genomic surveillance elucidates Ebola virus origin and transmission during the 2014 outbreak' #### Epidemia de Ébola en África Occidental podría infectar a 20.000 personas: OMS Por Stephanie Nebehay y Tim Cocks GINEBRA/LAGOS (Reuters) - La epidemia de ébola en África Occidental podría infectar a más de 20.000 personas, dijo el jueves el organismo de salud de Naciones Unidas, y advirtió que se necesitan casi 500.000 millones de dólares para apuntalar los esfuerzos internacionales destinados a superar el brote. El mismo día en que la Organización Mundial de la Salud (OMS) anunció su plan estratégico para combatir el virus, GlaxoSmithKline dijo que probará en humanos una vacuna experimental contra el ébola y que espera producir hasta 10.000 dosis si los resultados son positivos. La OMS estima que le tomará entre seis a nueve meses detener la epidemia de ébola en África Occidental, mientras que Nigeria dijo el jueves que un médico vinculado indirectamente con un liberiano-estadounidense que llevó la enfermedad al país murió en la nigeriana Port Harcourt. Hasta ahora se han reportado 3.069 casos del brote pero la OMS dijo que el número real en Guinea, Sierra Leona y Nigeria podría ser entre dos a cuatro veces mayor. "Esto no es un tema de África Occidental. Este es un problema de salud pública global", dijo Bruce Aylward, director asistente general sobre polio, emergencias y cooperación de países de la OMS, a periodistas en Ginebra. Con una tasa de mortalidad del 52 por ciento, la cifra de muertos alcanzó las 1.552 el 26 de agosto. El número es casi tan alto como el total de fallecidos en todos los brotes registrados desde que el ébola fue descubierto en lo que ahora es la República Democrática del Congo en 1976. Las cifras no incluyen las muertes de un brote separado de ébola revelado este fin de semana en el Congo, que fue identificado como una cepa diferente del virus. #### TERAPIAS EXPERIMENTALES Contener y combatir la enfermedad podría costar un estimado de 490.000 millones de dólares y requerir la ayuda de miles de trabajadores sanitarios locales y de 750 expertos internacionales. "Es una gran operación. Estamos hablando de más de 12.000 personas como empleados locales y de 750 expertos internacionales y existen circunstancias de alto riesgo. Es una operación costosa", dijo. La operación constituye un importante refuerzo de las medidas ya tomadas por la OMS, que ha sido acusada por algunas agencias humanitarias de reaccionar demasiado lentamente a la expansión de la enfermedad. Naciones Unidas llevará adelante un plan paralelo desde fines de septiembre para afrontar los efectos secundarios del brote en seguridad alimentaria, agua, atención de salud primaria y secundaria y educación, sostuvo la OMS. Previamente este mes, la OMS dijo que la actual epidemia de ébola era una "emergencia de salud internacional". El temor de que la enfermedad pudiera propagarse fuera de Africa Occidental permitió el uso de fármacos aún en desarrollo para tratar algunos de los casos. Dos trabajadores de salud estadounidenses, que contrajeron ébola cuando trataban a pacientes en Liberia, recibieron una terapia experimental llamada ZMapp, un cóctel de anticuerpos desarrollado por la firma Mapp Biopharmaceutical. Ambos se recuperaron y fueron dados de alta del hospital la semana pasada. La vacuna anunciada por GSK, que está siendo desarrollada junto a los Institutos Nacionales de Salud de Estados Unidos (NIH, por su sigla en inglés) sería suministrada a voluntarios saludables en Gran Bretaña y Estados Unidos desde mediados de septiembre y posteriormente el programa sería extendido a Gambia y Mali. La mayor farmacéutica de Gran Bretaña dijo el jueves que los ensayos en fase I comenzarían tan pronto como reciban la aprobación de organismos éticos y regulatorios. El Instituto Nacional de Alergia y Enfermedades Infecciosas de la NIH también trabaja en un programa mayor de ensayos clínicos, incluyendo pruebas de una versión de la vacuna de GSK que podría combatir a una segunda cepa de ébola, así como también a la de África Occidental. #### Senegal confirma su primer caso de ébola DAKAR (Reuters) - El primer caso de ébola fue registrado en Senegal, un importante centro de negocios y de cooperación de África Occidental, dijo el viernes la ministra de Salud Awa, Marie Coll Seck, en una rueda de prensa. La funcionaria dijo que el paciente era un guineano que había llegado desde el país vecino, donde en marzo se detectó el primer caso de la epidemia de ébola. #### La falta de equipamiento de protección deja a los médicos en riesgo ante un brote de Ébola Los investigadores reportan una escasez de guantes y mascarillas en Liberia y Sierra Leona años antes de la epidemia actual MedlinePlus Robert Preidt Los trabajadores sanitarios de los países pobres con frecuencia no tienen suficiente equipamiento de protección para mantenerlos seguros de la infección con los virus transmitidos por la sangre, como el Ébola y el VIH, muestra un estudio reciente. Aunque el estudio fue llevado a cabo antes del inicio del brote actual de Ébola en África occidental la primavera pasada, sus hallazgos son confirmados por las estadísticas publicadas el lunes por la Organización Mundial de la Salud (OMS). La agencia sanitaria internacional reportó que un número "sin precedentes" de trabajadores sanitarios han perdido la vida en el brote de Ébola, en gran medida debido a una escasez de equipamiento protector. Alrededor de 240 de las 2,615 infecciones reportadas desde marzo han sido en médicos y enfermeros, y 120 de ellos han muerto, según la OMS. "El Ébola ha acabado con las vidas de médicos prominentes en Sierra Leona y Liberia, privando a esos países no solo de una atención médica experimentada y dedicada, sino también de unos héroes nacionales que han sido fuente de inspiración", señaló la agencia sanitaria en una declaración. "En muchos casos, el personal médico está en riesgo porque no hay equipamiento de protección disponible, ni siquiera guantes y mascarillas", añadía la declaración de la OMS. Pero en el estudio, que aparece en la edición en línea del 26 de agosto de la revista Tropical Medicine and International Health, los investigadores de la Universidad de Johns Hopkins hallaron que esa escasez existía mucho antes de este brote de Ébola más reciente. En Liberia, apenas el 56 por ciento de los hospitales tienen gafas protectoras para médicos y enfermeros, y solo el 63 por ciento cuentan con guantes estériles. En Sierra Leona, esas cifras son del 30 y del 70 por ciento, respectivamente, hallaron los investigadores. "Tristemente, uno de los pocos beneficios de la crisis del Ébola en África occidental podría ser resaltar la falta básica de equipamiento de protección para el personal, como gafas, guantes y delantales para los trabajadores sanitarios", señaló en un comunicado de prensa de la Facultad de Salud Pública Bloomberg de la Universidad Johns Hopkins el líder del estudio, el Dr. Adam Kushner, asociado del departamento de salud internacional de la Hopkins. "Esos artículos son esenciales para proteger la salud de los trabajadores sanitarios ahora, pero ya hacían falta mucho antes de la crisis actual. Lo hemos visto durante años con el VIH", añadió. Los investigadores de la Hopkins analizaron datos de 399 hospitales en 13 países con unos ingresos bajos y medios: Afganistán, Bolivia, Gambia, Ghana, Liberia, Mongolia, Nigeria, Sierra Leona, las Islas Salomón, Somalia, Sri Lanka, Tanzania y Zambia. En general, apenas el 29 por ciento de los hospitales del estudio siempre tenían gafas protectoras para el personal, el 64 por ciento siempre tenía equipos de esterilización y el 75 por ciento siempre contaba con guantes estériles, según el estudio. Las tasas variaban mucho entre los países. Por ejemplo, todos los hospitales de Bolivia y Nigeria tenían guantes estériles, frente a una cuarta parte de los hospitales de Afganistán. Ninguno de los países tenía una disponibilidad del 100 por ciento de todos los artículos de protección, que son un estándar en los hospitales estadounidenses. El enfoque de este estudio fue la prevención de la infección con el VIH, pero el virus del Ébola se transmite de la misma forma, a través del contacto con fluidos corporales de las personas infectadas o con los artículos contaminados con dichos fluidos, anotaron los investigadores. En el brote de Ébola en África occidental se han infectado muchos trabajadores sanitarios, con frecuencia debido a una falta de los procedimientos adecuados de control de las infecciones al trabajar de cerca con los pacientes. "Todos podemos aprender de esta nueva epidemia y estar mejor preparados para la próxima al recordar que un equipamiento de protección barato puede mantener seguros frente a la infección a médicos y a enfermeros, así como permitirles cuidar mejor de los pacientes que lo necesitan", enfatizó Kushner. "Es imperativo que lo convirtamos en una prioridad". FUENTES: Johns Hopkins University, news release, Aug. 26, 2014; World Health Organization #### Liberia: Los nuevos centros para pacientes de Ébola de MSF, al límite de su capacidad "No es solo un brote de Ébola, es una emergencia humanitaria que necesita una respuesta a gran escala." -Lindis Hurum, coordinadora de emergencia de MSF en Monrovia. Médicos Sin Fronteras (MSF) está ampliando sus operaciones en Liberia al tiempo que la respuesta internacional al brote de Ébola en África Occidental continúa siendo caótica y totalmente inadecuada. Tan solo una semana después de su puesta en marcha, el nuevo centro de pacientes de Ébola, también conocido como ELWA3, en la capital, Monrovia, ya está al límite de su capacidad, con 120 pacientes y se planea su ampliación. Mientras tanto, en el norte del país, los pacientes continúan acudiendo en masa al centro de Foya, recientemente rehabilitado. “Es simplemente inaceptable que, cinco meses después de la declaración del brote, se inicien ahora discusiones sobre liderazgo y coordinación internacional”, argumenta Brice de le Vingne, director de operaciones de MSF. “Los estados se preocupan por su propia seguridad, estados que tienen recursos y experiencia suficientes como para poder marcar una diferencia decisiva en los países afectados. Si pueden hacer mucho más, entonces, ¿por qué no lo hacen?”. El brote de Ébola se extiende rápidamente en Monrovia y satura los escasos centros médicos que aceptan pacientes infectados. Gran parte del sistema sanitario de la ciudad ha dejado de funcionar debido al miedo de los propios médicos, enfermeros y pacientes al virus. Muchísima gente se ha quedado sin acceso a la salud, generando una segunda emergencia en la propia emergencia. “Sería impensable que después de un terremoto hubiera tan pocos sitios para que las mujeres pudieran parir a sus hijos o donde los pacientes pudieran ser tratados de urgencia”, dice Lindis Hurum, coordinadora de emergencia de MSF en Monrovia. “Esto no es sólo un brote de Ébola, es una emergencia humanitaria que necesita una respuesta humanitaria a gran escala”. El número de pacientes que requiere de atención médica en el nuevo centro de Monrovia, abierto el pasado 17 de agosto, aumenta a un ritmo mucho más rápido del que los equipos médicos pueden gestionar, tanto por número de camas como por la propia capacidad del personal. Los pacientes proceden de diferentes distritos. El equipo sanitario ve cada vez más complicado atender a los pacientes recién llegados, cuidar a los admitidos y/o trasladar a los fallecidos al crematorio de forma segura. “El número de pacientes que vemos no tiene nada que ver con brotes anteriores”, dice Hurum. “Nuestras guías de actuación, por ejemplo, hablan de centros de 20 camas, y ahora mismo estamos expandiendo un centro de más de 120 camas. Esto supone que tenemos que adaptarnos cada día, reclutar y formar a más gente, día y noche. Las prioridades actuales pasan por mantener un centro seguro, separar los casos sospechosos de los probables y confirmados, y ofrecer cuidado médico”. Como otros centros de Ébola, el ELWA3 juega un rol muy importante en frenar el brote, al aislar a los enfermos y evitar más infecciones. Sin embargo, la gran afluencia de pacientes está forzando a MSF a reducir la atención médica. Por ejemplo, por el momento, no es posible administrar tratamientos intravenosos. MSF está preparando una nueva construcción e instalará tres tiendas con capacidad con 40 camas cada una. En la zona remota de Foya, cerca de la frontera con Guinea, la falta de asistencia está agravando la situación de emergencia. Los equipos de MSF trabajan día y noche para contener la epidemia y el centro para pacientes con Ébola acoge actualmente a 67 pacientes. “Hemos llegado a una situación de caos extremo y apenas se ven organizaciones de ayuda”, dice Hugues Robert, coordinador de emergencias. “En la periferia de Foya, en algunos pueblos, el Ministerio de Salud, está quedándose sin equipos de protección que son esenciales para el personal sanitario”. En Nigeria, MSF también ha comenzado a apoyar de forma técnica a las autoridades en su lucha contra el brote de Ébola en la ciudad de Lagos. MSF ha puesto a disposición de las autoridades su experiencia técnica en temas como aislamiento, seguimiento de contactos de enfermos, formación y educación pública. La actuación de MSF durará alrededor de un mes y es exclusivamente de apoyo técnico. En estos momentos, Nigeria no necesita un despliegue de grandes recursos y personal. El equipo, de seis personas, supervisa el centro de aislamiento instalado en el Hospital de Enfermedades Infecciosas, el centro de referencia para pacientes de Ébola en Lagos. MSF inició su intervención de Ébola en África Occidental en marzo de 2014 y está presente en Guinea, Liberia, Nigeria y Sierra Leona. La organización gestiona cinco centros de asilamiento con un total de 415 camas. Desde marzo, MSF ha tratado a 1.885 pacientes, 905 de los cuales resultó positivo para virus del Ébola y 170 se han recuperado. MSF ha desplegado a casi 200 trabajadores internacionales y emplea a 1.800 trabajadores locales. Médicos sin Fronteras Argentina #### Hoja de ruta para combatir el brote La OMS presenta su plan para frenar el ébola La Organización Mundial de la Salud ha presentado hoy su hoja de ruta para coordinar la respuesta internacional frente al brote de ébola en África Occidental. Según el recuento oficial, el virus ya ha afectado a 3.096 personas de las que 1.552 han fallecido. La Organización Mundial de la Salud (OMS) ha presentado hoy su esperada hoja de ruta para coordinar los esfuerzos internacionales con el fin de acabar con el brote del virus del Ébola que afecta a África Occidental y que ya cuenta con 3.096 afectados y 1.552 fallecidos, el 40% de ellos durante las tres semanas anteriores. El objetivo del organismo internacional es "controlar la transmisión del virus en todo el mundo en un plazo de seis a nueve meses y dar una adecuada respuesta a las consecuencias de su propagación internacional", según ha afirmado en un comunicado emitido esta mañana. En él la organización hace referencia "a la necesidad de abordar, de forma paralela, el impacto socioeconómico del brote". Esta hoja de ruta responde a la necesidad urgente de ampliar de forma ostensible la respuesta internacional a esta crisis, que parece no haber alcanzado todavía su momento más crítico, ya que la mayoría de los casos se han producido en las últimas semanas. La hoja de ruta responde a la necesidad de ampliar de forma ostensible la respuesta internacional a esta crisis #### Según la OMS, "el documento ha sido realizado teniendo en cuenta las aportaciones de los funcionarios de la salud en los países afectados, la Unión Africana, los bancos de desarrollo, otros organismos de las Naciones Unidas, Médicos Sin Fronteras, así como los países que proporcionan ayuda financiera directa.Zonas calientes El plan servirá como un marco para la actualización de los planes operativos y da prioridad a las necesidades de tratamiento y centros de gestión, la movilización social y a eliminar los entierros como uno de los focos de propagación del virus. Es más, el informe aporta un mapa de situación con los puntos de acceso o las zonas calientes, señala cómo el brote está evolucionando en el tiempo y recaba toda la información conocida acerca de la ubicación de las instalaciones de tratamiento de la enfermedad y laboratorios. #### La hoja de ruta abarca las dimensiones de la respuesta internacional, incluyendo posibles cuellos de botella que se puedan dar en el futuro –situaciones especialmente complicadas que requerirían de la coordinación internacional– como el suministro de equipos de protección, desinfectantes o bolsas para proteger los cadáveres.Apoyo del Banco Mundial Según la OMS, este plan se complementará con el desarrollo de una plataforma operativa de la ONU que recogerá las habilidades y capacidades de otras agencias, incluyendo las áreas de logística y el transporte. Según las últimas informaciones aportadas por la agencia de la ONU, el brote se sigue acelerando Dicha plataforma "tiene como objetivo facilitar la prestación de servicios esenciales, como los alimentos y otras provisiones, abastecimiento de agua y saneamiento, así como la atención primaria de la salud. La organización cuenta con apoyo del Banco Mundial para realizar un seguimiento de los fondos aportados para combatir el brote. Además, según las últimas informaciones aportadas por la agencia de la ONU, "el brote se sigue acelerando". Así, se estima que el número de infectados podría llegar a los 20.000 y que la cifra de casos reales puede ser en la actualidad hasta cuatro veces superior a los conocidos oficialmente. Por países y según datos actualizados hasta el pasado martes, Sierra Leona es el más afectado con 935 casos y 380 muertes, seguido por Guinea con 482 casos y 287 muertes; Liberia con 322 casos y 225 muertes, y Nigeria, con trece casos y cinco fallecidos. Según ha precisado la OMS, actualmente el índice de mortalidad del brote se sitúa en el 52% de los casos y oscila entre el 42 % de Sierra Leona al 66 % de Guinea. Por otra parte, la OMS ha recordado que en República Democrática del Congo se ha confirmado un "brote separado de ébola que no está relacionado con el brote en África Occidental". Agencia SINC #### Compañía canadiense anuncia avances en el desarrollo de una vacuna para el ébola WINNIPEG (Reuters) - Cuatro monos sobrevivieron al virus del ébola tras recibir un tratamiento experimental elaborado por Immunovaccine, según dijo el lunes la pequeña compañía en un anuncio que disparó su valor en bolsa. La empresa con sede en Halifax, Nueva Escocia, dijo que cuatro monos recibieron su vacuna y sobrevivieron luego a una dosis del virus del ébola que normalmente hubiera sido letal. Dos simios a los que no se les administró el tratamiento murieron en una semana. Las pruebas fueron realizadas en los Institutos Nacionales de Salud del Departamento de Salud de Estados Unidos, situado en Maryland. Immunovaccine, que contaba con una capitalización de mercado de 77 millones de dólares canadienses el viernes, es una de las compañías que está probando potenciales vacunas contra el virus del ébola, que ya ha provocado la muerte de 1.500 personas en África Occidental. Entre otras compañías que están realizando pruebas se encuentra la estadounidense NewLink Genetics, que tiene la licencia de una vacuna desarrollada por el gobierno canadiense y por Profectus BioScience, una compañía privada. Immunovaccine dijo que está buscando opciones para desarrollar la vacuna con varias organizaciones. La compañía está desarrollando tratamientos contra el cáncer y una vacuna contra el antrax. Su valor en el índice TSX Venture Exchange de Toronto ha subido un 44 por ciento y mejoró un 26,8 por ciento a 1,23 dólares canadienses el lunes al mediodía. #### OMS dice envía equipos y suministros a Congo por brote de ébola GINEBRA (Reuters) - La Organización Mundial de la Salud (OMS) envió suministros y equipos para el personal médico de la República Democrática del Congo, donde las autoridades confirmaron dos casos de ébola en un área remota. "El Ministerio de Salud ha declarado un brote y estamos tratándolo como tal", dijo el lunes a Reuters el portavoz de la OMS Tarik Jasarevic en Ginebra. La República Democrática del Congo informó del brote de ébola en la provincia Equateur el domingo luego de que dos de ocho pacientes examinados dieran positivo con la enfermedad, dijo el ministro de Salud, Felix Kabange Numbi. #### Costa de Marfil cierra fronteras occidentales por la amenaza del ébola ABIYÁN (Reuters) - Costa de Marfil ha cerrado las fronteras terrestres con sus vecinos del África Occidental afectados por el ébola para evitar la propagación a su territorio del brote más mortal de este virus, anunció el sábado el gobierno del país. Varios países africanos han desafiado los consejos de la Organización Mundial de la Salud (OMS) y han impuesto restricciones a viajar hacia y desde los países en los que ha aparecido el ébola, que incluyen a Sierra Leona y Nigeria. Filipinas ordenó el sábado el regreso de 115 efectivos militares que estaban en misión de paz en Liberia debido al brote del virus en este país. Costa de Marfil, francoparlante y primera economía del África Occidental, ya había prohibido los vuelos desde y hacia Sierra Leona y Guinea. "Enfrentado a nuevos lugares del brote y con la reactivación de otros anteriores, el Gobierno de Costa de Marfil decide cerrar sus fronteras terrestres con las repúblicas hermanas de Guinea y Liberia", dijo en un comunicado leído por la televisión pública a última hora del viernes. Nimba County, en Liberia, en la frontera con Costa de Marfil, ha visto como el número de casos de ébola se disparaba en las últimas semanas. Según Moses Massaquoi, responsable de la gestión de la crisis del ébola en el Ministerio de Sanidad liberiano dijo que se habían dado en esa zona 65 casos, de los que 25 fueron confirmados. "El número de casos en Nimba ha saltado recientemente y se ha convertido en una zona preocupante", dijo Massaquoi a Reuters. El virus del ébola ha matado a 1.427 personas de un total de 2.615 casos identificados desde que el brote se identificó en Guinea en marzo, según cifras desveladas el viernes por la OMS. Sin embargo, casos de familias que ocultaron a seres queridos infectados en sus casas y la existencia de "zonas grises" no permite apreciar la verdadera escala de la epidemia, dijo el organismo. La OMS ha reiterado que no recomienda restricciones de paso ni comerciales en los países afectados por el ébola porque dichas medidas podrían provocar una mayor escasez de alimentos. #### Enfermo británico de ébola llega a Londres, nuevo brote congoleño Por Josephus Olu-Mammah y Kylie MacLellan FREETOWN/LONDRES (Reuters) - Un trabajador médico británico, el primer ciudadano de ese origen infectado en la epidemia de ébola, llegó el domingo a Londres proveniente de África Occidental, y un nuevo brote de la enfermedad fue declarado en la República Democrática del Congo. Un avión de carga de la fuerza aérea británica especialmente adaptado recogió el domingo al voluntario médico que trabajaba en Sierra Leona luego de que el secretario de Asuntos Externos británico, Philip Hammond, autorizó su repatriación para que sea tratado. El Departamento de Salud británico dijo en un comunicado que el hombre -cuya identidad no fue suministrada- no estaba enfermo de gravedad. El paciente será tratado en una unidad de aislamiento en el Royal Free Hospital en Londres. La fiebre hemorrágica ha matado al menos a 1.427 personas, en su mayoría en Sierra Leona, Liberia y la vecina Guinea, en el que hasta el momento es el brote más mortal de la enfermedad. El ébola ha ingresado también en Nigeria, donde murieron cinco personas. El Royal Free Hospital tiene la única unidad de aislamiento de alto nivel en Gran Bretaña para el tratamiento de enfermedades infecciosas, así como un equipo especialmente entrenado. #### Dos médicos estadounidenses, que se contagiaron el ébola en Liberia y fueron evacuados a su país, fueron dados de alta la semana pasada tras recibir tratamiento con el fármaco experimental ZMapp. No quedó claro que papel tuvo el medicamento en sus recuperaciones.NUEVO BROTE En República Democrática del Congo, el ministro de Salud Félix Kabange Numbi confirmó un brote de ébola en la remota provincia norteña de Equateur -a 1.200 kilómetros de la capital Kinshasa- pero es una cepa diferente a la del virus hallado en África Occidental. Docenas de personas han muerto en Equateur por una misteriosa enfermedad en las últimas semanas, pero la OMS dijo el jueves que se cree que se trata de un tipo de gastroenteritis hemorrágica. Sin embargo, Kabange Numbi dijo que dos de los ocho casos analizados han dado positivo de ébola y señaló que la zona de los alrededores de la ciudad de Djera quedará en cuarentena. "Esta epidemia no tiene absolutamente ninguna relación con lo que está pasando en África Occidental", declaró el ministro en conferencia de prensa. Un portavoz de la Organización Mundial de la Salud (OMS) dijo que no podía confirmar los resultados de los análisis, que fueron efectuados por autoridades congoleñas. Ha habido seis brotes de ébola en República Democrática del Congo desde que la enfermedad fue descubierta en 1976, con un total de más de 760 muertes. En forma separada, la organización informó que un trabajador médico enviado a Sierra Leona ha dado positivo de ébola. Es el primer caso en que una persona que trabaja para la OMS se infecta, dijo la misma organización en un comunicado. La OMS ha dicho que más de 225 trabajadores médicos han contraído la enfermedad y casi 130 han perdido sus vidas desde que el brote de ébola fue detectado en las selvas del sudeste de Guinea en marzo. #### Sierra Leona convierte en delito el ocultamiento de víctimas ébola, británico se contagia Por Umaru Fofana y Joe Bavier FREETOWN/ABIYAN (Reuters) - El Parlamento de Sierra Leona convirtió el sábado el ocultamiento de víctimas de ébola en un delito punible con dos años de prisión, en un intento por frenar la propagación del mortal virus, al tiempo que autoridades de salud revelaron el caso del primer británico infectado con la enfermedad en Africa. La decisión de Sierra Leona se produjo después de que la Organización Mundial de la Salud (OMS) advirtió que la negativa en reportar a las víctimas y la existencia de "zonas grises" en las que los médicos no pueden ingresar impiden dimensionar la verdadera escala de la epidemia. Unas 1.427 personas han muerto entre los 2.615 casos documentos desde que el inicio del actual brote - el peor en la historia desde que se descubrió la enfermedad - que apareció en marzo en Guinea, de acuerdo a cifras dadas a conocer el viernes por la OMS. Un funcionario de salud de Sierra Leona confirmó el sábado que un ciudadano británico en el país africano se contagió con ébola y dijo que expertos médicos estaban evaluando su situación para garantizar que reciba un tratamiento apropiado. "El riesgo general (de contagio ) entre el público en Gran Bretaña sigue siendo bajo", afirmó el médico John Watson, sin ofrecer detalles. Legisladores en la capital de Sierra Leona, Freetown, votaron a favor de la ley de enmienda de salud pública del 2014, que modifica una normativa legal de 54 años. "La nueva regulación ordena un procesamiento sumario, lo que implica un proceso en una corte con un solo magistrado", dijo a Reuters el ministro de Justicia Frank Kargbo. Los casos de ébola no reportados han sido un problema particularmente grave en Sierra Leona y Liberia, los países más afectados por el actual brote. Nigeria, el cuarto país al que se expandió la enfermedad, ha registrado 14 casos de ébola. El temor, el estigma y la negación han hecho que muchas personas escodan a sus familiares de las autoridades de salud. En otros casos, los pacientes han sido removidos a la fuerza de centros de salud y aislamiento, creando el riesgo de que la enfermedad se propague más. Pese a las declaraciones iniciales de las autoridades de salud de la región de que el virus había sido contenido en los inicios del brote, los casos y muertes por ébola han subido dramáticamente en los últimos meses. A medida que la enfermedad se propagaba desde el centro inicial de Guinea, los gobiernos en la región han ido aplicando restricciones cada vez más severas. Costa de Marfil cerró sus fronteras terrestres con Guinea y Liberia en un intento por evitar que el virus llegue a su territorio, dijo el Gobierno tarde el viernes. Costa de Marfil, la mayor economía de Africa Occidental y el principal productor de cacao del mundo, impuso previamente una prohibición de vuelos desde y hacia Sierra Leona, Liberia y Guinea. ### Día a día II #### El fármaco experimental cura el ébola en monos by Nuño Domínguez Los primeros datos de la eficacia de Zmapp muestran que curó el ébola en el 100% de los casos en un estudio con macacos. La empresa responsable del medicamento fabricado con tabaco transgénico reinicia la producción, y planea un ensayo en humanos para enero de 2015Mientras el brote de ébola sigue fuera de control en África Occidental, investigadores de EEUU, China y Canadá publican hoy datos esperanzadores sobre Zmapp, el fármaco experimental que han recibido de urgencia siete personas infectadas y del que aún se ignora su eficacia real.En un estudio con macacos, el medicamento ha curado las infecciones a todos los primates que lo recibieron, una eficacia del 100%. Los resultados son un importante espaldarazo para probar el Zmapp en humanos en ensayos clínicos y posiblemente usarlo como tratamiento compasivo en personas ya infectadas por el virus, para el que de momento no existe ni cura ni vacuna. En el estudio, 18 macacos infectados con ébola recibieron el Zmapp, un cóctel de tres anticuerpos, hasta cinco días después del contagio. Todos los animales sobrevivieron, a pesar de que algunos ya mostraban hemorragias, problemas hepáticos y otros síntomas de ébola avanzado. Mientras, los tres animales del grupo de control que no recibieron el tratamiento murieron por las fiebres hemorrágicas que causa el virus. Lo que hace importantes los datos es el hecho de que se puedan revertir los síntomas hasta cinco días después de la infección, pues hasta ahora otros anticuerpos sólo habían podido hacerlo si se administraban. Hasta ahora otros anticuerpos habían demostrado una eficacia del 100% solo si eran administrados una hora después de la infección. Aunque la variante del virus usada en el estudio no es la que actualmente ha causado el brote en Nigeria, Sierra Leona, Guinea y Liberia, los responsables del estudio sí han comprobado que el cóctel de anticuerpos es capaz de neutralizar esa variante en cultivos celulares en un laboratorio. Además el equipo tiene datos “preliminares” de que el fármaco también funciona contra la nueva variante en ensayos con animales, según confirmó hoy Gary Kobinger, microbiólogo de la Universidad de Manitoba (Canadá) y de la Agencia de Salud Pública de Canadá y coautor del estudio, en una rueda de prensa. Veintiséis autores de EEUU, Canadá y China firman el estudio publicado por la revista Nature y en el que se han comparando diferentes cócteles de anticuerpos y demostrado la efectividad superior de Zmapp. El siguiente paso será probar el fármaco en humanos en un ensayo de fase I, algo que está fijado para enero de 2015 y cuyos resultados se esperan para la primavera de ese año, ha explicado Kobinger. Esos ensayos probarán en personas sanas si el fármaco es seguro y no provoca efectos secundarios serios. Si esos resultados son positivos, ha explicado el microbiólogo, se podría empezar a dar el fármaco a personas infectadas como tratamiento compasivo. Una cura gracias a los transgénicos Los datos llegan cuando la situación en África Occidental sigue siendo extremadamente grave. La Organización Mundial de la Salud ya ha contabilizado 3.069 casos y 1.552 muertos, pero la agencia de la ONU calcula que el número de infectados puede superar los 20.000 antes de que se pueda poner fin a este brote. En la actualidad, el único tratamiento posible de los infectados consiste en mantenerlos vivos el mayor tiempo posible para así dar la oportunidad a su sistema inmune a que reconozca al virus y consiga eliminarlo, algo que sucede en el 49% de los casos, según los datos de la OMS. Rafael Delgado, un virólogo del Servicio de Microbiología del Hospital 12 de Octubre que estudia el virus del ébola, resalta la importancia de estos resultados. “Este fármaco es el que ha demostrado un eficacia más clara”, resalta. El experto explica que, aunque 18 monos pueda parecer un número reducido de animales para estar seguros de la eficacia de un tratamiento, cuando se trata de ébola es un número excepcionalmente alto. Esto se debe a las dificultades técnicas de manejar animales infectados, algo que solo es posible en un ‘reducidísimo’ número de laboratorios en todo el mundo. El experto opina que, ahora, “lo más lógico dada la actual situación un poco caótica que se vive en África sería comenzar el uso compasivo del fármaco en personas ya infectadas a la vez que se desarrollan los ensayos clínicos de fase I”. Zmapp ha sido desarrollado durante más de 10 años de complicados experimentos con animales en un laboratorio de máxima seguridad en EEUU. Su desarrollo ha sido financiado por el Ejército de ese país y la Agencia de Salud Pública de Canadá. La empresa de San Diego (EEUU) Mapp Biopharmaceutical ha sido hasta ahora la encargada de fabricar el Zmapp gracias al uso de plantas de tabaco transgénicas capaces de producir anticuerpos humanos. Este mes se comenzaron a administrar las pocas dosis que quedaban del fármaco a trabajadores médicos infectados. Por el momento, las existencias del tratamiento están totalmente agotadas, según informa la web de Mapp Biopharmaceutical. “Hemos empezado a producir de nuevo pero puede que no tengamos el próximo lote listo hasta finales de año”, ha explicado Kobinger. “Estamos intentando reducir ese tiempo a la mitad, pero aún no sabemos si lo lograremos”, ha añadido el investigador. Por el momento no hay evidencia de que Zmapp funcione en humanos. El fármaco fue administrado a varios trabajadores sanitarios, incluido el misionero español Miguel Pajares, como tratamiento compasivo ante la falta de fármacos capaces de combatir al virus. Pajares no sobrevivió a la infección, ni tampoco lo ha hecho un médico liberiano que también recibió el fármaco. Sin embargo, dos misioneros estadounidenses, Nancy Writebol y Kent Brantly, también recibieron el fármaco y se salvaron, aunque aún se ignora si el Zmapp tuvo algo que ver. “Es crucial que empiecen los ensayos clínicos en humanos cuanto antes”, ha resaltado Peter Piot, el médico belga que descubrió el virus del ébola en 1976 durante un brote en el Zaire, en declaraciones a Science Media Center. Desde entonces, la variante Zaire es una de las tres descubiertas que producen la letal fiebre hemorrágica que caracteriza al ébola. “Nunca creí que 40 años después de que me encontrase con el primer brote de ébola esta enfermedad seguiría llevándose las vidas en una escala tan devastadora”, ha reconocido. Otros expertos relativizan la importancia de Zmapp. “A pesar de estos resultados prometedores, este tratamiento no detendrá el brote”, ha declarado Jonathan Ball, profesor de virología molecular en la Universidad de Nottingham (Reino Unido. “La prevención y control de las infecciones es la única manera de ganar al ébola y necesitamos mucho más esfuerzo internacional del que hemos visto hasta ahora”, ha resaltado. En una línea similar se viene pronunciando Médicos Sin Fronteras, que trabaja en primera línea en los tres países más afectados, en ocasiones sin ayuda externa, y que resalta la falta de recursos básicos en los centros médicos y la llegada del virus a ciudades como principales problemas para atajar la epidemia. La excepcional situación también ha acelerado los planes para desarrollar una vacuna contra el ébola para proteger de infecciones. Una de las más prometedoras comenzará a probarse la próxima semana en EEUU entre voluntarios sanos, según informaron los Institutos Nacionales de Salud. REFERENCIA 'Reversion of advanced Ebola virus disease in nonhuman primates with ZMapp' doi:10.1038/nature13777 Fuente: Materia #### Estudio sobre el medicamento ZMapp El suero contra el ébola hecho de tabaco transgénico elimina la infección en monos En plena epidemia del virus del Ébola en África occidental, todas las miradas se centran en los posibles avances de la comunidad médica para lograr un tratamiento eficaz. Una edición especial de la revista Nature revela los prometedores resultados detectados en monos con el ZMapp, un fármaco experimental producido en plantas similares al tabaco. #### SINC Hasta el momento, los logros en la lucha contra el ébola son escasos. Sin embargo, un estudio publicado hoy on line por la revista Nature, hace pública la eficacia de un nuevo medicamento experimental desarrollado a partir de tabaco transgénico, el ZMapp, contra la infección por el virus en monos. La administración del fármaco consiguió la recuperación en el 100% de los 18 macacos Rhesus tratados, incluso cuando el tratamiento se inició hasta cinco días después de la infección. Tal y como expone el artículo, “el ZMapp todavía requiere pruebas de seguridad en humanos, pero los resultados confirman que podría tratarse de una prometedora opción terapéutica”. “El ZMapp todavía requiere pruebas de seguridad en humanos, pero los resultados confirman que podría tratarse de una prometedora opción terapéutica” El brote actual en África occidental ha puesto de manifiesto la falta de vacunas o alternativas de tratamiento adecuadas contra la infección por el virus del Ébola. Hasta ahora, la mejor opción terapéutica postinfección engloba anticuerpos monoclonales –proteínas que se unen a proteínas extrañas–, que muestra beneficios clínicos importantes. El reciente trabajo, liderado por Gary Kobinger, investigador de la Agencia de Salud Pública de Canadá, revela la eficacia del ZMapp, desarrollado como un cóctel de tres anticuerpos monoclonales optimizados a partir de dos cócteles de anticuerpos anteriores. Los autores afirman que tres dosis de ZMapp, administradas en intervalos de tres días empezando el día tres, cuatro o cinco después de que los 18 macacos rhesus fueran infectados con el virus de Ébola, consiguieron la supervivencia de todos los animales. Así, el tratamiento revirtió los síntomas graves de la enfermedad como el sangrado excesivo, las erupciones cutáneas y las enzimas hepáticas elevadas. Por el contrario, los tres macacos rhesus que no recibieron ZMapp sucumbieron a la infección el día ocho. #### Distinta cepa de virus La cepa del virus de Ébola utilizada para infectar monos en este experimento es diferente a la cepa del brote actual en África Occidental, pero los autores realizaron una comparación directa de las dos variantes que establece que ZMapp es capaz de inhibir la replicación de la nueva cepa. Los autores señalan que esta hipótesis puede ser apoyada tras el uso compasivo de ZMapp en dos trabajadores de la salud estadounidenses infectados durante el actual brote de ébola, aunque los resultados hasta ahora son insuficientes. #### El suero experimental en humanos En la actualidad, apenas hay casos de personas infectadas tratadas con este suero experimental –no probado antes en humanos– y los resultados son bastante irregulares como para valorar su seguridad o eficacia. Entre los éxitos, los casos del médico Kent Brantly y la misionera Nancy Writebol, que fueron dados de alta tras recuperarse de la enfermedad en EE UU. Sin embargo, el doctor Abraham Borbor, subjefe médico del hospital más grande de Liberia y uno de los primeros africanos que recibieron el fármaco, falleció esta semana a causa del virus. El tratamiento también fue administrado a un cura español contagiado en Liberia, Miguel Pajares, que murió el 12 de agosto. #### Referencia bibliográfica: • Xiangguo Qiu, Gary Wong, Jonathan Audet, Alexander Bello, Lisa Fernando, Judie B. Alimonti, Hugues Fausther-Bovendo, Haiyan Wei, Jenna Aviles, Ernie Hiatt, Ashley Johnson, Josh Morton, Kelsi Swope, Ognian Bohorov, Natasha Bohorova, Charles Goodman, Do Kim, Michael H. Pauly, Jesus Velasco, James Pettitt, Gene G. Olinger, Kevin Whaley, Bianli Xu, James E. Strong, Larry Zeitlin & Gary P. Kobinger. Reversion of advanced Ebola virus disease in nonhuman primates with ZMapp. • Nature 29 de agosto de 2014. http://dx.doi.org/10.1038/nature13777 DOI: 10.1038/nature13777 Link: http://www.intramed.net  Keyword(s): Ébola #### Muerte súbita en el adulto Muerte súbita en el adulto Publicado en Revista Creces, Junio 1986 Es frecuente escuchar que una persona "falleció de repente" o murió mientras dormía, sin que se advirtieran alteraciones visibles en su estado general. El tema ha sido una suerte de callejón sin salida para los clínicos. Ofrecemos aquí un estado de avance de algunas investigaciones destacadas sobre el tema. La llamada muerte súbita cardiaca es la principal causa de decesos en adultos de los países industrializados. En Chile son aproximadamente 30 mil las muertes anuales causadas por fallas agudas del corazón. La mayoría de ellos son hombres. El paro cardíaco es la causa de muerte de uno de cada tres adultos. Sus víctimas son generalmente individuos llenos de vida y hasta que se produce el accidente parecen haber gozado de buena salud. En la actualidad los cardiólogos se están preocupando mucho de este síndrome, porque ahora tienen algunas posibilidades para combatirlo. Los hallazgos sugieren que la causa de la muerte súbita cardíaca puede estar influida o motivada por factores emocionales, ya sea porque lentamente éstos van creando una predisposición a la muerte cardíaca o porque en una crisis emocional aguda, abruptamente la causan. Figura 1: Corto circuito eléctrico en el corazón. Las células marcapasos propagan los impulsos por todo el corazón mediante un sistema de fibras musculares (amarillo, diagrama superior). Cuando las fibras de Purkinje son lesionadas por un exceso de catecolaminas, ellas impiden el paso de los impulsos (abajo) y la fibrilación puede resultar fatal. Sin registro previo Hay dos formas de muerte cardíaca: a) por un infarto del miocardio, como resultado de la esclerosis de las arterias coronarias, y b) la muerte súbita, propiamente tal, que se inicia por una sobrecarga de estímulos eléctricos de los nervios que inervan el corazón. Los ventrículos que constituyen la bomba del corazón comienzan a acelerarse produciendo una taquicardia, hasta que la contracción cardíaca se vuelve anárquica (fibrilación), y el corazón ya no se contrae sino que sólo se sacude como lo haría una masa de gusanos. Esta situación se hace incontrolable y termina con la muerte del paciente, salvo que se aplique un desfibrilador o se lo introduzca en una máquina de resucitación cardiopulmonar. Estudios señalan que alrededor del 20% de los enfermos que fallecen de muerte súbita tienen las arterias coronarias totalmente normales, y no han tenido hipertensión, no han sido fumadores excesivos, no han tenido alto su nivel de colesterol ni son obesos. Es decir, casi el 20% de los que fallecen no han tenido ninguna enfermedad previa. Más aun, el 75% de los que fallecen por muerte súbita no han tenido infartos previos. Es como si el corazón se cansara de latir rítmica y armónicamente, comandado por alguna orden superior. La pregunta que los médicos tratan de responder es: ¿Por qué se produce esto?. La causa final es aún inexplicable incluso para aquellos que padecen enfermedades cardíacas previas. Personas con enfermedades graves al corazón pueden vivir muchos años, pero de repente fallecen de muerte súbita. Pareciera que son factores emocionales los que desencadenan el problema: miedo, depresión, soledad son antecedentes frecuentes. Con mayor razón si su corazón está previamente dañado. Se sabe que el cerebro ejerce un control sobre el funcionamiento del corazón, aunque no se conoce exactamente cómo lo realiza. James Skinner, un neurólogo del Baylor College of Medicine, en Houston, Estados Unidos, estima que existe una substancia química (neuropéptido o una enzima) que no funciona adecuadamente en el lóbulo frontal de algunas personas. Su mal funcionamiento no altera la inteligencia, la percepción, la memoria u otras condiciones de las personas, actuando sólo sobre la regulación del corazón, lo que se pone en evidencia en pacientes con enfermedades cardíacas y con problemas emocionales, desencadenando la fibrilación del músculo cardíaco. A todos se nos acelera el corazón si tenemos una emoción o un susto, pero en algunos esto desencadena el caos (fibrilación), mientras que a los más, se pasa la aceleración (taquicardia) una vez que transcurre el miedo o la ira. Figura 2: Por qué las ratas no son presas de muerte súbita. De acuerdo con Skinner, el lóbulo frontal humano (arriba) permite un rango de respuestas al estrés que algunas veces incluye mensajes antagonistas capaces de desatar la fibrilación. Las respuestas en los roedores son conducidas a través del núcleo amigdaliano, limitando las reacciones a combate o huida. Evidencias Esta conexión entre factores emocionales y muerte súbita es algo nuevo. Hasta hace 25 ó 30 años, los cardiólogos eran renuentes a aceptar esta relación y sólo durante los últimos años la literatura médica comienza a preocuparse de ella. En este sentido hay algunas evidencias: • El 20% de los pacientes que ha fallecido o sobrevivido a un paro cardíaco, ha tenido algún motivo de angustia o emoción en las 24 horas anteriores al accidente. Cada uno de nosotros tiene alguna experiencia de parientes, amigos o conocidos, qué fallecieron después de una emoción fuerte. Tal vez por eso existe la frase: ¡casi me muero de miedo!. • En un trabajo se confirmó que entre las viudas desconsoladas, el riesgo de muerte súbita es un 40% más alto que en las mujeres casadas de la misma edad. (Afortunadamente no todas las viudas son desconsoladas). • La muerte súbita aumenta en frecuencia durante los primeros meses después de la jubilación. • En animales de experimentación (perros), Richard Verrier, investigador de la Universidad de Harvard, EE.UU., demostró que la ira aumenta notablemente las posibilidades de fibrilación cardíaca. Peter Reich, también de Harvard, demostró que la intensa rabia en los seres humanos, en muchas ocasiones precede a la muerte súbita. • Cuántas veces hemos oído a las señoras de edad frases como ésta: ¡Este niño me va a terminar matando del corazón!. • Algunas substancias químicas de la sangre, llamadas catecolaminas, que son producidas por las glándulas suprarrenales y el sistema nervioso simpático, durante un estrés extremo producen destrucción de las fibras (de Purkinje) del músculo cardíaco, con lo que se altera el sistema de transmisión del estímulo nervioso, desencadenando una fibrilación. • Son muchos los casos de muerte súbita en situaciones de estrés, como durante un discurso o cuando se va manejando un auto en un camino con mucho tráfico. En choferes, por ejemplo, se han podido comprobar alteraciones cardíacas mediante electrocardiógrafos portátiles. Muchas veces hemos oído casos de muerte súbita en los estadios, en los momentos que se marca un gol, tanto del equipo favorito como del contrario. En Chile es frecuente que un temblor de mediana intensidad deje por lo menos un muerto debido al susto. Numerosos trabajos se han publicado en los últimos años sugiriendo que el aislamiento prolongado, las frustraciones en el trabajo o las depresiones elevan los riesgos de muerte súbita. Es curioso que este tipo de factores emocionales afecta más a aquellos individuos con mayor grado de educación. En ellos el riesgo de muerte súbita es mayor. No sólo el aumento de las catecolaminas sino también el de la adrenalina, que se produce después de fuertes o sostenidas emociones, pueden interferir en el proceso. La adrenalina produce contracción de los pequeños vasos del corazón, lo que obliga a este órgano a aumentar sus contracciones para bombear más sangre, lo cual significa aumentar los riesgos de fibrilación. La adrenalina es la causante de la sensación de "frío pánico" que experimentamos cuando, por ejemplo, estuvimos a punto de chocar o ser atropellados. Figura 3: Cómo el cerebro envía señales de alarma al corazón. Bajo la acción del estrés, el lóbulo frontal ordena al hipotálamo la liberación de catecolaminas de las glándulas adrenales y de los nervios simpáticos del corazón. Cuando el organismo funciona bien, el nervio vago es simultáneamente desactivado y previene al sistema parasimpático de la transmisión de mensajes antagónicos causantes de la fibrilación. Investigaciones Aceptando la hipótesis de que factores emocionales alterarían la normal regulación que el cerebro ejerce sobre el corazón, muchos investigadores están tratando de interferir en la producción o transmisión de estos "mensajeros de la muerte". Unos pocos pacientes logran sobrevivir a un primer paro cardíaco. Si no se les hace nada, un 30% vuelve a tener un nuevo paro cardíaco. En la actualidad puede reducirse este índice a un 4% usando drogas antiarrítmicas y teniendo al paciente en un constante monitoreo. Desgraciadamente las drogas también actúan bloqueando estímulos eléctricos que van a otras partes del cuerpo, produciendo alteraciones de la memoria, trastornos digestivos o impotencia sexual. Parecen existir también otras alternativas de prevención. Algunos cirujanos han comenzado a utilizar pequeños electrodos para eliminar minúsculos trozos de tejido cardíaco que pueden hacer de cortocircuito en la transmisión nerviosa de los impulsos eléctricos. Otros han observado que cortando una rama nerviosa, llamada ganglio estelar izquierdo, fuera del músculo cardíaco, puede en los animales prevenir la fibrilación. James Skinner (Oklahoma, EE.UU.) estudió la posibilidad de impedir la fibrilación, actuando al nivel de la región frontal del cerebro. El ha trabajado con cerdos, que a veces mueren de miedo en el matadero. Ha observado que ligando sus coronarias y luego estimulando la región frontal con impresos eléctricos, se produce fácilmente fibrilación. Con este método está tratando de destruir las neuronas que envían el mensaje de la muerte y dice haber obtenido éxito, destruyendo algunas zonas específicas del lóbulo frontal. El mismo investigador también estudia en ratas actuando directamente sobre el hipotálamo y el núcleo amigdaliano, que es la región que controla las reacciones del miedo. A través de estas lesiones él puede prevenir que el mensaje llegue al corazón. El neurólogo pretende ir más lejos. Según él, en el cerebro hay más de diez mil tipos diferentes de neurotransmisores (substancias químicas que traspasan el estímulo eléctrico de una neurona a otra) y cada uno de ellos estimula o inhibe la transmisión en algunas células o funciones específicas de ellas. El pretende conocer cuál es el nuevo transmisor específico para este caso y para buscar un antídoto. Otro grupo de la Universidad de Harvard, encabezado por E. Lowns, está usando dietas que modifiquen los niveles de serotonina del cerebro, ya que éste es un potente neurotransmisor que amortigua las substancias químicas que pueden alterar la función cardíaca, cuando se produce un estado de ira o pánico. Algunos investigadores afirman que los niveles de serotonina están muy bajos en estados de depresión y que incluso su determinación es útil para predecir decisiones como los suicidios. Los niveles de serotonina también se encuentran disminuidos en los alcohólicos, lo que puede independientemente predisponer a la muerte súbita. La serotonina se produce a partir de un aminoácido llamado triptótano, que a su vez aumenta al ingerir alimentos como hígado, huevos o leche. Los cardiólogos generalmente aconsejan a los pacientes en riesgo de muerte súbita no ingerir tales alimentos. Como se puede ver, la relación entre cerebro y corazón es muy compleja. La muerte súbita y la fibrilación cardíaca parece que continuarán siendo responsables de la mayor parte de los decesos de los hombres adultos, pero en ciencia nada se puede vaticinar. Para saber más (1) Lown, B. Tratamiento de pacientes con alto riesgo de muerte repentina. Am Heart J 103:689, 1982. En: Rev. Méd. Chile, 111:221-226, 1983. (2) Henríquez, Alejandra y Chuaqui, Benedicto. Un caso de lipomatosis del sistema excitoconductor y muerte súbita. Rev. Méd. Chile 111: 447-450, 1983. (3) Northcote, A. J., Ballantyne, D. Muerte repentina cardíaca en deporte. Br Méd J 287:1357, 1983. En: Rev. Méd. Chile 112:745-752, 1984. (4) Illanes, Guillermo et al. Incidencia de arritmias ventriculares y su correlación con muerte súbita en pacientes con miocardiopatía dilatada idiopática. Rev. Méd. Chile 112:877-883, 1984. (5) Milei, J. Patología de la muerte súbita. Arch Inst Cardiol Mex 52:135, 1982. En: Rev. Méd. Chile 111:637-641, 1983. Link: http://www.creces.cl  Keyword(s): Muerte súbitaadulto #### Muerte súbita en el deporte Entrevista al Dr. Gonzalo Grazioli (Hospital Clinic de Barcelona) | 25 AGO 14 ### Muerte súbita en el deporte: prevalencia, causas y estrategias de prevención Un fenómeno que causa preocupación en todos los sectores, cómo actuar basado en las mejores evidencias disponibles. Fuente: IntraMed La muerte súbita en el deporte es un tema que ocasiona honda preocupación médica y social. Los casos que toman estado público resultan siempre dramáticos y conmovedores. Es por ello que el diseño de estrategias preventivas basadas en evidencias científicas se ha convertido una imperiosa necesidad. IntraMed ha realizado una entrevista con un experto en el tema, el Dr. Gonzalo Grazioli MD, MTSAC. Cardiólogo del Hospital Clinic de Barcelona. Consell Català de l’Esport. Entrevista ¿Cuál es la prevalencia de la muerte súbita en deportistas? La prevalencia se estima entre 1-2 por cada 100.000 deportistas, por lo que comparado con otras enfermedades se puede decir que es baja, sin embargo el impacto social que esta causa por lo inesperada y que se produce en personas jóvenes es de gran relevancia. La estimación de la prevalencia es variable según las diferentes poblaciones analizadas en Europa12345 o USA6; siendo la edad media y el sub-registro de muerte súbita las principales causas de variación de la prevalencia entre los estudios realizados. ¿Cuáles son las causas más frecuentes que se han identificado? Un metanálisis de los estudios de 6 estudios citados anteriormente que valoraron muerte súbita en el deporte nos expresa estos resultados: ¿Cuáles son los deportes donde ocurre con mayor frecuencia? Los deportes “acíclicos”; es decir los que tienen un rápido ascenso de la frecuencia cardiaca, como son el futbol o basquetbol; son aquellos en los que se registró un mayor número de muertes súbitas. Pero también se observa una relación con el número total de deportistas según el país, y como ejemplo de esto podemos mencionar el futbol americano que es la primer causa en USA6. ¿De qué modo resulta razonable ejercer su prevención? El modelo de screening pre-participativo sugerido por la Sociedad Europea de Cardiología7 es el más usado a nivel mundial, el mismo consiste en la realización de: 1) Historia familiar y personal 2) Examen físico 3) ECG Reservando una segunda línea de estudios si el screening básico se encuentra alterado, con estudios complementarios como el ecocardiograma, prueba de esfuerzo, Holter 24 horas, RMN cardíaca o estudio electrofisiológico. ¿Qué estudios complementarios han demostrado su efectividad para la detección de grupos de riesgo? En primer lugar ECG, con un 95% de sensibilidad para el diagnóstico de miocardiopatía hipertrófica8, >50% para la displasia arritmogénica del ventrículo derecho9 y alta para las canalopatías como el síndrome de Brugada10 o el QT largo11. Si bien es cuestionado en USA por el costo-efectividad, esto posiblemente se halla en relación al sub-registro de incidencia de muerte súbita en el deporte en ese país, que la estimada menor a 1 por cada 100.000 deportistas12. En segundo lugar, el ecocardiograma, que el uso podría ser útil en jóvenes y como método descreening al menos un vez en la vida13, con especial utilidad en la elevada sensibilidad que presenta para detectar las anomalías coronarias, la hipertrofia ventricular y la patología aórtica. ¿Cuál sería la actitud apropiada ante el deporte en personas con diagnóstico de patología cardiaca? Un reciente trabajo del grupo de cardiología deportiva de la Sociedad Europea de Cardiología14aporta recomendaciones para el deporte recreativo que en recomendaciones previas no habían sido incorporados, como así también el deporte competitivo. También esta publicación agrega un cambio de utilidad práctica en el momento de dar una recomendación médica para la realización de deportes, ya que mantiene el componente estático de clasificación Mitchell pero cambia el componente dinámico de la clasificación de por el porcentaje de frecuencia cardiaca máxima obtenido en una prueba de esfuerzo con gases o bien con el equivalente en la escala de Borg de esfuerzo percibido. ¿Cuál es la importancia de otros factores no cardiacos como desencadenante de muerte súbita en el deporte, como la hiponatremia y el golpe de calor? Presentan una gran importancia, si bien en la mayor serie de muerte súbita en maratón se describió un 7% de hiponatremia15, este resultado podría estar subestimado debido a que se registraron las hiponatremia severas (Na < 120 mEq); pero aún no se sabe el rol de la hiponatremia moderada (Na 120-130 mEq) como factor facilitador de arritmia asociada con patología cardiaca previa. En relación a los golpes de calor (heat stroke) una reciente publicación16 sugiere que son mucho más frecuentes que las patologías cardiacas que traen complicaciones, y que la prevención del mismo como así el diagnóstico precoz presenta utilidad para disminuir las complicaciones que requieren de cuidados intensivos o bien la muerte post-carrera del deportista. ¿Resulta costo-efectivo contar con desfibriladores y personal entrenado en RCP en campos deportivos? Resulta difícil contestar con evidencia científica esta pregunta debido a la baja incidencia de la muerte súbita en el deporte y los escasos estudios que reportan el porcentaje de paros cardíacos reanimados4; pero si resulta evidente que la presencia de personas entrenadas en RCP y un desfibrilador aumenta la posibilidad de sobrevida cerca de 4 veces; por esta razón la recomendaciones de la Sociedad Europea de Cardiología17 en los estadios y la FIFA18 en las canchas de fútbol sugieren el entrenamiento en RCP y la presencia de un desfibrilador automático externo. Referencias Bibliográficas 1. Corrado D, Basso C, Rizzoli G, Schiavon M, Thiene G. Does sports activity enhance the risk of sudden death in adolescents and young adults? J Am Coll Cardiol. 2003;42(11):1959-1963. doi:10.1016/j.jacc.2003.03.002. 2. Manonelles Marqueta P, Aguilera Tapia B, Boraita Pérez A, Luengo Fernandez E, Pons de Beristain C, Suárez Mier MP. La muerte súbita en el deporte . Registro en el Estado español. Apunts. 2007:26-35. 3. De Noronha S V, Sharma S, Papadakis M, Desai S, Whyte G, Sheppard MN. Aetiology of sudden cardiac death in athletes in the United Kingdom: a pathological study. Heart. 2009;95(17):1409-14. doi:10.1136/hrt.2009.168369. 4. Marijon E, Tafflet M, Celermajer DS, et al. Sports-related sudden death in the general population. Circulation. 2011;124(6):672-81. doi:10.1161/CIRCULATIONAHA.110.008979. 5. Risgaard B, Winkel BG, Jabbari R, et al. Sports-related sudden cardiac death in a competitive and a noncompetitive athlete population aged 12 to 49 years: Data from an unselected nationwide study in Denmark. Heart Rhythm. 2014:1-9. doi:10.1016/j.hrthm.2014.05.026. 6. Maron BJ, Doerer JJ, Haas TS, Tierney DM, Mueller FO. Sudden deaths in young competitive athletes: analysis of 1866 deaths in the United States, 1980-2006. Circulation. 2009;119(8):1085-92. doi:10.1161/CIRCULATIONAHA.108.804617. 7. Corrado D, Pelliccia A, Bjørnstad HH, et al. Cardiovascular pre-participation screening of young competitive athletes for prevention of sudden death: proposal for a common European protocol. Consensus Statement of the Study Group of Sport Cardiology of the Working Group of Cardiac Rehabilitation and. Eur Heart J. 2005;26(5):516-24. doi:10.1093/eurheartj/ehi108. 8. Gersh BJ, Maron BJ, Bonow RO, et al. 2011 ACCF/AHA Guideline for the Diagnosis and Treatment of Hypertrophic Cardiomyopathy: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Developed in collaboration with the American As. J Am Coll Cardiol. 2011;58(25):e212-60. doi:10.1016/j.jacc.2011.06.011. 9. Zaidi A, Ghani S, Sheikh N, et al. Clinical significance of electrocardiographic right ventricular hypertrophy in athletes: comparison with arrhythmogenic right ventricular cardiomyopathy and pulmonary hypertension. Eur Heart J. 2013;34(47):3649-56. doi:10.1093/eurheartj/eht391. 10. Serra G, Baranchuk A, Bayés-De-Luna A, et al. New electrocardiographic criteria to differentiate the Type-2 Brugada pattern from electrocardiogram of healthy athletes with r’-wave in leads V1/V2. Europace. 2014:1-7. doi:10.1093/europace/euu025. 11. Brosnan M, La Gerche A, Kalman J, et al. The Seattle Criteria increase the specificity of preparticipation ECG screening among elite athletes. Br J Sports Med. 2013. doi:10.1136/bjsports-2013-092420. 12. Wheeler MT, Heidenreich PA, Froelicher VF, Hlatky MA. Cost-Effectiveness of Preparticipation Screening for Prevention of Sudden Cardiac Death in Young Athletes. An Intenal Med. 2010;152:276-286. 13. Grazioli G, Merino B, Montserrat S, et al. Usefulness of Echocardiography in Preparticipation Screening of Competitive Athletes. Rev Esp Cardiol. 2014;(x). doi:10.1016/j.recesp.2013.11.023. 14. Budts W, Börjesson M, Chessa M, et al. Physical activity in adolescents and adults with congenital heart defects: individualized exercise prescription. Eur Heart J. 2013;34(47):3669-74. doi:10.1093/eurheartj/eht433. 15. Kim JH, Malhotra R, Chiampas G, et al. Cardiac arrest during long-distance running races. N Engl J Med. 2012;366(2):130-40. doi:10.1056/NEJMoa1106468. 16. Yankelson L, Sadeh B, Gershovitz L. Life-Threatening Events During Endurance Sports. J Am Coll Cardiol. 2014;64(5). doi:10.1016/j.jacc.2014.05.025. 17. Borjesson M, Serratosa L, Carre F, et al. Consensus document regarding cardiovascular safety at sports arenas: position stand from the European Association of Cardiovascular Prevention and Rehabilitation (EACPR), section of Sports Cardiology. Eur Heart J. 2011;32(17):2119-24. doi:10.1093/eurheartj/ehr178. 18. Dvorak J, Kramer EB, Schmied CM, et al. The FIFA medical emergency bag and FIFA 11 steps to prevent sudden cardiac death: setting a global standard and promoting consistent football field emergency care. Br J Sports Med. 2013;47(18):1199-202. doi:10.1136/bjsports-2013-092767. Gonzalo Grazioli MD - Cardiólogo. Universidad de Buenos Aires - Ministerio de Educación de España. - Fellow en pruebas de ejercicio y rehabilitación cardiovascular. Fundación Favaloro. - Miembro Titular Sociedad Argentina de Cardiología (MTSAC). - Membership. European Association for Cardiovascular Prevention and Rehabilitation (EACPR). - Cardiólogo. Hospital Clínic Barcelona. Consell Català de l'Esport. Linkedin: https://www.linkedin.com/pub/gonzalo-grazioli/41/a0a/309  Keyword(s): Muerte súbitadeporte #### Bajar la presión arterial, ¿hay un límite? Mortalidad y nefropatía terminal ### Bajar la presión arterial, ¿hay un límite? ##### El tratamiento de la hipertensión disminuye la morbimortalidad, pero aún no está definido cuál es la presión óptima que se debe alcanzar. La PAS superior o inferior a 130 - 139 mm Hg y la PAD superior o inferior a 60 - 79 mm Hg se asocian con peor evolución en pacientes hipertensos que reciben tratamiento. Autor: Sim JJ, Shi J, Kovesdy CP et al Fuente: Journal of the American College of Cardiology vol. 6 4, no. 6, 2 0 1 4 Impact of Achieved Blood Pressures on Mortality Risk and End-Stage Renal Disease Among a Large, Diverse Hypertension Population Fuente: IntraMed | Traducción y resumen objetivo: Dr. Ricardo Ferreira #### Intraducción A medida que el tratamiento y la normalización de la hipertensión arterial (HTA) continúan mejorando, los debates se centraron sobre la presión más apropiada en pacientes hipertensos tratados, específicamente en relación con el grado de intensidad con que se debe tratar su presión arterial (PA). Se supone que hay una relación lineal entre la PA y el riesgo vascular y de mortalidad. Las PA más bajas en todos los grupos etarios se asociaron con los mayores beneficios de morbilidad y supervivencia. Estas observaciones llevaron a la conclusión de que el descenso de la PA a lo largo de ese eje lineal generará la disminución proporcional del riesgo. La percepción es similar para el riesgo de insuficiencia renal. Se demostraron reducciones del riesgo significativas en estudios intervencionistas que lograron el descenso de la PA en pacientes con HTA grave. Sin embargo, no se han mostrado beneficios con el descenso tensional intensivo que, incluso, puede ser contraproducente. En poblaciones de alto riesgo, como aquéllas con diabetes mellitus (DM) y nefropatía crónica, las intervenciones para disminuir la PA por debajo de los niveles deseados habituales no demostraron mejoras en los resultados. En realidad, el descenso intensivo se asoció con peores resultados, lo que sugiere una curva en forma de J. Esta curva no lineal es similar a la observada en otros factores de riesgo cardiovascular. De manera que para la población general con HTA, la relación entre el tratamiento de la HTA y la evolución del paciente no está bien definida. Los autores estudiaron una población que recibía tratamiento médico para la HTA a fin de evaluar la PA lograda y el riesgo ulterior de mortalidad y de nefropatía terminal (NPT). Métodos Se efectuó un estudio de cohortes retrospectivo en pacientes del sistema de salud Kaiser Permanente Southern California, (KPSC) entre enero de 2006 y diciembre de 2010. Este sistema se compone de 14 centros médicos y más de 200 consultorios médicos. La población que se atiende es de gran diversidad étnica y socioeconómica. Se estudió a pacientes hipertensos tratados mayores de 18 años. Tratamiento de la HTA en Kaiser Permanente. Desde 2005, KPSC dispone de un algoritmo simplificado para el tratamiento de la HTA. La mayoría de los médicos de la institución siguen este algoritmo. Durante el período del estudio, las tasas de descenso de la HTA en la población del KPSC fueron del 65% al 80%. Criterios de valoración. El criterio principal de valoración fue una combinación de mortalidad o NPT. Los criterios secundarios fueron la NPT y la mortalidad por separado como riesgos que compiten y, en los análisis estratificados de aquéllos con diabetes o sin ella, la edad < 70 o ≥ 70 años y las puntuaciones CCI (Índice de comorbilidades de Charlson). Se emplearon los modelos de regresión de riesgos proporcionales de Cox para evaluar los riesgos (índices de riesgo) para mortalidad y NPT entre diferentes clases de PA con estratificación para diabetes mellitus y ancianidad o sin ella. Los valores de 130 - 139 y 80 - 89 mm Hg se emplearon como referencia para la PA sistólica (PAS) y la PA diastólica (PAD), respectivamente. Resultados Se estudiaron 398.419 pacientes hipertensos que recibían tratamiento. La PA media fue 131/73 mm Hg con desvíos estándar para la PAS (11 mm Hg) y la PAD (8 mm Hg), respectivamente. En los pacientes que murieron, la PAS media disminuyó 7 mm Hg durante los 60 días previos a la muerte (124 vs. 131 mm Hg [p < 0,01]). Las diferencias en la PAD no fueron tan pronunciadas, con disminución de 3 mm Hg (70 mm Hg antes y 67 mm Hg dentro de los 60 días de la mortalidad [p < 0,01]). Se consideró que el 83% de la población con HTA había normalizado su PA (< 140 mm Hg) durante el período de observación. Se dispuso de información sobre el índice de masa corporal (IMC) en el 99% de la cohorte del estudio y se consideró obeso al 43% de los participantes. La frecuencia de enfermedades concomitantes (comorbilidades) fue la siguiente: DM 30%; cardiopatía isquémica 19% y enfermedad cerebrovascular 8%. La media de la creatininemia y de la filtración glomerular estimada (FGe) fue 1,0 mg/dl and 74 ml/min/1,73 m2, respectivamente. En total, el 24% de la población tuvo una FGe inferior a 60 ml/min/1,73 m2. Los medicamentos administrados fueron en general los de las recomendaciones del KPSC: diuréticos (80%), inhibidores de la enzima convertidora de angiotensina (70%), beta-bloqueantes (44%) y bloqueantes de los canales de calcio (37%). Los grupos con PAS más baja y más alta tuvieron las mayores tasas de mortalidad Tasas de mortalidad o NPT. Un total de 28919 personas (el 7,3%) en la cohorte alcanzaron el criterio de valoración compuesto de mortalidad o NPT. La media y la mediana de seguimiento fueron de 4,0 y 4,5 años, respectivamente. Los grupos con PAS más baja y más alta tuvieron las mayores tasas de mortalidad/NPT (22,9% y 15,7%). Si se toman los criterios de valoración por separado, se produjo mortalidad en 25182 (6,3%) y NPT en 4957 pacientes (1,2%). Las tasas de mortalidad también fueron mayores en los grupos de PAS más baja y más alta. Las tasas de NPT parecieron aumentar con las PAS más altas (6,9% de los pacientes ≥ 170 mm Hg). En cambio, no pareció haber un aumento desproporcionado de la NPT en los grupos con la PAS más baja (3,4% de los pacientes < 110 mm Hg). Análisis estratificados. Los índices de riesgo (IR) para mortalidad/NPT en pacientes con DM, en relación con pacientes no diabéticos se desplazaron a las PA más bajas y tuvieron mejor evolución. Las PA más bajas en pacientes con DM fueron 131 y 69 mm Hg para la PAS y la PAD, respectivamente, mientras que en los pacientes no diabéticos fueron de 142 y 73 mm Hg. Cuando se evaluó sólo la mortalidad, los pacientes no diabéticos tuvieron mayor supervivencia en los extremos superiores de PA que la subpoblación diabética. Para los análisis de la NPT sola, las personas con DM, en relación con los pacientes no diabéticos, tuvieron mejor evolución en los extremos inferiores de PA. Sin embargo, las personas con DM evolucionaron peor con la PA más alta que aquéllos sin DM. Edad. Las PA más bajas estimadas para mortalidad/ NPT en personas ≥ 70 años fueron 140 y 70 mm Hg para la PAS y la PAD, respectivamente, mientras que en pacientes más jóvenes las PA más bajas fueron 133 y 76 mm Hg. Para el riesgo de NPT sola, el grupo < 70 años evolucionó mejor con valores más bajos de PA en relación con aquéllos de ≥ 70 años, pero fueron más susceptibles con la PA más alta. Enfermedad cardiovascular previa. Las interacciones entre cardiopatía isquémica y PA fueron significativas para la mortalidad (p < 0,001) y la combinación de mortalidad/ NPT (p < 0,001). Las interacciones entre enfermedad cerebrovascular y PA fueron significativas sólo para mortalidad/ NPT ESRD (p = 0,02). Se efectuaron IR para los criterios de valoración mortalidad/ NPT en aquéllos con cardiopatía isquémica previa y sin ella y también en aquéllos con enfermedad cerebrovascular y sin ella. En relación con los pacientes sin enfermedad cardiovascular y PAS 130 - 139 mm Hg, los IR para mortalidad/ NPT fueron: • en los pacientes con cardiopatía isquémica previa: 4,19, 2,21, 1,43, 1,36, 2,03, 3,73, 4,38y 7,69; • en los pacientes con enfermedad cerebrovascular previa: 6,18, 2,33, 1,63, 1,44, 2,06, 2,74, 4,05 y 4,77 para PAS <110, 110 - 119, 120 - 129, 130 - 139, 140 - 149, 150 - 159, 160 – 169 y >169 mm Hg, respectivamente. Nefropatía crónica. Cada disminución de 10 ml/min/1,73 m2 en la FGe se asoció con un IR de mortalidad/ NPT de 1,08 (IC del 95%: 1,07 – 1,09). #### ¿Cuál es el nivel óptimo de presión arterial? #### Discusión Este estudio de observación de una cohorte grande y diversa de personas con HTA tratada médicamente demuestra que la PA lograda tanto en los límites superiores como en los inferiores se asocia con aumento del riesgo de mortalidad y de NPT. Se observó una curva en U para el criterio de valoración compuesto de mortalidad/ NPT con PAS >139 y <130 mm Hg. Hubo aumentos graduales del riesgo en ambas direcciones. Las PAD < 60 y > 79 mm Hg también tuvieron mayor riesgo. Las PA más bajas asociadas con los mejores resultados fueron 137 mm Hg para la PAS y 71 mm Hg para la PAD. Las PAS y el riesgo de NPT solo mostraron una curva un poco en forma de J con menor riesgo con PAS de 110 - 139 mm Hg. La población del estudio incluyó gran cantidad de pacientes diabéticos y de pacientes ≥ 70 años. Los análisis estratificados, tanto en la población con DM como en la de ≥70 años demostraron una curva de riesgo en U. En este estudio, los pacientes con DM tuvieron mejor evolución con PA más baja que los no diabéticos, pero su PAS óptima siguió en la gama de 130 - 139 mm Hg. Históricamente la PA más baja se asoció con mejor supervivencia de la enfermedad vascular y con menor mortalidad. Estudios intervencionistas que lograron el descenso de la PA en poblaciones con HTA extrema demostraron mejoría significativa de la morbimortalidad en pacientes tanto con DM como sin ella. Esto generó iniciativas para aumentar la conciencia sobre la HTA y la implementación de estrategias para su descenso. Se hizo hincapié en que cuanto más baja la presión mejor sería la evolución del paciente. Esto no necesariamente se aplica a la población con HTA que recibe tratamiento. La PA ideal en la población hipertensa no ha sido estudiada satisfactoriamente. Si bien la hipertensión es perjudicial, los beneficios del tratamiento se mostraron sobre todo cuando se logró una PAS >130 mm Hg. El tratamiento intensivo de la HTA para lograr presiones muy bajas puede tener consecuencias negativas. Varios estudios sugirieron peores resultados con el tratamiento para lograr un PA relativamente más baja, mientras que otros sugirieron que quizás no haya beneficios demostrados del tratamiento de los pacientes con HTA leve salvo que tengan evidencia de daño orgánico. Las recomendaciones recientes de 2014 basadas en la evidencia para el tratamiento de la HTA sugieren PA y umbral para el tratamiento más altos en los pacientes con DM, nefropatía crónica y edad ≥60 años. Limitaciones del estudio. La PA lograda quizás no necesariamente refleje la PA que se deseaba con el tratamiento, sino que puede representar un biomarcador para una población más enferma. Un ejemplo de esta limitación es la frecuencia desproporcionada de cardiopatía isquémica a través de todos los valores de PA. Las interacciones estudiadas entre la cardiopatía isquémica y la PA demostraron significación, lo que denota que la enfermedad cardiovascular prexistente puede afectar el IR. Sin embargo, en análisis separados de las poblaciones con enfermedad cardiovascular y sin ella, el IR a través de todos los valores de la PA continuó demostrando una curva en U. La obesidad también fue muy frecuente en la población estudiada: el 43% tuvo un IMC ≥30 kg/m2. Esta cohorte también demostró una paradoja de la obesidad similar a la mencionada en el pasado en otras poblaciones de alto riesgo. La obesidad tuvo efecto protector y los que eran obesos tuvieron un IR de mortalidad/NPT de 0,85 (IC del 95%: 0,83 – 0,88). Debido a que la PA disminuye hacia el final de la vida, la PA media durante el período de observación puede tener efectos de confusión, ya que quizás refleje los procesos que conducen a la NPT o a la muerte más que la PA actual tratada. Otro factor de confusión es el efecto del tratamiento medicamentoso sobre la evolución. Las diferentes clases de medicamentos y la cantidad de los mismos pueden tener efectos pleiotrópicos además del efecto hipotensor. El sesgo de los médicos puede haber sido otra limitación, ya que los pacientes que ellos identificaron como más enfermos quizás hayan sido vistos con mayor frecuencia y tratados de manera más intensiva. A pesar de estas limitaciones, las fortalezas de este estudio son la gran población con HTA, con diversidad étnica y gran número de pacientes diabéticos y ancianos. #### Conclusiones Los autores hallaron que los pacientes hipertensos tratados, con PAS de 130 - 139 mm Hg y PAD de 60 - 79 mm Hg son los que tuvieron el riesgo más bajo de sufrir el criterio de valoración compuesto de mortalidad y NPT. Los pacientes con PA superior o inferior tuvieron mayor riesgode sufrir estos parámetros. Mientras que las recomendaciones de los EEUU hacen hincapié en los límites superiores de los objetivos terapéuticos, es necesario tener en cuenta los posibles riesgos del tratamiento excesivo. Tanto el aumento como la suspensión de los medicamentos pueden ser apropiados para tener resultados óptimos en la población con HTA. #### REFERENCIAS 1. Cutler JA, Sorlie PD, Wolz M, Thom T, Fields LE, Roccella EJ. Trends in hypertension prevalence, awareness, treatment, and control rates in United States adults between 1988-1994 and 1999- 2004. Hypertension 2008;52:818–27. 2. Egan BM, Zhao Y, Axon RN. US trends in prevalence, awareness, treatment, and control of hypertension, 1988-2008. JAMA 2010; 303:2043–50. 3. Lewington S, Clarke R, Qizilbash N, Peto R, Collins R. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet 2002; 360: 1903–13. 4. Whelton PK, He J, Appel LJ, et al. Primary prevention of hypertension: clinical and public health advisory from The National High Blood Pressure Education Program. JAMA 2002; 288: 1882–8. 5. Klag MJ, Whelton PK, Randall BL, et al. Blood pressure and end-stage renal disease in men. N Engl J Med 1996; 334:13–8. 6. Group VACS. Effects of treatment on morbidity in hypertension. Results in patients with diastolic blood pressures averaging 115 through 129 mm Hg. JAMA 1967; 202:1028–34. 7. SHEP. Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension. Final results of the Systolic Hypertension in the Elderly Program (SHEP). SHEP Cooperative Research Group. JAMA 1991;265: 3255–64. 8. Turnbull F, Neal B, Ninomiya T, et al. Effects of different regimens to lower blood pressure on major cardiovascular events in older and younger adults: meta-analysis of randomised trials. BMJ 2008; 336:1121–3. 9. Group UPDS. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. UK Prospective Diabetes Study Group. BMJ 1998; 317: 703–13. 10. Hansson L, Zanchetti A, Carruthers SG, et al. Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial. HOT Study Group. Lancet 1998; 351:1755–62. 11. Julius S, Kjeldsen SE, Weber M, et al. Outcomes in hypertensive patients at high cardiovascular risk treated with regimens based on valsartan or amlodipine: the VALUE randomised trial. Lancet 2004; 363:2022–31. 12. Staessen JA, Fagard R, Thijs L, et al. Randomised double-blind comparison of placebo and active treatment for older patients with isolated systolic hypertension. The Systolic Hypertension in Europe (Syst-Eur) Trial Investigators. Lancet 1997; 350:757–64. 13. Staessen JA, Gasowski J, Wang JG, et al. Risks of untreated and treated isolated systolic hypertension in the elderly: meta-analysis of outcome trials. Lancet 2000; 355:865–72. 14. Cushman WC, Evans GW, Byington RP, et al. Effects of intensive blood-pressure control in type 2 diabetes mellitus. N Engl J Med 2010; 362: 1575–85. 15. Appel LJ, Wright JT Jr., Greene T, et al. Intensive blood-pressure control in hypertensive chronic kidney disease. N Engl J Med 2010; 363: 918–29. 16. JATOS Study Group. Principal results of the Japanese trial to assess optimal systolic blood pressure in elderly hypertensive patients (JATOS). Hypertens Res 2008; 31:2115–27. 17. Ogihara T, Saruta T, Rakugi H, et al. Target blood pressure for treatment of isolated systolic hypertension in the elderly: valsartan in elderly isolated systolic hypertension study. Hypertension 2010;56: 196–202. 18. Benavente OR, Coffey CS, Conwit R, et al. Blood-pressure targets in patients with recent lacunar stroke: the SPS3 randomised trial. Lancet 2013; 382:507–15. 19. Wright JT Jr., Bakris G, Greene T, et al. Effect of blood pressure lowering and antihypertensive drug class on progression of hypertensive kidney disease: results from the AASK trial. JAMA 2002; 288:2421–31. 20. Iseki K, Miyasato F, Tokuyama K, et al. Low diastolic blood pressure, hypoalbuminemia, and risk of death in a cohort of chronic hemodialysis patients. Kidney Int 1997; 51:1212–7. 21. Port FK, Hulbert-Shearon TE, Wolfe RA, et al. Predialysis blood pressure and mortality risk in a national sample of maintenance hemodialysis patients. Am J Kidney Dis 1999; 33:507–17. 22. Kovesdy CP, Bleyer AJ, Molnar MZ, et al. Blood Pressure and Mortality in U.S. Veterans With Chronic Kidney DiseaseA Cohort Study. Annals of Internal Medicine 2013; 159:233–42. 23. Yusuf S, Teo KK, Pogue J, et al. Telmisartan, ramipril, or both in patients at high risk for vascular events. N Engl J Med 2008; 358:1547–59. 24. Bangalore S, Messerli FH, Wun CC, et al. J-curve revisited: An analysis of blood pressure and cardiovascular events in the Treating to New Targets (TNT) Trial. Eur Heart J 2010; 31:2897–908. 25. Ruggenenti P, Perna A, Loriga G, et al. Blood pressure control for renoprotection in patients with non-diabetic chronic renal disease (REIN-2): multicentre, randomised controlled trial. Lancet 2005; 365:939–46. 26. Verma S, Gupta M, Holmes DT, et al. Plasma renin activity predicts cardiovascular mortality in the Heart Outcomes Prevention Evaluation (HOPE) study. Eur Heart J 2011; 32:2135–42. 27. Koebnick C, Langer-Gould AM, Gould MK, et al. Sociodemographic characteristics of members of a large, integrated health care system: comparison with US Census Bureau data. Perm J 2012; 16:37–41. 28. Bhandari SK, Pashayan S, Liu IL, et al. 25-hydroxyvitamin D levels and hypertension rates. J Clin Hypertens (Greenwich) 2011; 13:170–7. 29. Levey AS, Stevens LA, Schmid CH, et al. A new equation to estimate glomerular filtration rate. Ann Intern Med 2009; 150:604–12. 30. Sim JJ, Bhandari SK, Shi J, et al. Characteristics of resistant hypertension in a large, ethnically diverse hypertension population of an integrated health system. Mayo Clin Proc 2013; 88:1099–107. 31. Sim JJ, Bhandari SK, Shi J, et al. Plasma renin activity (PRA) levels and antihypertensive drug use in a large healthcare system. Am J Hypertens 2011; 25:379–88. 32. Sim JJ, Handler J, Jacobsen SJ, Kanter MH. Systemic implementation strategies to improve hypertension: the Kaiser Permanente Southern California experience. Can J Cardiol 2014; 30:544–52. 33. Go AS, Chertow GM, Fan D, MCCulloch CE, Hsu CY. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. N Engl J Med 2004; 351:1296–305. 34. Zanchetti A. Blood pressure targets of antihypertensive treatment: up and down the J-shaped curve. Eur Heart J 2010; 31:2837–40. 35. Perry HM Jr., Davis BR, Price TR, et al. Effect of treating isolated systolic hypertension on the risk of developing various types and subtypes of stroke: the Systolic Hypertension in the Elderly Program (SHEP). JAMA 2000; 284:465–71. 36. Cooper-DeHoff RM, Gong Y, Handberg EM, et al. Tight blood pressure control and cardiovascular outcomes among hypertensive patients with diabetes and coronary artery disease. JAMA 2010; 304:61–8. 37. DeFelice A, Willard J, Lawrence J, et al. The risks associated with short-term placebo-controlled antihypertensive clinical trials: a descriptive metaanalysis. J Hum Hypertens 2008; 22:659–68. 38. Diao D, Wright JM, Cundiff DK, Gueyffier F. Pharmacotherapy for mild hypertension. Cochrane Database Syst Rev 2012; 8:CD006742. 39. James PA, Oparil S, Carter BL, et al. 2014 Evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA 2014; 311:507–20. 40. Romero-Corral A, Montori VM, Somers VK, et al. Association of bodyweight with total mortality and with cardiovascular events in coronary artery disease: a systematic review of cohort studies. Lancet 2006; 368:666–78. 41. Diehr PH, Thielke SM, Newman AB, Hirsch C, Tracy R. Decline in health for older adults: five-year change in 13 key measures of standardized health. J Gerontol A Biol Sci Med Sci 2013;68:1059–67.  Keyword(s): Bajarpresión arteriallímite #### Healthcare's Future-Ready IT Platforms ### Building Future-ready IT Platforms To keep pace with healthcare’s evolving landscape, IT systems must be scalable, adaptable and secure. Few industries face the magnitude of change that healthcare is undergoing today. Accelerated in the U.S. by sweeping and ongoing reforms, a radical transformation is taking place globally, driven in large part by the well-documented rise in chronic diseases and aging populations. These demographics, combined with rising costs, are colliding with fiscal realities, causing healthcare spending to consume an ever-increasing portion of the world economy, widely seen as unsustainable. Please read the attached whitepaper.  Keyword(s): HealthcareFuture-readyIT Platforms #### The House Call of the Future ### The House Call of the Future – Breakaway Thinking The following is a guest blog post by Jennifer Bergeron, Learning and Development Manager at The Breakaway Group (A Xerox Company). Check out all of the blog posts in the Breakaway Thinking series. The closest I’ve come to experiencing a house call was watching Dr. Baker on “Little House on the Prairie” visit the good folks of Walnut Grove. Today, most people have no choice but to trek to their doctors’ offices and hospitals for health maintenance, diagnoses and check-ups. But new technologies are returning the personalized attention of the house call and will need to be adopted to retain the convenience and accessibility they offer. I haven’t met anyone with a practice like Dr. Baker’s, though I recently read a news article that highlights the comeback of the house call. Some practitioners are banding together to provide round-the-clock care to patients who benefit from the fast response and lower cost: If a deductible or copay is higher than the price of the doctor’s visit, the patient may opt for the home visit.(1) The updated versions of the house call, however, are born of the technology used for telehealth, mobile health and health stations. Telehealth allows a person to connect with a provider via the Internet. Patient and doctor can video conference, share informational media, and experience a face-to-face interaction without either party traveling from his or her home or office.(2) This allows patients better access to specialists who may have been too far away to visit and more frequent care at the right time to reduce the chances of serious complications or hospitalization. For patients who require frequent care over time, telehealth enables them to receive the medical attention they need while staying near their support network.(4) For providers, access to networks of specialists who can provide remote consultation helps them retain and ensure the highest level of care for patients rather than refer patients to another location.(3) Both patients and providers also save time and money when there is no commute to an office or to a patient’s home. This is especially true of patients who live in rural areas and have to travel long distances for care. The quicker a patient can connect with the right specialist to treat or prevent serious illness, the lower the overall cost of care. (3) Mobile health, or mHealth, takes technology one step further by allowing providers to track and monitor patient health on mobile devices such as tablets or phones. This includes monitoring devices that measure heart rate, blood pressure, oxygen levels, blood glucose and body weight. mHealth can be used in the office or taken on the road the way mobile clinics do. When healthcare is mobile, the ability to bring a doctor’s office to a neighborhood gives access to communities that otherwise wouldn’t seek or know how to find care. Currently, all 50 U.S. states have mobile clinics.(4) Another trend in the making is the health kiosk. These look like private pods, about the size of four phone booths side by side. Think of it as telehealth combined with a mobile clinic. HealthSpot, a provider of health kiosks, describes them as “the access point to better healthcare.”(5) In addition to providing interaction with healthcare professionals via video conferencing, each station has an attendant and an automatic cleaning system. HealthSpot aims to give patients a private, personal, efficient experience. Healthcare is on the move to better accommodate our lives, schedules, family structures and communities, which have vastly evolved from the “Little House on the Prairie” days and even from a decade ago. At the same time, our industry faces challenges in making the new technologies simple to use in order for them to be effective. With telehealth, for example, people typically need help setting up a home system and technical assistance. Meanwhile, providers face communicating and documenting in a new environment. As we enter this new, modern, faster era of healthcare, both patients and providers will need to learn how to implement and adopt new systems, technologies and ways of interacting. Easing adoption is what we are prepared to do at The Breakaway Group. Once the learning-and-comfort curve is overcome, patients can experience the convenience of Dr. Baker’s updated home visit. References: (1) Godoy, Maria, (December 19, 2005). A Doctor at the Door: House Calls Make Comeback. (2) Health Resources and Services Administration Rural Health, (2012). Telehealth. (3) Hands on telehealth, (2013). 15 Benefits of telehealth. (4) Hill, C., Powers, B., Jain, S., Bennet, J., Vavasis, A., and Oriol, N. (March 20, 2014). Mobile Health Clinics in the Era of Reform. (5) The HealthSpot Station. Xerox is a sponsor of the Breakaway Thinking series of blog posts. Related Posts: John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 15 blogs containing almost 6000 articles with John having written over 3000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 14 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John launched two new companies: InfluentialNetworks.com and Physia.com, and is an advisor to docBeat. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and Google Plus. Healthcare Scene can be found on Google+ as well.  Keyword(s): House Call #### The Home Microbiome Project ### The Home Microbiome Project #### BACTERIA FROM NEW RESIDENTS POPULATE HOMES WITHIN ONE DAY, ACCORDING TO STUDY Written By: David J. Hill Worried about leaving a digital footprint behind? Your bacterial footprint could be much worse and even incriminating. Recently, researchers traced the microbes that live on and around people within their homes. Findings from the study showed that the composition of indoor microbe communities is significantly affected by people and changes rapidly with their presence or absence. For example, after three of the families moved into new homes, it took less than 24 hours for the microbes to spread, to the extent that the new home looked microbially the same as the previous home. One of the couples who moved had been staying in a hotel–their new home was rapidly populated with the microbes from the hotel room. The results serve as another insight into a complex relationship between humans and the bacteria that live in, on, and around us. We want to know where these bacteria come from,” said microbiologist Jack Gilbert, who led the study at Argonne National Labs as part of the Home Microbiome Project, in the press release. “As people spend more and more time indoors, we wanted to map out the microbes that live in our homes and the likelihood that they will settle on us.” The Home Microbiome Project is an initiative aimed at uncovering the dynamic co-associations between people's bacteria and the bacteria found in their homes.The hope is that the data and project will show that routine monitoring of the microbial diversity of your body and of the environment in which you live is possible. The research, recently published in the journal Science, was conducted over the course of six weeks. Participants included 18 people within 7 diverse American families that were recruited on Twitter for the study. There were even three dogs and one cat in the mix. Participants swabbed their hands, feet, and noses daily as well as various surfaces in their dwellings, such as light switches, doorknobs, countertops, and floors. The samples were then sent to Argonne for DNA analysis. The composition of bacteria was most similar on hands, given the number of common surfaces people share, while noses showed more unique compositions. Furthermore, closer relationships showed more microbe sharing–whether between couples or even parents and their young children. In one instance, bacteria called Enterobacter (known to infect immunocompromised individuals) was traced passing from one person’s hand to a countertop then to another person’s hands. The researchers commented that though we may be exposed to pathogens routinely, disease may only result when the immune system is disrupted in some way. Mounting evidence suggests that the human-microbiome relationship may affect physical and mental health, such as obesity, along with development. In one recent study,gut bacteria from thin and obese mice can induce weight loss or gain in normal mice. “We know that certain bacteria can make it easier for mice to put on weight, for example, and that others influence brain development in young mice,” Gilbert said. “They are essential for us to understand our health in the 21st century.” Unravelling the mystery of the human microbiome will take some time due to the complexity of the composition. One startup called uBiome recently raised$4.5M from investors to sequence the human microbiome after bringing in $350,000 via a crowdfunding campaign in 2012. Scientists recently reported that 10 million genes of the microbiomehave now been sequenced. Along with considering the health implications of these findings, the researchers noted that our microbiomes were characteristic, meaning that the microbial composition is enough to identify at least the family that left it behind. Hence, microbiome analysis could be helpful in forensics. Because the microbial community changes after a person leaves a house, “You could theoretically predict whether a person has lived in this location, and how recently, with very good accuracy,” Gilbert said. Though it will take a number of years for the microbiome to be understood, the implications of this research are deep. With all the attention in the world of technology on data to understand everything about humans, it may be the tiniest of living things that speak volumes. [Media credit: Home Microbiome Project/Argonne National Lab, Human Genome via Science] This entry was posted in Longevity And Health and tagged Argonne National Labsbacteriaforensic toolshome microbiome projectmicrobiome,uBiome.  Keyword(s): Home Microbiome Project #### Public Mission-Critical Apps ### Taking mission-critical apps public requires a strong cloud SLA ##### A solid service-level agreement is your best line of defense when migrating mission-critical applications to public cloud. Can your SLA withstand the seemingly insurmountable roadblocks? The loss of some IT control is one of the most difficult transitions for a business to make when moving to the cloud. There is a distinct loss of visibility into the provider's infrastructure, which makes workload performance monitoring difficult -- if not impossible. Some amount of service downtime is unavoidable as the provider maintains and upgrades its own facilities. And the continuing trend toward automation and self-service can limit the response times or escalation paths for some cloud support intervention. All of these concerns have traditionally been insurmountable roadblocks for mission-critical applications. In order for mission-critical workloads to really work in a public cloud setting, businesses must first determine the actual amount of downtime that is tolerable. This is the amount of downtime that you can live with for this important application -- it's not the amount of downtime you currently experience or the amount of downtime that you might prefer. This requires some honest self-assessment, but as long as the cloud provider's service-level agreement (SLA) guarantees less downtime than you're prepared to tolerate, moving the workload to a public cloud should not put the business at undue risk. For example, Microsoft Azure notes an availability of 99.95% -- about 21 minutes per month of downtime. It may be possible to further mitigate downtime by selecting a cloud service that is geared for important workloads, such as VMware's vCloud Air Dedicated Cloud. Such services may be able to migrate important workloads to other servers or make other arrangements for continuity before maintenance or upgrade cycles, but get those services and associated guarantees in writing in your cloud SLA. The actual reporting of uptime can itself be problematic, so evaluate and understand the provider's cloud SLA reporting policies and processes and know how they measure adherence to uptime guarantees. Look for providers that allow outside monitoring and reporting to verify uptime, and avoid providers that put the onus on users to prove downtime. #### Even though the idea of mission-critical workloads in the cloud is gaining acceptance, it's far from ubiquitous. Next, have a clear understanding of the provider's support contact options and escalation paths. For example, look for features like 24/7/365 live telephone support from a provider handling your critical workloads and know how quickly problems can be elevated to a senior administrator or engineer. By contrast, if the only available support is through a self-service portal or an email address routed to a remote time zone, chances are that you might not get the timely support your important application demands. Test the provider's support regularly and stay abreast of any changes in support policy or availability. Remember that technical support may carry an additional cost. For example, Microsoft Azure carries a separate cost of$29 per month for all generally available services.

Even though the idea of mission-critical workloads in the cloud is gaining acceptance, it's far from ubiquitous. Some applications are simply so important that they require extraordinary deployments -- like multi-node and distributed clusters -- to effectively eliminate downtime under all but the most cataclysmic situations. In these cases, it may be best to forgo the cloud and continue hosting the workload on-premises.

Stephen J. Bigelow is the senior technology editor of the Data Center and Virtualization Media Group. He can be reached at sbigelow@techtarget.com.

 Keyword(s): PublicMission-Critical Apps

### Five steps to moving mission-critical applications to the cloud

#### Some enterprises see migrating mission-critical apps to public cloud as an insurmountable obstacle. But, common sense precautions can smooth the transition of even the most crucial workloads.

The public cloud has emerged as a popular hosting alternative for some enterprise applications. The cloud promises rapid provisioning and vast scalability -- perfect for bursting resource-hungry workloads without putting undue strain on local data centers. However, hybrid and public cloud deployments have routinely been reserved for low-priority, test and development applications, or general-purpose business apps where some amount of downtime is tolerable.

Mission-critical workloads have typically been left on-premises, where dedicated administrators and infrastructure can ensure continued availability without compromise. This philosophy has started to change today as more organizations entrust criticalapplications to public and hybrid cloud providers. But before migrating a vital business workload to the cloud, it's important to weigh the risks and address the challenges involved.

Ultimately, computing is taking on the character of a utility, and the idea of hosting a mission-critical application in a public or hybrid cloud is becoming a more acceptable notion. But there are still serious hurtles that can torpedo the initiative in some situations. Don't rush vital workloads to the public cloud – instead, follow through on these five crucial steps before any migration.

Never make a commitment to a cloud provider until you have read every word of the cloud service-level agreement (SLA). Your chosen provider should spell out specifics about uptime -- a vital element for critical workloads. However, it's not all about performance. Companies must also ensure that compliance regulations are met, and remember that this burden doesn't fall entirely on your provider. Don't put pen to paper until you're happy with the contract and are comfortable trusting your mission-critical apps to this provider.

#### Keep cloud costs in budget

It costs money to keep mission-critical apps running, particularly if you don't do your due diligence before migrating. During the cloud planning stages, look into your application's resource usage, the CPU, memory, disk and network I/O. Then, take the steps to make sure that these variations won't break your budget when aligned with a provider's pricing structure.

#### Prepare for disaster to strike

As IT pros have learned again and again, you must always expect the unexpected. Disaster can strike even for the strongest cloud environment. This is why, in order to keep your critical workloads running, you need to ask the right questions about your cloud provider's disaster recovery protocols.

#### Know how to break up with your cloud provider

Sometimes things just don't work out. There are many reasons to end a relationship with your cloud provider, but it's what happens next that's most crucial. Always give yourself an out, particularly when you're working with mission-critical apps, and be ready to return the application in-house or move it to a better provider as needs and opportunities dictate.

Stephen J. Bigelow is the senior technology editor of the Data Center and Virtualization Media Group. He can be reached at
sbigelow@techtarget.com.

 Keyword(s): Movingmission-critical applicationscloud

### Dime-sized device can separate healthy and cancerous cells

#### The microfluidic instrument employs sound waves to sort cells

MIT scientists have developed a dime-sized microfluidic device that can sort rare cancer cells from healthy ones using sound waves--an innovation that could have applications for cancer diagnosis, drug discovery and clinical research.

"Acoustic pressure is very mild and much smaller in terms of forces and disturbance to the cell. This is a most gentle way to separate cells, and there's no artificial labeling necessary," MIT researcher and study co-author Ming Dao said in a MIT news release.

The team, also comprising scientists from Carnegie Mellon and Penn State, managed to separate healthy cells from cancerous ones by running acoustic sound waves across the device's microchannel so that they met at an angle, creating a line of low pressure. Upon encountering the low pressure while flowing through the microchannel, the cancerous and noncancerous cells separate onto either side of the channel. The separation occurs based on different cellular properties such as cell size and compressibility, MIT explains.

The device was able to sort 71% of breast cancer cells from white blood cells. The team has filed a patent on the device. Next, the researchers plans to test the device using the actual blood of cancer patients, to see how it performs at separating the cells in clinical settings, according to the news release. More details are available in the Proceedings of the National Academy of Sciences.

"If you can detect these rare circulating tumor cells, it's a good way to study cancer biology and diagnose whether the primary cancer has moved to a new site to generate metastatic tumors," Dao said in the release.

Microfluidic devices aim to create a "lab-on-chip" by acting as platforms that mimic biological systems in a simplified, in vitro (outside the body) setting.

The journal Microfluidics and Nanofluidics describes microfluidics as "the study of mass (including molecular and colloidal) and momentum transfer, heat transfer, and reactive processes, coupled with transport in microscale and nanoscale systems."

The FDA's device arm is encouraging the creation of in vitro models for medical device development and assessment through the launch of a pilot program to validate research tools such as this one. However, in this case, the new device is likely to prove most useful as a tool for drug development or cancer diagnosis.

- read the MIT news release
- here's the study abstract in PNAS
read the article in its entirety (PDF)

 Keyword(s): Dime-sized deviceseparatehealthycancerouscells

### Moody's: Non-profit hospitals see constricted revenue growth

No benefit from ACA until 2015

 Keyword(s): Non-profithospitals

### Apple tightens health data privacy rules ahead of HealthKit launch

 Keyword(s): AppleHealthKit

#### MOBILITY STRATEGIES IN HEALTHCARE 2014

The rise in mobile device usage in hospitals brings the potential for faster communications that can improve patient care. With smartphone and tablet usage, however, come concerns about information security and questions about access to different types of information. These questions are prompting many hospitals to develop mobility strategies detailing how these devices can be leveraged, who pays for them, and more. In June 2014, Spok surveyed more than 600 healthcare organizations to take a snapshot of this trend and see how far along hospitals are in devising their strategies. Survey participants were from hospitals of all sizes across the globe and included leadership in clinical, IT, and telecommunications departments. Thank you to all who participated - your input is greatly appreciated.

 Keyword(s): MOBILITY STRATEGIESHEALTHCARE2014

### Are EHRs Life Savers? Maybe So, According to Preliminary Research

by Rajiv Leventhal

Can the adoption and implementation of electronic health records (EHRs) be tied to hospital performance and lowered mortality rates? While we might be a bit of time away from being able to make that precise claim, new research does suggest a measurable beneficial relationship.

The findings were revealed by HIMSS Analytics, the research arm of the Healthcare Information and Management Systems Society (HIMSS), and Healthgrades, an online resource for comprehensive information about physicians and hospitals. The value of EHRs has long been discussed, but until now evaluations have lacked comprehensive clinical data, according to HIMSS officials.

Using HIMSS Analytics’ Electronic Medical Record Adoption Model (EMRAM) and mortality rate measures collected by Healthgrades across 19 unique procedure and condition based clinical cohorts, the analysis found that hospitals with advanced EHR capabilities (as reflected in high EMRAM scores) demonstrated significantly improved actual mortality rates, most notably for heart attack, respiratory failure, and small intestine surgery.

Most cohorts experienced improvement in predicted mortality rates when compared to hospitals with lower EMRAM scores. The predicted mortality rate is an indicator of the level of documentation and capture of patient risk factors that are correlated to increased risk of mortality.  In total, 4,583 facility records were selected from the HIMSS Analytics database, representing the total number of facilities with complete data from 2010 through 2012.

Collecting the Data

One such facility that participated in the study was the Charlottesville-based University of Virginia Health System, which includes a 604-bed hospital, Level I trauma center, cancer and heart centers, and primary and specialty clinics throughout central Virginia. According to UVA Health System’s CIO, Richard Skinner, who is also a board member for HIMSS Analytics, while the EMRAM model has enabled healthcare systems to see where they rank as far as EHR maturity, any kind of data that describes the impact of implementing an EHR on clinical performance has been missing until now. “The reason for this study was to describe potential benefits from the EHR, and preliminary results say there are benefits,” Skinner says.

For years, HIMSS Analytics has collected a very detailed data set from each hospital in the U.S. with the exception of some very small ones; the model has very specific criteria for which capabilities a facility needs to have for each stage (0-7) on the scale. “Every year, [HIMSS] will call someone from each hospital and ask them to renew that data set. They ask questions such as, ‘Do you have an electronic medical administration record and do you do CPOE (computerized physician order entry)’, for example. With all of that data in hand, HIMSS can then say Hospital A is at Stage 4,” says Skinner.  Then, Healthgrades takes Centers for Medicare & Medicaid Services (CMS) data and looks at people who have died in a specific facility, and CMS’ grading of if those people in the aggregate were expected to have died given their diagnoses and so forth, Skinner says.

Early Implications

According to Skinner, to date, the study has shown that those facilities that are higher on the EMRAM (in Stages 6-7) have a better ratio of actual mortality to expected mortality than do hospitals that are lower down on the scale. But Skinner does say that a deeper dive of the data is coming, and that the analysis is very preliminary. “We don’t know why that is yet, but to date that’s what the data has showed us. And you might ask about other factors—‘Are the ones higher on the EMRAM better funded, bigger, and in urban areas?’ There are a host of factors that can come into play. But again, the preliminary data shows a correlation between mortality rate and implementation of EHRs,” says Skinner.

As of today, the study hasn’t gotten down to institutional level to see what happened at a given organization, Skinner says. “And it might not, because the power of the study is the size of the sample’ and it’s the size that enables being able to discover the correlation,” he says.”If you did it at one hospital, there would be so many other variables that statistically, you couldn’t make that association.”

At UVA Health System, Skinner says he has looked at the organization’s clinical performance indicators over time and whether they are improving or not. “For some of those indicators, it’s clear there is at least an association with having better data and having that data in front of clinical decision makers. For others, it’s hard to tell, he says. “Things like urinary tract infection (UTI rates) are getting markedly better, but is that all because of EHRs? No, but you can credit the EHR with at least being able to expose the data and communicate it effectively.”

Skinner says that the reason why such evaluations have lacked comprehensive clinical data is two-fold. First of all, the EHR is a relatively new phenomenon, as most organizations have only implemented a comprehensive EHR in the last few years, and getting it to operate effectively takes some time, he says. The second factor is that the contributing factors to an improvement in clinical performance are, even in the simplest cases, “numerous and interrelated.” So analytically, Skinner says, “It’s difficult to figure out what the most causative variable happen s to be in improvement in expected mortality, or whatever it is that you’re trying to measure. I think the message to the industry is that for hospitals with EHRs, there exists great potential to get further benefits from these tools as we mature in figuring out how to use them,” he says.

Richard Skinner

Skinner adds that he feels confident in saying there is a “statistical” correlation between advanced EHR capabilities and improved mortality rates. “But again, what part of that correlation is causative awaits further analysis of the data and is not in the preliminary report. All we can say at this point is that there is a correlation. Now, intuitively, it stands to reason that further analysis will filter out those other variables to get to the real contribution to having an EHR.”

What’s more, Skinner does say that the results so far are exactly in line with what he expected. “Of course I am a biased CIO who has a stake in this business,” he says. “But organizations that have spent billions in the aggregate to implement EHRs obviously have the same expectations. While meaningful dollars play a role in that, the entire industry has the expectation that having better information better organized in front of clinical decision makers will lead better results. This study indicates that we’re starting to see that.”

Skinner says he feels that it’s important for the industry to demonstrate this not only because of the magnitude of the investment that’s already been made, but also because there is a huge amount of work left to make truly optimal use of these tools to improve performance. “That’s the hill we are climbing as an industry,” he says.

Clearly a proponent of EHRs, Skinner says that those who criticize the technology for not providing clinicians enough value might not be accurately measuring what the “value” really is. “It may be that a specific clinician hasn’t found much value to him or her, but that doesn’t mean his or her use of the EHR hasn’t proved value to the patient, to the institution as a whole, or to other parts of the institution,” he says.

Skinner notes that the case is easier to make at the organizational level than it is than it is at the individual physician level. “Providers do have a point in that they are being asked to do more and put their hands on a tool they never had to worry about. So there’s no question they have acquired added burdens. But the real question is, ‘Has the institution and its patients gotten sufficient benefit to justify that extra burden?’”

 Keyword(s): EHRsLife Savers

### Will (Human) Radiologists Be Turned Into Digital Apps? Don’t Worry, It Won’t Be Like That

by Mark Hagland

It was fascinating to read a rather existential blog written by Douglas G. Burnette, Jr., M.D., a practicing radiologist, in the online edition ofDiagnostic Imaging.

In his August 22 blog, Dr. Burnette says this: “Radiologists along with the rest of society are becoming digitally detached and the more detached we are, the harder it is to assert our value. Our virtual omnipresence and digital efficiency may have sown the seeds of our destruction.”

Further, “Have you noticed how often websites offer live chats lately?” he asks. “I believe that while this is a very efficient way to communicate, it also removes the barriers and stigma of language and ethnicity from the exchange of information. The frustration of dealing with someone in a phone bank in India is gone. It will be just that easy to replace us someday.”

Then, Burnette asks, “What do we offer to counter this? Radiology services are being effectively commoditized. I admire the efforts to educate the public and put our best face forward to patients and referring physicians. Unfortunately, in today’s busy practice, it is rarely practical to speak directly with patients on a routine basis. I have found that my pace has gradually increased to cope with peak work flow times and I am unable to slow the pace even when there is a lull in the action.”

What Burnette worries about—quite legitimately—is this: “Radiology services are rapidly becoming commoditized.”

Thus, arguably the most technology-focused and technology-enabled medical specialty is facing a rather existential conundrum: the same advances in medical, imaging, and information technology that have made radiologists hyper-efficient have also potentially made their specialty the very easiest (and one of the few in actuality) to offshore.

And Burnette is far from the only radiologist pondering the place of himself and his colleagues in the emerging healthcare. How will radiologists show their value to their referring physician peers? Inevitably, with offsite, sometimes offshore, radiologic studies having become commonplace, how can those radiologists affiliated with hospitals, medical groups, and integrated health systems feel themselves integrated with their physician colleagues anymore?

In fact, Burnette concludes his blog with this thoroughly pessimistic statement: “Over the years it has been difficult to earn the respect of my medical colleagues even to the extent on occasion of having to assert that I am a real doctor not a technologist. I suspect that as medicine evolves or devolves (depending on your point of view) we may, indeed, become essentially technologists. One day we may even become an app on a digital device—the ultimate in digital detachment.”

That viewpoint seems a bit dystopic to me. But what is true is that radiologists need to begin to concretely demonstrate their value to the care delivery process in their organizations. Back in December of 2013, Rasu Shrestha, M.D., vice president of medical information technology and medical director for interoperability and imaging informatics at the vast University of Pittsburgh Medical Center (UPMC) health system, told me this, about radiologists in the new healthcare:  “[L]et’s focus on two challenges. One challenge is that of what I call efficiency pressures; everyone is being challenged to do more with less. And the other type of pressure is quality of care pressures. And that means you’re being challenged to make sure to give the appropriate treatment to a patient at the point in time of care. So even if we focus on these two specific challenges, for that average Joe radiologist or chief of radiology or CMO—the average radiologist knows he’s being judged on his throughput and productivity. But what that’s evolving into is being measured on value.”

As Dr. Shrestha went on to say, “The problem is that in today’s siloed systems, it’s very difficult to measure real value. So you have metrics that say, I read 40 studies and yesterday, I read 50. Does that make me less valuable? If the outcomes were better today, and I was able to close the loop better with the ordering physician, or able to communicate test results more efficiently, that’s value. And without data liquidity, if the transformation of healthcare is in the balance, we need to have the right metrics in place. So what’s my value score at a particular point in time? Where are my peers, and what’s my target? I need a dashboard and I need it to be ingrained into the fabric of my workflow.”

And that’s where CIOs, CMIOs, CTOs, directors of imaging informatics, and other healthcare IT leaders need to step in, both to support radiologists in their work, and to partner collaboratively across all medical specialties, to help shift patient care organizations towards new, value-driven missions and visions. Will such efforts towards shifting the fundamental mentality of healthcare organizations and the healthcare system be difficult? Of course they will.

But radiologists won’t be alone in this. Instead, everyone will be in this together, as the healthcare system begins to move forward in this conceptual shift—one with a very strong practical component—away from a purely volume-based incentive system to one based on a combination of volume, efficiency, and true value. And inevitably, what radiologists do and how they work, will be impacted very strongly by that shift, going forward.

 Keyword(s): Radiologists Be Turned Into Digital Apps

### Reader/CHIME survey reveals 12 ICD-10 delay surprises

#### SearchHealthIT survey results show varied responses, and measures the financial impact of delaying ICD-10 until 2015.

As varied as one can imagine the providers in the U.S. healthcare system, so is the impact of Congress's forcing CMS to levy an ICD-10 delay. While some welcome the extra time, others find Congress's gambit onerous in cost and inconvenience, according to survey results conducted over six weeks in July and August.

The SearchHealthIT reader survey, in cooperation with the College of Healthcare Information Management Executives (CHIME) drew 326 responses, 269 of them were IT workers at healthcare providers as well as 57 more from payers and accountable care organizations.

Some of the surprises may catch even seasoned ICD-10 experts and observers off-guard, as they reveal a healthcare system quite divided over the implementation of the diagnostic coding language:

1. More than 59% of respondents indicated they have not begun testing.

2. Of that 59%, more than three quarters have not yet completed software upgrades on their networks to support ICD-10.

3. The good news: 11% of respondents indicate they're ready for ICD-10.

4. The ICD-10 delay will incur additional consultant retainer costs for 41% of respondents, which will take away resources from other health ITimplementation initiatives because there was no budget for such cost runovers.

5. How much will that cost? While 10% of respondents indicated less than $10,000, 45% said more. Gauging the final tally won't happen until much later, as another 45% couldn't yet estimate what the delay will add up to in dollars. 6. Respondents are divided on whether the ICD-10 helps or hurts. Some 37% said it would help, 23% said it will worsen preparedness efforts and a full 40% said it will neither help nor hurt. Respondents that feel positively about the ICD-10 delay will use their time making these improvements (they could select more than one). 7. Similarly, 55% said the ICD-10 delay won't allow for IT staff to implement more IT systems for better documentation, coding, etc. But 45% will. 8. For the 45% that indicated it will help them implement ICD-10 more thoroughly, half said clinical documentation systems would be improved, and half said they would be able to conduct more sophisticated ICD-10 testing. 9. Happy about the delay? Then you're with the majority of respondents -- but it's not a landslide by any means (56%-44%). 10. Two-thirds indicated the ICD-10 delay will not negatively affectmeaningful use stage 2 attestation. 11. However, 31% said they will consider skipping a year of stage 2 incentivesto make ICD-10 work, because there aren't enough resources to accomplish both. 12. Respondents were split 52%-48% as to whether or not they believe ICD-10 will be further delayed beyond 2015. The "yes it will be delayed again" camp squeaked out a slim majority. Let us know what you think about the story; email Don Fluckinger, news director or contact @DonFluckinger on Twitter. Link: http://searchhealthit.techtarget.com ### Hackensack CIO tells personal tale of health data interoperability woe Editor's note: This podcast and a companion interview with Michael Archuleta, director of IT and PACS administrator for Mt. San Rafael Hospital in Trinidad, Colorado, respond to the results of the 2014 Health IT Purchasing Intentions Survey from SearchHealthIT.com and the College of Healthcare Information Management Executives (CHIME). Download your copy here. Shafiq Rab is an M.D., as well as the VP and CIO of Hackensack University Medical Center in New Jersey. More importantly, he's a husband and father. In the days leading up to this podcast interview, one of Rab's family members had a healthcare episode that started out looking like an emergency situation but that turned out to be nothing more than a close call. While all's well that ends well, Rab found out firsthand about the very real health data interoperability woes in the U.S. healthcare system, as he struggled to get an EKG from one provider to another. He finally took matters into his own hands by shooting a picture of the EKG with his smartphone and texting the picture back to a Hackensack cardiologist himself. It led Rab to declare at the HealthImpact East conference that you should keep copies of your medical records on your smartphone for now, "if you want to live." This story and some of Rab's other opinions -- informed by his recent personal foray into the nuts and bolts of health data interoperability -- feature heavily in this podcast. We discuss the many health IT requirements for meaningful use stage 2, ICD-10 implementation, the ramifications of the ICD-10 delay, and 2014 and 2015 ONC certification standards. More importantly, we also cover how a CIO can budget for all the tech transitions currently piling up for U.S. healthcare providers. ### Download this podcast Let us know what you think about the story; email Don Fluckinger, news director, or contact @DonFluckinger on Twitter. Link: http://searchhealthit.techtarget.com #### App and Desktop Virtualization ### The Rising Value and Falling Cost of App and Desktop Virtualization When vendors compete, desktop virtualization customers win. Moore’s Law and market forces lead to better solutions at a lower cost. The rapid increases in computing power described by Moore’s Law offer theoretical advantages for IT organizations—but it’s market competition that translates those benefits into real value. As vendors battle for market share, costs are falling for every part of the desktop virtualization architecture. Meanwhile, desktop virtualization technology itself is advancing quickly, providing new ways to enable business mobility and enabling the flexibility that people and organizations need to thrive. This trend is a double win for customers—better solutions at a lower cost—and it’s making the benefits of a service-based approach to IT available to any organization. No longer just for early adopters and innovators, desktop virtualization has become a mainstream IT strategy for companies of all sizes. As business mobility and cloud computing transform IT, desktop virtualization enables the transition to IT. Able to meet the needs of users more effectively and securely wherever, however and on whatever device they work from, IT can better support the business while fulfilling its mission of innovation. Please read the attached whitepaper  Keyword(s): AppDesktopVirtualization #### Routers & Switches ### The Network Administrator's Guide to Routers & Switches Today's networks are facing trends like mobility, virtualization and cloud computing making today's network administrators rethink their router and switch designs. IT pros must not only choose the right products but understand current design trends, best practices and the top protocols to help make their networks efficient and resilient - for the long haul. Please read the attached whitepaper  Keyword(s): Network AdministratorGuideRoutersSwitches #### Future of Virtual Healthcare ### The Future of Virtual Healthcare #### 5 Questions for Dr. Douglas Wood, Mayo Clinic Publicado por mnblatt en Intel Health & Life Sciences ### Video The Mayo Clinic’s Center for Innovation will be holding its 2014 Transform Symposium Sept. 7-9. The event offers both in-person and online opportunities to participate. I will be part of an online panel discussion on Monday, September 8, from Noon to 1 p.m. CT, addressing virtual care with several experts from the Mayo Clinic, including Dr. Douglas Wood. A practicing cardiologist, Dr. Wood spends half his time seeing patients with complex cardiologic problems and the other half as the Medical Director for the Center for Innovation. I caught up with Dr. Wood recently to talk more about virtual care and where we’re headed in the future. #### Intel: What is the future of virtual healthcare? Wood: To Mayo Clinic, the future of virtual health is really the future of healthcare. Healthcare today is more illness care than anything else. Most often we wait for people to have symptoms or illnesses and then we have them come and see us in a clinic or an emergency room or a hospital. The technologies that are available now to enable virtual health can become tools for us to help people make good decisions about their health. Delivering care virtually, and in a different way from today, is really a fundamental aspect of healthcare of the future. #### Intel: How do we make the transition to virtual care? Wood: The transition from traditional models of care to virtual health is challenging for some physicians, and for some patients. After all, many physicians have been trained in a method of delivering care one person at a time during a 15-minute visit. We can be free of all of the problems related to that system by using new methods of care. Physicians should devote their time to patients who really need their expertise. For others, we could deliver care with a virtual visit or an email interaction. This gives us a chance to let physicians use their skills in the most productive way possible, and at the same time, allows patients to get their needs met in the most efficient way possible so that we don’t always make them come into the facility. #### Intel: What needs to be done to make virtual care a reality? Wood: Studies we’ve conducted showed us that physicians were really necessary for only about 6 percent of clinic interactions. A large number of the other interactions could have been provided by advanced practice nurses, physical therapists, pharmacists, dieticians, or even non-licensed people. A certain number of visits didn’t even need to occur in the context of going to a clinic. We could’ve delivered information to them at home, at school, or in the grocery store where they’re shopping. Our current system of care does not permit this to happen because we are constrained by our existing payment systems. Why should we stick to a system that creates so much generalized unhappiness when we have an opportunity to do something that would be much more satisfying, and more productive, for everybody—physicians, nurses, and patients? #### Intel: How is technology advancing the possibility of virtual care? Wood: Technology is a part of everything we do in the Center for Innovation. We are thinking about how we can improve an interaction that we have with a person coming for our care, and using different technologies to learn much more about them when they arrive. Right now we acquire information by listening and then parroting that data to a dictated format that’s not searchable and not useful. We need to use natural language processing or other kinds of technologies to make the information easier to acquire and analyze. Then we are helping physicians come to better decisions about what additional diagnostic studies or even treatments might be appropriate. #### Intel: Who will lead this effort toward virtual health? Will it be collaborative? Wood: It’s important to recognize that innovation is really collaboration, so partners are absolutely essential to success. We believe that innovation begins with fundamentally understanding the needs of people and then looking at ways that we can meet those needs. We don’t need to invent solutions that are already around. There are many technologies that we could adopt rapidly with little modification. There are other technologies that we would need to adapt. The point is we don’t need to spend our time in the Center for Innovation at Mayo Clinic doing any of that work. We instead should be looking for partners who can help us move faster with our implementation. So partners like Intel are absolutely critical to our success. On the other hand, we are concerned about blindly applying technologic solutions without really understanding what people need.  Keyword(s): FutureVirtualHealthcare #### Unnecessary Medical Imaging ### Up to$12B in Unnecessary Medical Imaging Is Wasted Annually

The United States wastes nearly $12 billion dollars on unnecessary medical imaging each year, according to a recent study by peer60 that explores new survey of 196 hospital leaders. Since 2012, the United States has spent at least$2.8 trillion on health care yearly.  But according to all the research reports and statistical data out there, the extra funds are not doing us any favors; most other developed countries have significantly lower costs.

Smart Data pioneer peer60 reached 196 healthcare leaders about medical imaging in less than two weeks and found a number of reasons for the squandered resources. Ninety-two percent of provider respondents said that defensive medicine is a key contributor to the problem, while 65 percent said that patient demand is also a factor. Other causes include physicians’ lack of familiarity with appropriate diagnostic tests.

Key Findings

Based upon this research:

• Reducing unnecessary imaging is a top strategic priority for a majority of providers.
• The cost of unnecessary imaging in the United States is at least $7.47 billion each year and may be as high as$11.95 billion annually, and even that metric may understate the problem.
• Defensive medicine is the most widespread cause of unnecessary imaging. Over 90% of hospital physician leadership said it was a prime contributing factor in unnecessary imaging.
• Patient demand also contributes significantly to unnecessary imaging according to 65% of physician leadership.
• A majority of surveyed physician leadership (60%) also indicated physicians being unfamiliar with appropriate diagnostic tests has significantly contributed to this unnecessary imaging.
• Very few providers feel they have developed a homegrown system to correct this problem.
• By and large, the solution to unnecessary imaging at hospitals has been through internal processes, rather than using an outside vendor.
• There is a huge opportunity for a vendor who can create a solution that will address unnecessary imaging, as almost all providers have expressed a need for it.

There is much more great information in the study, so please don’t hesitate to fill out the form below to download the full report. Alternatively, if you’re not a fan of online forms, just send a message to tpage@peer60.com and we’ll email the full report right back to you.

 Keyword(s): UnnecessaryMedical Imaging

### 5 Best Practices to Make Healthcare Innovation Partnerships Work

Healthcare innovation partnerships can make a huge difference in the way common ailments are regarded by the medical care community. By promoting efficient distribution of data and enhancing the ability to combine resources to gain a deeper perspective into these issues, such partnerships can play a major role to in furthering medical advancements. The collaboration of Merck Medical Information and Innovation M2i2 and online research community PatientsLikeMe is a case in point.

Sachin Jain, M.D., M.B.A

Entrepreneurs and start-ups are preferred partners for Merck because they have the ‘best technology that‘s out there and they bring the Silicon Valley DNA to the thinking process…’,says Sachin Jain.

The initial agenda of the partnership was to test how information on real world health outcomes assimilated by an online evidence network could impact drug development, with the original test community being psoriasis patients. However, it was found that the partnership did not really live up to expectations as data on outcomes was very limited. This is a risk that is inherent in such partnerships. Under the leadership of Chief Medical Information and Innovation Officer Sachin Jain, M.D., M.B.A., M2i2 turned the partnership around by shifting focus to another key area of interest, sleep deprivation. The initial disappointment and subsequent success gave Dr. Jain a unique insight into the following 5 best practices on leveraging collaborations/partnerships in healthcare.

#### 1) Sharing risk and responsibility with the partner judiciously

Risk and responsibility are both extensively involved in such partnerships and it is necessary to choose a partner organization that is trustworthy enough to be given due flexibility to work independently within its own space. The most important requirement is that your partner shares your commitment to arrive at valuable conclusion/inferences. At the same time, you have to demonstrate your reliability and adaptability to encourage your partner to reciprocate the same.

#### 2) Transparency is priority

Stealth innovation may be the preferred path for many, but at Merck, the partnership exercise clearly indicated that complete transparency was necessary for seamless continuation of research. Despite having to contend with red tape, transparency brings all of the key players on board in both the organizations involved in the partnership. This makes data accessing easy, allows for improved collaborative efforts, and enables the pooling of a wider set of skills to make data collection and analysis easier and more accurate. Transparency necessitates the establishment of strong guidelines that help immensely when significant changes need to be made in the partnership agenda.

#### 3) Measure progress against the objectives

Measuring the progress of the partnership against the original objectives allows you to view the success of the partnership objectively. In the case of the M2i2-PatientsLikeMe partnership, the initial lack of success prompted Dr. Jain to quickly switch over to another viable agenda instead of simply letting the partnership run its course and end up with data that was worth little to the company. Reviewing the success of the partnership and being ready to switch tracks or pull out is essential in the partnership game.

#### 4) A skilled team at the center makes a difference

To ensure that the partnership flourishes, joint effort from both organizations is necessary. This can happen only when skilled individuals are involved in the task at both ends. Collaboration needs to be carried out effectively, such as with said partnership where a Merck team member was working with the PatientsLikeMe weekly. This helped Merck derive quality results in minimum time despite the much smaller size and completely different business structure of PatientsLikeMe.

#### 5) Remain committed when your focus changes

With the M2i2- PatientsLikeMe partnership, both organizations quickly refocused and committed resources and support to the new agenda. A decline in enthusiasm may be inevitable when the focal point of such research and study suddenly changes, but it is up to the team leaders at both the partner organizations to keep the team motivated for the new scope and objective of the partnership.

The final word is that with such partnerships, it is necessary for each and every member involved in the task to take personal responsibility for the success of the project. Publicizing the partnerships and its perceived benefits at company-wide gatherings gives the team members involved the enthusiasm and passion necessary to derive maximum benefits.

Another very important factor behind the success of healthcare innovation partnerships is that the collaboration needs to remain agile and effective. Only then can the best resources of both partners be utilized optimally to make the partnership truly beneficial for themselves, the health care community, and the patients who are the ultimate beneficiaries of any innovation in this field.

References:

http://www.mmm-online.com/how-to-make-healthcare-innovation-work-in-the-real-worldmercks-partnership-with-patientslikeme/article/359789/

 Keyword(s): Best PracticesMake Healthcare InnovationPartnershipsWork

### Principales técnicas para prevención de pérdida de datos móviles

por Michael Finneran

Proteger los datos en los dispositivos móviles es el primer paso para la seguridad en un entorno de empresa consumerizado. Pero incluso con el cifrado adecuado y la protección de contraseñas en su lugar, TI tiene que enfrentar el hecho de que a veces los dispositivos se pierden o los empleados sin saberlo descargan algo malicioso.

Entonces, ¿qué hace usted en ese caso? Como parte de sus actividades de gestión de información móvil, debe aprender a proteger los dispositivos de las amenazas externas.

#### Protección contra dispositivos perdidos o robados

Si un teléfono que almacena información corporativa se pierde o es robado, eso crea una exposición seria. Los datos deben estar cifrados y la contraseña activada, pero los administradores por lo general quieren detener la amenaza borrando los datos corporativos del teléfono. Esto se puede lograr de maneras diferentes.

En primer lugar, herramientas como Exchange ActiveSync de Microsoft y Notes Traveler de IBM proporciona una capacidad de limpieza remota. Es, sin embargo, un enfoque de "instrumento contundente". Cuando se envía el comando de limpieza, todo el contenido del teléfono es borrado, incluyendo fotos personales, música, aplicaciones, tonos de llamada y otros artículos.

Teniendo en cuenta que este dispositivo se encuentra ahora en manos desconocidas, el usuario podría querer los contenidos del teléfono borrados. Con suerte, el usuario habrá seguido la guía de TI y realizado una copia de seguridad del contenido de manera regular.

Otro escenario que los planes de seguridad móvil deben abordar es cuando un empleado deja la organización. En ese caso, un sistema de gestión de dispositivos móviles (MDM) tiene la ventaja de ser capaz de borrar solo el contenido corporativo, dejando la información personal del usuario intacta. También puede ofrecer una capacidad de limpieza total si el usuario lo solicita.

Es importante señalar que la limpieza a distancia no es 100% eficaz. Si el teléfono está apagado, en modo de avión o simplemente en una zona donde no se puede conectar a una red, no será capaz de recibir el comando de limpieza.

Además, si el cliente MDM se desinstala, o si la cuenta de Exchange o Notes Traveler se desactiva, el dispositivo no responderá a un comando de limpieza. En la mayoría de casos, sin embargo, desinstalar el cliente MDM o cancelar la cuenta de correo electrónico hará que cualquier dato asociado con el dispositivo sea borrado.

#### Prevención de pérdida de datos

Perder un dispositivo móvil es una forma de perder el control de la información corporativa, pero no es la única preocupación en la gestión de información móvil (MIM). Se sabe que los usuarios transmiten correo electrónico de negocios a sus cuentas personales o suben archivos corporativos a servicios de almacenamiento en la nube para consumidores como Dropbox. Si todo lo demás falla, un empleado puede simplemente utilizar las funciones de copiar y pegar para mover la información desde el correo electrónico corporativo o archivos adjuntos hacia cualquier lugar que deseen.

Afortunadamente, los proveedores de MDM son conscientes de esta amenaza y han desarrollado métodos para proteger a la empresa en contra de ella. La herramienta básica es un "contenedor seguro" o "sandbox", que es esencialmente una región definida por software, protegida por contraseña, en el dispositivo, que almacena la información corporativa de manera independiente a los archivos personales del usuario. Si el dispositivo se pierde o es robado, o si el usuario sale de la empresa, el contenedor seguro puede ser borrado de forma remota.

La otra característica clave del contenedor seguro es que cualquier dato de la empresa que se envía a él es etiquetada y no puede ser enviada fuera del recipiente. Correo electrónico o archivos adjuntos no se pueden reenviar, ni sus contenidos se pueden copiar y pegar.

La región segura también puede almacenar otras aplicaciones, y su contenido tampoco puede ser reenviado. Un producto MDM puede incorporar una capacidad de almacenamiento seguro en la nube para eliminar la necesidad de servicios abiertos como Dropbox.

“Doble personalidad” es el término pegadizo que han acuñado los proveedores de MDMpara describir este enfoque. BlackBerry Ltd. tenía una de las primeras capacidades de este tipo con su BlackBerry Balance, y otros fabricantes ahora la ofrecen para prácticamente todos los sistemas operativos móviles.

Samsung recientemente presentó su propia tecnología de contenedor seguro como parte de Knox para la plataforma Android. Knox trabaja con una serie de soluciones de MDM y también proporciona una función de arranque seguro.

La ironía es que todas estas medidas de seguridad pueden venirse abajo si un dispositivo se infecta con malware. Las aplicaciones móviles están disponibles desde diverso número de fuentes, y los proveedores toman muy diferentes enfoques de cómo –o si– ponen a prueba las aplicaciones en busca de malware antes de distribuirlos.

La exposición se agrava si el dispositivo tiene "jailbreak" (un término iOS) o “rooting” (el término Android), un proceso en el cual los mecanismos básicos de seguridad integrados en el dispositivo son desactivados, lo que permite instalar aplicaciones desde cualquier fuente. El software para jailbreaking o rooting está disponible gratuitamente en internet.

Prácticamente todos los productos MDM proporcionan detección de jailbreaking/rooting, y un dispositivo se puede bloquear para evitar el acceso al correo electrónico corporativo y a otros sistemas hasta que vuelva a cumplir con los requisitos de seguridad. Dada la naturaleza de su diseño, no ha habido casos reportados de jailbreaking o rooting en dispositivos BlackBerry o Windows Phone, por lo que este es un problema limitado a iOS de Apple y Android de Google.

En cuanto a las propias aplicaciones, siempre y cuando un usuario esté descargando aplicaciones desde la tienda iTunes de Apple, están bastante bien protegidos. Apple hace numerosas pruebas sobre aplicaciones para detectar el malware antes de su distribución. Por supuesto, si un dispositivo es jailbroken, el usuario puede descargar las aplicaciones de iOS desde cualquier lugar, y todas las apuestas se apagan.

Hasta este punto, Android ha sido el objetivo de la mayoría del malware móvil. En suReporte de Tendencias de Consumidor Móvil de febrero de 2014, la firma de seguridad McAfee informó que el malware para Android se ha casi triplicado de 2012 y 2013, registrando casi cuatro millones de muestras.

La mayoría de los casos parecen estar dirigidos hacia el robo simple, causando principalmente que el dispositivo envíe textos premium a través del servicio de mensajes cortos (SMS). Tenga en cuenta que hay versiones que pueden permitir a un hacker vigilar las comunicaciones o arrebatar prácticamente cualquier archivo de datos fuera de un teléfono.

Para protegerse contra este tipo de ataque, la detección de jailbreaking/rooting es el primer paso. Si no hay un sistema MDM instalado, la política de movilidad de la organización debería prohibir explícitamente el jailbreaking/rooting.

Los sistemas MDM también pueden permiten a los administradores poner aplicaciones en la lista negra, y hay productos antivirus para Android disponibles de compañías como Avast, Bitdefender y Kaspersky Labs. Según la firma independiente de seguridad de TI AV-Test, muchos de los mejores productos tienen hasta un 95% de efectividad.

Para un control aún más estricto de las aplicaciones móviles, algunas empresas están dando el paso de poner en práctica sus propias tiendas de aplicaciones internas. La mayoría de proveedores de MDM, así como especialistas como Apperian o App47, proporcionan estas capacidades. Además de controlar la distribución y actualización de aplicaciones, estas tiendas de aplicaciones internas también pueden gestionar cualquier software corporativo con licencia.

### “El sistema de telemedicina que estamos desarrollando busca mejorar la capacidad de resolución local”

##### El Dr. Joaquín Héctor Gonzalez está a cargo del Departamento de Comunicación a Distancia del Hospital Garrahan y en esta entrevista repasa cuándo se inició, en qué consiste y cómo funciona el programa interprovincial de telesalud.

El Hospital de Pediatría Prof. Dr. Juan Pedro Garrahan, de Argentina, es un nosocomio público de alta complejidad que desarrolla desde 1997 el primer programa de telemedicina del país.

El proyecto, llamado Referencia-Contrarrefencia, promueve polos de salud a nivel provincial y regional, y busca alentar el acceso igualitario a consultas con médicos especializados.

El pediatra Joaquín Héctor Gonzalez es el responsable del departamento de Comunicación a Distancia y, desde hace 25 años, se desempeña como médico de la oficina de comunicaciones del hospital. En esta entrevista repasa cuándo se inició, en qué consiste y cómo funciona el programa interprovincial.

¿Cómo surgió la idea de implementar telemedicina en el Hospital Garrahan?

El programa empezó en el Hospital de Día en 1997; la mejora del servicio de internet en el país permitió el trabajo punto a punto con los hospitales. Desde su implementación se recibieron unas 50 mil consultas y el 80% de los pacientes no tuvieron necesidad de trasladarse hasta el hospital, ubicado en la Ciudad Autónoma de Buenos Aires.

¿Qué motivos impulsaron el proyecto?

Varios: teníamos chicos que venían desde lejos por una enfermedad que se agravaba durante el viaje; recibíamos a niños que se acercaban sin información clínica y, una vez terminado el tratamiento, no teníamos a quién transferirlo porque no sabíamos quién era su médico de cabecera; atendíamos a pacientes que podían ser atendidos perfectamente en su zona de residencia; y la lista sigue…

¿Cómo es el sistema de gestión de turnos?

Se dan turnos programados, esto permite que un paciente del interior que llega a la mañana sea internado en un horario determinado para hacer los estudios y las consultas necesarias.  A las 8 horas ya se tiene un resumen de la revisación o alguna conclusión, tratamos de hacer todo en 24/48hs. De hecho, los turnos se programan considerando que el paciente quedará dos días en el hospital.

A su vez, luego de programar el turno, nos comunicamos con el lugar donde el niño es atendido habitualmente y, a través del servicio social, se genera la derivación considerando que va  a estar en Buenos Aires por lo menos un día.  Entonces fijamos, así, dónde va a pasar la noche, puede ser en Casa Garrahan o en un alojamiento externo.

Los hospitales con los que trabajan, ¿son sólo públicos?

Se complica el asunto del manejo de lo público y lo privado. Por ahora, nos manejamos sólo con hospitales públicos porque no generamos actividades con lucro, aunque cada tanto hacemos alguna excepción.

Nosotros disponemos del equipamiento como para no necesitar ninguna contraprestación al hospital privado, pero ellos, en cambio, generan un lucro facturando el servicio que nosotros le ofrecemos sin costo.

De todos modos, en la provincia están viendo de generar convenios con hospitales del ámbito privado; sobre todo con los que tienen seguros de salud en la provincia, que se consideran como públicos pero en los hechos no lo son.

¿Qué planes se están desarrollando a nivel nacional?

Hay un subsidio del Banco Interamericano de Desarrollo (BID), a través del Ministerio de Ciencia y Técnica, para equipar a 140 hospitales con aparatos de videoconferencia, una red de telefonía IP y un sitio web.

Todos los equipos, destinados a los hospitales de referencia y a los 23 Ministerios de Salud, van a ser utilizados para docencia e interconsulta. Además, se añadió un nuevo proyecto, al que se sumó el Ministerio de Planificación a través del Ministerio de Ciencia y Técnica por medio de un convenio con el Ministerio de Salud, que incorporará equipos de videoconferencia a otros hospitales y generará una red de atención a embarazadas y adultos.

Esta red se generaría, en un 90% de los casos, en las mismas instituciones de salud con las que trabajamos, porque la mayoría no son exclusivamente de niños: nosotros trabajamos en la red privilegiando lo pediátrico, que es lo que sabemos hacer, pero se está pensando aprovechar las mismas oficinas, la infraestructura que se tiene, los vínculos de contacto que se están haciendo a través de la red pediátrica, para generar una red de adultos y de maternidad.

¿Cómo es el trabajo con las provincias?

El sistema que usábamos hasta 2001/2002 con los hospitales de las otras provincias generaba un quiebre en el sistema de referencia local. Por ejemplo, tenemos el caso de Neuquén: nos dimos cuenta de que trabajábamos con el hospital de Zapala, que es de mediana complejidad, y los médicos, en lugar de consultar al hospital central de la provincia, nos consultaban a nosotros. Se terminaban generando derivaciones de pacientes que no cumplían el recorrido que tenían que hacer dentro de la provincia para volver el sistema más eficiente; es decir, se venían a Buenos Aires por algo que bien se podía resolver allá.

Entonces cambiamos el objetivo y decidimos armar una red de hospitales de referencia en pediatría en cada provincia; y, a su vez, que cada provincia generara su red interna.

En Neuquén hay un solo polo central, pero, por ejemplo, en Río Negro hay cuatro unidades de la misma complejidad: Bariloche, General Roca, Cipolletti y Viedma. La provincia no tiene un solo polo central donde van todos, sino que distribuye la salud pública en cuatro polos. Nosotros respetamos esa referencia local, tratamos que interactúen entre ellos y trabajamos asumiendo que tienen cuatro polos de desarrollo, privilegiamos que la red sea armada por la provincia.

¿Y en las provincias cómo se está desarrollando las redes locales?

Todavía falta armar vínculos regionales entre las provincias. El sistema de telemedicina que estamos desarrollando busca mejorar la capacidad de resolución local.

En mi opinión, la telemedicina se divide en dos sistemas:

1. Tipo red sanitaria: va un ómnibus del Garrahan a una provincia con especialistas y equipamiento, atienden a los pacientes, se va el ómnibus, y no queda nada.

2. Programa Rederencia-Contrarreferencia, que es el que venimos desarrollando. Se trata de una estrategia de colaboración; mediante herramientas del sistema de comunicación a distancia, se generan vínculos que permiten la formación de especialistas a nivel local. Por ejemplo, se detecta que en una provincia no hay neurólogos y tienen una persona que quiere trabajar como neurólogo en el hospital. Supongamos que ya haya hecho la residencia y que tiene la edad adecuada para formarse, hay un examen al que puede aplicar para entrar como becario en el Garrahan y hacer la formación como especialista.

¿El Garrahan atiende a toda persona que se presente en el hospital o deriva en casos de no requerir alta complejidad?

Vienen muchos pacientes con patologías respiratorias que no serían alta complejidad sino patología estacional, y hay un montón de hospitales con capacidad de resolverlo. De todos modos, si alguien se presenta en el hospital es atendido. Los casos que no son demasiado complejos, que no requieren terapia intensiva, reciben un tratamiento operativo.

¿Este proceso no conduce a una saturación del sistema de salud del Hospital?

Esto es un hospital planificado para tener alta complejidad, pero también es abierto: pueden venir a atenderse cualquiera de cualquier lado. Cuando un paciente llega, tiene a su disposición un médico orientador. Lo que se trata es que lleguen los pacientes que haga falta atender acá, que no se puedan atender en otro lado.

¿Qué rol juega la Historia Clínica Electrónica (HCE) en el programa de telesalud?

La HCE está implementada en muy pocos países, hay  varios proyectos en pleno proceso de debate, pero todavía ninguno está aplicado. Hasta ahora el sistema es a través del fax, que era lo que había cuando empezamos. Le agregamos un mail para poder recibir las imágenes que antes mandábamos por correo.

¿Cuál es su perspectiva a nivel nacional y continental sobre la telesalud?

Estamos con perspectivas de progreso. Nuestro programa se inserta en la colaboración con Ministerio, y la posibilidad del tendido de la red de fibra óptica que está desarrollando el plan Argentina Conectada es muy prometedora.

Podríamos aprovechar esa red para darle conectividad a las videoconferencias y generaríamos una plataforma bastante importante para vincular a todos los hospitales en red.

Brasil, por ejemplo, tiene una red de telemedicina bastante importante. A partir de lo que nosotros vimos, tienen un programa centrado en el centro universitario para consulta de médicos generalistas que atienden a grupos en zonas rurales. Lo que no realizan, en comparación con nuestro programa, es manejar la información de ida y vuelta.

Consultan al centro universitario por un paciente, le ofrecen una devolución  sobre el procedimiento a realizar o si requiere internación,  y luego el médico generalista que está en la zona rural debe averiguar adónde derivarlo. La videoconferencia sirve como consulta en línea de lo que hay que hacer y el médico tiene que proseguir con lo que requiera el paciente, no tienen integrada la respuesta con una implementación programada de qué hacer.

Por otro lado, la Organización Panamericana de la Salud (OPS) está trabajando con un programa, como una clínica virtual, que falló porque tenía problemas de conectividad. Se intentó empezar un programa piloto en Jujuy que quedó demorado por problemas de conectividad. En la agenda de la OPS está presente el tema de la salud en red, es decir, la red como un concepto de redes integradas al servicio de salud.

 Keyword(s): Telemedicina

### Panorama de los sistemas de información de medicamentos: ¿qué se necesita?

##### Paul Bonnet, director general de Vidal Vademecum Internacional, aporta una reflexión sobre los errores en la administración de medicamentos y repasa cuáles son las herramientas disponibles para consultar información farmacológica.

Cada año se producen errores en la prescripción de medicamentos con consecuencias fatales para la salud, que además suponen unos elevadísimos costes para los organismos sanitarios.

Uno de estos fallos derivó, en cierta ocasión en la ciudad de Denver, en el fallecimiento de un recién nacido que recibió, por vía intravenosa, la administración de un medicamento con una dosis 10 veces superior a la que había sido prescrita.

En tal caso, el error se produjo por una serie de fallos: administración de un medicamento innecesario, prescripción médica ilegible, falta de verificación de la orden médica por parte del farmacéutico, mal etiquetado de la especialidad farmacéutica, e inexperiencia del personal de farmacia y de enfermería en el manejo del medicamento en cuestión; es decir, una cadena de errores que se podrían haber evitado.

En la prescripción de medicamentos, estos errores no sólo tienen consecuencias en la salud de los pacientes sino, que además, derivan en unos costes para los sistemas de salud realmente importantes.

En concreto, y según datos del Centro para el Control y Prevención de Enfermedades de Estados Unidos (CDC USA, por sus siglas en inglés), al año se producen en Estados Unidos 700.000 ingresos en urgencias por interacciones de medicamentos, de los que 120.000 requieren ingreso hospitalario, ocasionando un coste estimado de unos 3.500 millones de dólares.

Sin embargo, otros datos de otras regiones no son más optimistas. Por ejemplo, un estudio realizado por el National Health Service (NHS) de Reino Unido calculó que aproximadamente una media de 60 pacientes mueren cada día debido a un error adverso a la medicación prescrita; y en Nueva Zelanda, el Ministerio de Salud estima que cada año cerca de 5.000 pacientes están sujetos a errores en su medicación. De estos pacientes, cerca de 150 fallecen y más de 400 sufren una discapacidad permanente.

En la misma línea y volviendo a apuntar a Europa, en España, según un estudio del Ministerio de Sanidad sobre eventos adversos de la medicación, el 9,3% de las estancias hospitalarias se deben a efectos adversos graves, siendo los errores asociados con la medicación los más abundantes -con más del 30% del total-.

Diferentes organismos han puesto en marcha una serie de protocolos para evitar errores en la prescripción de medicamentos. El Consejo de Salubridad General de México, por ejemplo, recomienda que, para una correcta farmacovigilancia, se debe cumplir el estándar M.M.U 5.1. de la Joint Commision para México DF, referente al Manejo y Uso de Medicamentos -Medication Management and Use (MMU)-.

Este proceso incluye la evaluación de:

b) duplicación terapéutica

d) interacciones reales o potenciales entre medicamentos o alimentos

e) variación con respecto al criterio del uso del medicamento en el hospital

f) peso del paciente, información fisiológica

g) otras contraindicaciones.

#### Herramientas disponibles

En la actualidad acudimos, en primer lugar, a las fuentes oficiales a la hora de consultar información farmacológica. En México, la aplicación del Cuadro Básico de Medicamentos (CBM) y Catálogo de Insumos en la Administración Pública Federal ha permitido contar con un sistema único de clasificación y codificación de insumos para la salud, lo cual ha contribuido a homogeneizar las políticas de adquisición de las instituciones públicas federales del Sistema Nacional de Salud.

Pero además de las fuentes oficiales, existen otras formas de acceder a información clínica y farmacológica de referencia, tanto en diferentes websites como mediante bases de datos farmacológicas que pueden estar integradas en los sistemas informáticos.

El problema aquí es que son escasos los actores globales que se dedican a indexar y conectar información sanitaria/farmacológica, y menos aún los que están disponibles en idioma español y con farmacopeas “non FDA”.

Y es que para garantizar prescripciones de fármacos seguras, que eviten errores o reacciones adversas de medicamentos, se hace necesario contar con bases de datos que contengan, al tiempo, información clínica así como información oficial local, todo ello en un entorno normalizado, con la información indexada, codificada y actualizada y que sean herramientas que puedan estar interconectadas.

 Keyword(s): Sistemas de informaciónmedicamentos

### Los hospitales sufren un aumento exponencial de robos de información personal

Gerente de Governance, Risk & Compliance (GRC) en Cybsec S.A.

Los centros sanitarios invierten muy poco en seguridad informática frente a otras industrias, por ello las redes informáticas de los hospitales son cada vez un objetivo más frecuente de los hackers. Recientemente se ha producido un robo de datos de 4,5 millones de personas que habían recibido tratamiento en Community Health Systems (CHS, en EEUU), una empresa que gestiona más de 200 hospitales. Los ataques de malware están aumentando en muchas industrias, aunque los investigadores de la firma de seguridad Websense aseguran que la velocidad con que han crecido los ataques a los hospitales en el último año no tiene precedentes.

En los centros de salud la seguridad de los datos no suele ser muy alta, y los hackers están atacando sistemas repletos de tesoros de información personal de gran valor, almacenada en historiales clínicos electrónicos, según los investigadores de Websense, que añaden haber observado un aumento del 600% en los ataques a hospitales durante los últimos 10 meses.

Los proveedores de software lanzaron parches inmediatamente después del anuncio del fallo, pero una investigación reciente indica que cientos de miles de sistemas probablemente siguen siendo vulnerables. Aunque los autores de malware pueden infiltrarse en las redes y robar información delicada de muchas otras maneras, "la enorme cantidad de sistemas susceptibles a esta vulnerabilidad es algo destacable", señala Leonard desde Websense.

La seguridad de los datos no ha sido una prioridad para muchas organizaciones de atención sanitaria, lo cual agrava el problema. La industria de la salud gasta muy poco en TI en comparación con otras industrias, asegura el jefe de información y decano de Tecnología de la Escuela de Medicina de Harvard (EEUU), John Halamka. "¿Dónde crees que vas a encontrar las vulnerabilidades?", se pregunta.

Mientras que los números personales de tarjetas de crédito y de afiliación la Seguridad Social de EEUU se venden por relativamente poco dinero en los mercados clandestinos de robo de identidad, cierta información de identificación personal procedente de los historiales de salud puede alcanzar un valor de cientos de dólares para aquellas personas sin seguro médico que quieran hacerse pasar por otra persona y obtener atención médica que no podrían costearse de otro modo, afirma Halamka.

Las autoridades federales de EEUU y la empresa de seguridad Mandiant han señalado a la Comisión de Valores de Estados Unidos (SEC, por sus siglas en inglés) que el robo de datos en CHS fue llevado a cabo por un sofisticado grupo en China. Aunque por lo general el grupo ha tenido como objetivo la propiedad intelectual relacionada con dispositivos y equipos médicos, en esta ocasión, según la SEC, ha robado "datos no médicos de identificación de pacientes" en vez de datos médicos, de tarjeta de crédito o información clínica. Sin embargo, nadie sabe qué estaban buscando los hackers

FUENTE: MIT Technology Review (Escrito por Por Mike Orcutt / Traducido por Francisco Reyes)

### Reproducir vídeo

##### Presentación de la disertación sobre Seguridad de la Información en el Ambiente de Sanidad
 Keyword(s): Robos de información personalhospitales

### Entró en vigencia la ley de telesalud en Venezuela

Será aplicada en centros de salud públicos junto con la Ley de Infogobierno bajo el principio de gratuidad; y en los centros privados que la están aplicando, se vigilará para que no se cobre de forma excesiva el uso de las Tecnologías

La Ley de Telesalud, sancionada ayer por la Asamblea Nacional, es vanguardista y revolucionaria porque coloca al alcance de todo el pueblo venezolano la posibilidad de usar las Tecnologías de la Información y la Comunicación de una forma integral, además de ser una herramienta para que el personal de salud se empodere de conocimiento.

Así fue definido este texto legal por la diputada Betty Cróquer (PSUV/Aragua), vicepresidenta de la Comisión Permanente de Ciencia, Tecnología e Innovación, proponente de la Ley, quien destacó que su puesta en práctica representará un gran avance para la medicina en el país.

La normativa sancionada define la Telesalud, como un conjunto de acciones y estrategias en materia de salud que hacen uso combinado de las tecnologías de la información y telecomunicaciones en software libre, con propósitos de atención integral y promoción a la salud, entre otros aspectos.

“Esta ley permitirá, por ejemplo, que el médico de un sitio remoto se comunique con el especialista del hospital más cercano, quien le dará recomendaciones para estabilizar el paciente, mientras se traslada a este centro donde lo estarían esperando con un diagnóstico preciso”.

En el programa “Asamblea Viva”, transmitido por ANTV, también participó la diputada Miriam Pérez (PSUV/Carabobo), miembro de la Comisión, quien explicó que este instrumento legal será aplicado tanto en los centros de salud públicos, como en los privados y al entrar en vigencia, todos ellos, deberán buscar las normas para que esta tecnología se ponga de manifiesto.

Precisó que dentro de los principios de esta Ley está el de gratuidad y aunque en las clínicas privadas se practica desde hace tiempo la Telesalud -aunque no se denominaba así-, era necesario legislar porque cobran de forma excesiva por el uso de tecnología básica. “Las clínicas deben entender que no se puede mercantilizar con la salud”.

Explicaron las parlamentarias que la Ley de Telesalud se aplicará en conjunto con la Ley de Infogobierno, que está próxima a entrar en vigencia, sobre todo, porque a la gente le preocupa lo de la confiabilidad de la información y es a través de esta última que se puede garantizar esto.

Con la aplicación de estas leyes, Venezuela va hacia la sistematización de la historia médica, a través de la digitalización, lo que beneficiará además al ambiente, al reducirse el consumo de papel.

Queda pendiente el reglamento de la Ley que tendrá carácter orgánico y lo hará el Ministerio de la Salud, el cual seguramente será consultado con el pueblo, como se hizo con el de Infogobierno.

Vigencia de la ley de Infogobierno

Recordando que la Ley de Infogobierno entrará en vigencia el 17 de este mes, destacaron las diputadas que ya muchas instituciones están trabajando para poner en práctica esta legislación que las obliga a migrar a software libre, lo cual, permitirá seguir reforzando la soberanía del Estado y acabar con la dependencia de las transnacionales de la tecnología.

En este sentido, recordaron lo sucedido son el saboteo tecnológico de PDVSA en el año 2002, pues aunque en ese entonces no existía la Ley de Infogobierno, gracias a hombres y mujeres comprometidos, se logró la recuperación tecnológica de la empresa, pero hoy gracias a esta legislación se están protegiendo los equipos y la información vital para el país, “porque no podemos permitir que se acceda a desmontar lo que se está haciendo en revolución”.

Al culminar el primer período parlamentario, las diputadas manifestaron estar complacidas con el trabajo realizado por la Comisión, enfatizando que las leyes elaboradas fueron consultadas con el pueblo legislador, trasladándose a zonas remotas de Delta Amacuro y Amazonas.

Para el próximo período, tienen previsto trabajar la Ley de Acceso al Libre Conocimiento y la Ley que Regula las Actividades del Espacio Ultaterrestre.

Fuente: La Red

 Keyword(s): Ley de TelesaludVenezuela

### What is Reverse-Engineering?

by Margo Ellis | Marketing and Communications at Caristix

Lacking an accurate HL7 interfacing spec? Consider reverse-engineering.

#### Why consider reverse-engineering? Lack of accurate specs

If you’ve worked on an interfacing team or for HIE, one of the issues you’ll hear about is a lack of accurate interface specifications. For instance, the vendor spec might be missing. Or the source or destination spec on hand might no longer match the production version.

So what do you do?

#### Lack of specs: what’s the impact on your ability to deliver?

Well, you might be facing weeks of digging and research. You’re missing a lot of information about the source and/or destination system you’re interfacing. You and your team will have to spend time getting that information, either in a series of kickoff and liaison meetings with the customer, or going back and forth with whichever application team is responsible for the system. And in a worst-case scenario, you’ll get piece-meal information that will allow you to get rough-draft style interface in place, and spend weeks testing and tweaking until it works.

If you’ve been through this process, you know that weeks can drag into months.

What if you could skip all that?

This is where reverse-engineering comes in.  So just what is reverse-engineering?

#### Reverse-engineering: create your own specs

Reverse-engineering is a technique and technology that we developed and incorporated into the Caristix platform. In a nutshell, reverse-engineering allows you to take sample messages from a source or destination system, and create a spec in a matter of minutes.

Reverse-engineering gives you a full list of application-specific elements and attributes:

• Message types
• Segments, including z-segments
• Fields
• Data types, including custom types
• Code sets, including custom elements
• Message-specific code sets (ability to differentiate field content A01 vs A08 messages, for instance)

#### What this means for your work

We’ve listed the data elements you obtain via reverse-engineering. Having them at your fingertips can transform how you and your team work.

Take code sets, for instance.

If you’re creating a lab interface, you’re probably working with a set a set of customized code sets. And these may change from time to time. Without reverse-engineering, you’d have to ask the lab system application manager to pull these codes manually. With reverse-engineering, you’d pull these codes automatically from the data itself – and the list would be complete.

That’s the advantage of reverse-engineering. A complete list of the structure and content elements. A lot less trial and error. And faster time to implementation.

#### Further resources

If you’d like to do a deep dive on Caristix reverse-engineering capabilities, check out the product help documentation:

http://caristix.com/help-center/v3/workgroup/profiles-scoping-and-updating-interface-specifications/creating-a-profile/reverse-engineering/

To see how reverse-engineering works, check out the video below.

See the whole Caristix platform in action in our 16-minute on-demand demo.

Categories : HL7 Data HL7 Interfacing

 Keyword(s): Reverse-Engineering

### Electronic Medical Record Design: The Quest for Information

Bizmed Founder, Margalit Gur-Arie  discusses electronic medical record design and the importance of defining our sources of information if patient care is the driving concern.

In Part I of this series, we engaged in a design exercise for an imaginary software product that has no stated (or hidden) purpose other than to improve patient care. Following our initial definition of patient care, we formulated three general requirements and several constraints, none of which were specific enough to start building software tools from. The next step in our journey will break down each requirement into more specific tasks. What follows below will seem like an unnecessary and laborious statement of the obvious to some. However, I would submit that the careless bypassing of fundamental analysis is precisely what led us to where we are today, and even if we are forced to cut corners eventually, it is imperative that we define all corners prior to cutting them, instead of feigning shock and surprise after the fact. So without further ado, let’s start where we left off.

#### System shall assist with gathering information from various sources (TBD) at the point of care

The first thing we need to do before we begin gathering anything is to figure out the sources of information that may be able to contribute to patient care, and the essence of each contribution, which will serve as a guide to any prioritization efforts that may be required down the road.

1. The Patient – You cannot provide patient care without a patient, and any activities undertaken without adequate input from the patient (or proper surrogate) do not fit our definition of patient care.  Therefore the patient is the primary and most important source of information. Information gathered from the patient can be subjective or objective. Subjective is not a derogatory term that implies lack of importance, and quite the opposite is true in most cases. Subjective information is the patient’s point of view, without which it would be quite impossible to do anything that qualifies as patient care. Objective information is something observed or measured by someone other than the patient, but the lines can be blurred when observation depends on patient voluntary response (e.g. range of motion). Information from the patient is available through several modalities and can be solicited or unsolicited.
1. Narrative – This is the patient’s story, historically delivered in person, but more recently also available through phones and now through electronic communications over the Internet. Originally, large parts of the patient story were known to the doctor who was part of the community he served, but to compensate for societal lack of wisdom, increasingly larger portions of the narrative are being solicited through paper forms, clerical assistants to physicians and most recently computer software (see below). In most cases, the patient still has the opportunity to relay unsolicited and unstructured information to the doctor, but the allotted time for this activity is shrinking by leaps and bounds. The patient narrative delivered in person has value beyond the story itself, as it exposes other forms of information that can be processed by humans, such as demeanor, tone of voice, body language, general appearance and even smell. It is worth noting here that this sensory exchange of information is bi-directional and the patient is also gleaning important information about the physician. Therefore, at this point in our analysis, we will make a note to consider this expanded definition of narrative when addressing our third general requirement dealing with patient-doctor relationship building.
2. Examination – The physical examination of the patient, once the hallmark of practicing medicine, is somewhat diminishing in its diagnostic importance nowadays. Palpation, auscultation and manual handling of the patient is being surpassed by machines that can accurately “see” inside the patient and analyzers measuring biophysical markers and functions that could only be hypothesized by inference or educated guess. Here we are going to use this new and expanded definition of patient examination to include input from any available equipment at the point of care (others will be considered in #3 below). However, as was the case with the narrative discussion above, the traditional “laying on of hands” has implications to our third general requirement. Since we are after all a type of animal, consensual agreement to intrusion by another person into our personal space (and beyond) implies the establishment of an uncommon level of trust and, in some cases, may have healing effects in and of its own. Therefore, we will make the same note as above.
3. Remote asynchronous – Although historically doctors acquired quite a bit of information about their patients asynchronously, and largely unsolicited, by virtue of being part of the same social community as their patients, those days are mostly gone, and here we will consider newer electronic forms of communication. From email to text messages to patient portals and direct transmission of monitoring data, patients today have multiple asynchronous venues to relay information to their physicians. These communication channels are used, when available, mostly for inquiries and requests for service, but they can also contain information pertinent to patient care. Monitoring data in particular (e.g. glucose levels, blood pressure, peak flows, etc.), whether in electronic or paper format, and subject to our constraint stating that patient care is not equivalent to lifestyle coaching, is obviously pertinent to caring for an individual patient, and in all cases this form of communications has implications for our third general requirement. We note this, and move on to the next item on the list.
2. The Chart – Before the chart, we had “papers”, ledgers, index cards and other less common methods of recording the most salient points of encounters with patients over time. This source of information forces us to consider the corollary to information gathering, which is the voluntary recording of information by the user. This is a fork in our design road. We can assume that information created as a byproduct of patient care is recorded by an external product, or we can add this capability as another requirement for our patient care software. We choose the latter and therefore add a requirement as follows: System shall assist with information recording at the point of care. This requirement will need to be further broken down, in a future iteration, to account for information sources as outlined in #1 above.
3. Other Facilities – In the world of modern day medicine, and primary care in particular, physicians providing patient care must bring into account information generated by others currently or previously engaged in the same activities. This information may be solicited by the physician, in the form of orders to diagnostic facilities or specialty consults, or unsolicited if the patient sought and received treatment at other facilities in the past, which may or may not be pertinent to the care provided by our user. There are two general categories of medical information generators that should be considered:
1. Diagnostic, Ancillary and Administrative Facilities – These include laboratory and imaging services purveyors as well as pharmacies and any other existing or future holders of information pertinent to patient care. Our product will be required to both solicit and accept unsolicited information from these entities.
2. Care Providing Entities – This is the entire universe of medical service providers surrounding our physician and patient interaction. Inpatient facilities, long term care facilities and other physicians, are included in this category and we become acutely aware of the need to build our software in a way that it can communicate with a large and extremely ill defined spectrum of other software and traditional partners. Summarizing both categories leads us to state that the System shall retrieve and accept information from external sources.

This item introduces another requirement originally put forward in the Holy Bible as “…all things whatsoever ye would that men should do to you, do ye even so to them” [Matthew 7:12]: System shall respond to all external legitimate requests for information. Note that here, and immediately above, we are not requiring the system to merely assist the user with this task, but instead we are requiring that the system takes full responsibility for exposing and/or sending appropriate information to other entities (the term appropriate or legitimate is an important constraint).

1. Literature – The final source of information pertinent to caring for patients is of course the science of medicine and the recorded experience of those similarly engaged in providing or receiving care from a medical professional. This body of knowledge is approaching magnitudes and velocities that are impossible to collect, analyze and entrust to human memory, particularly on the fly while caring for any one patient. We classify reliability and importance of clinical information, based on accepted practices, in descending order as follows:
1. randomized controlled trials
2. controlled trials, no randomization
3. observational studies
4. opinion of expert panel
5. clinical practice guidelines & recommendations

The first thing to note here is that unlike information to be gathered from all other sources, literature is not patient specific. To satisfy our fourth constraint prohibiting us from treating patient care as a commodity, information gathered from literature will require significant processing to make it useful when caring for an individual patient. We will therefore split this requirement into two parts: the first, System shall have the ability to access general published information, to be addressed here and the second, involving analysis and processing, to be addressed through our requirement pertaining to synthesis of gathered information. Although this is not the proper time to make technology decisions, we are noting here that gathering information from published materials is probably something we are going to buy off the shelf, instead of building our own module from scratch, as long as we can impose our requirements and, most importantly, our constraints on any commercially available software package. We will make a note to that effect here, and elaborate on it when considering our next general requirement which deals with information synthesis.

To summarize, our first requirement yielded several insights for future consideration and four sub-requirements as follows:

1. System shall assist with information recording at the point of care (needs more specificity)
2. System shall retrieve and accept information from external sources
3. System shall respond to all external legitimate requests for information
4. System shall have the ability to access published clinical information (consider buying)

Funny how certain things rise to the top and impose themselves on the software if patient care is the driving concern, and an orderly design process is undertaken.

And on this note, let’s pause, since we are quickly exceeding the boundaries of polite imposition on readers’ time. If you were expecting to be knee deep into buttons and font sizes by now, please understand that the user interface is the last thing to address in proper software design. If you paid close attention to the narrative so far, you should have noticed that we never mentioned buttons, screens, fields or anything of the sort. We cannot, and should not, define the problem in terms of its solution, just like you are not defining the patient complaint in terms of currently available prescription drugs. We will apply solutions, like buttons and pick lists, or maybe build new things that don’t exist just yet, after we completely understand the problem and the preferences of our users. The same can be said to those expecting discussion on standards, transport protocols and terminologies. We are not at a point where we should constrict our analysis to existing technology solutions, which by the way, are not serving us very well currently, this being the rationale for engaging in this thought exercise in the first place.

With this in mind, we will move on to Part III: A Better Haystack, where the need to synthesize and present the information we are gathering will be examined, forcing us to add specificity to our existing requirements (#1 should be most enlightening), before concluding our first design iteration in Part IV: Continuous Healing Relationships.

Margalit blogs regularly about healthcare technology on her site: On Health Care Technology where this article was first posted.

Image credit: paul bica via photopin cc

Electronic Medical Record Design: The Quest for Information by Margalit Gur-Arie

 Keyword(s): EMR Design

### Diálogos virtuales sobre presente y el futuro de las TIC y la Salud en las Américas

La Organización de la Salud / Organización Panamericana de la Mundial de la Salud (OPS / OMS) publicó la primera versión en castellano de una nueva publicación llamada “Conversaciones de eSalud”. La versión en Inglés de este eBook estará disponible muy pronto.

La obra consolida la visión de distintos profesionales que trabajan en el campo de la esalud quienes durante  varios encuentros intercambiaron intercambiar ideas, debatieron y reflexionaron sobre el presente y futuro de la utilización y aplicación de las tecnologías de información y comunicación en salud pública en las Américas.

La publicación de las “Conversaciones de eSalud”, desarrollada con el apoyo de la Agencia de Cooperación Española, representa una mejora importante para la estrategia de la OPS y el Plan de acción sobre eSalud, ya que explora las formas de aplicación de los mecanismos regionales con acceso libre y equitativo a la información y el conocimiento compartido.

Estas iniciativas están dirigidas a avanzar en el progreso hacia la meta de sociedades más informadas, equitativas, competitivas y democráticas, donde el acceso a la información de salud se considera un derecho básico. Una de las necesidades fundamentales para la mejora de la eSalud es la difusión de información, y la OPS está asumiendo un papel de liderazgo en este esfuerzo. El desarrollo de esta nueva publicación electrónica es un paso clave para difundir información estratégica, útil para los tomadores de decisiones, en el uso de estas tecnologías para la salud de las Américas.

A lo largo de sus 12 capítulos, Conversaciones eSalud presenta la opinión de especialistas, otras lecturas y experiencias exitosas de salud en línea. Este trabajo electrónica, presenta las conclusiones del proyecto en formato de diapositivas, e incluye entrevistas con los autores de las conversaciones y tweets difundidos a través de Twitter. Dado que el proyecto se basa en los componentes de la Estrategia eHealth y el Plan de Acción para las Américas, la obra aborda temas como la infraestructura, los sistemas de información, la telemedicina, el acceso a la información, las políticas, la educación, la seguridad del paciente, historia clínica electrónica, las normas para interoperabilidad, las cuestiones legales, la relación con los proyectos e iniciativas de administración electrónica y la gestión de la sanidad en línea. Cada tema fue discutido por un grupo de especialistas y la publicación cuenta con las conclusiones y recomendaciones sobre cada tema.

Debido a la variedad y actualidad de los temas abordados, este trabajo es útil para los profesionales de la salud, tomadores de decisiones, líderes políticos, los desarrolladores de programas relacionados con la salud y otros actores interesados ​​en el amplio campo de la salud en línea.
Estas recomendaciones pertinentes y otros aspectos analizados en Conversaciones eSalud ayudará a los países no sólo para desarrollar y mejorar sus tecnologías de la información y de la comunicación de planes estratégicos en materia de salud pública, sino también fortalecer los programas de salud electrónica en la Región de las Américas.

“Conversaciones sobre eSalud: Gestión de información, diálogos e intercambio de conocimientos para acercarnos al acceso universal a la salud”. Organización Panamericana de la Salud; 2014.

Los libros se pueden descargar en distintos formatos PDF ,  Epub (Para leer con iBooks, Nook, Sony Reader u otros lectores de libros electrónicos compatibles) y mobi desde la página de la OPS

### Diálogos virtuales abordan el presente y el futuro de eSalud en las Américas

La Organización Panamericana de la Salud/Organización Mundial de la Salud (OPS/OMS) convocó a profesionales involucrados en temas de eSaludpara aportar ideas, debatir y reflexionar sobre el presente y el futuro de estos temas en las Américas.

La publicación de "Conversaciones sobre eSalud", realizada con el apoyo de la Agencia de Cooperación Española, representa un gran avance para laEstrategia y Plan de acción de eSalud de la OPS, ya que explora formas de implementar los mecanismos regionales con acceso libre y equitativo a la información y el intercambio de conocimientos.

Estas iniciativas tienen como objetivo avanzar en el progreso hacia la meta de sociedades más informadas, equitativas, competitivas ydemocráticas, donde el acceso a la información de salud se considera un derecho básico. Una de las necesidades fundamentales para avanzar en laeSalud es la difusión de información, y la OPS está tomando un papel de liderazgo en este esfuerzo. El desarrollo de esta nueva publicaciónelectrónica es un paso importante para difundir información estratégica útil para los tomadores de decisiones sobre el uso de estas tecnologías parala salud en las Américas.

A través de sus 12 capítulos, Conversaciones sobre eSalud presenta la opinión de especialistas, lecturas recomendadas y experiencias exitosas eneSalud. La obra, en formato electrónico, presenta las conclusiones del proyecto e incluye entrevistas con los autores de las conversaciones y tweetsdiseminados a través de Twitter. Como el proyecto se basó en los componentes de la Estrategia y Plan de acción sobre eSalud para las Américas, laobra aborda temas como la infraestructura, los sistemas de información, la telemedicina, el acceso a la información, las políticas, la educación, laseguridad del paciente, la historia clínica electrónica, los estándares de interoperabilidad, asuntos legales, la relación con los proyectos e iniciativasde eGobierno y la gestión en eSalud. Cada uno de estos componentes fue discutido por grupos de especialistas, y en la publicación se exponen lasconclusiones y recomendaciones sobre los temas individuales.

Por la variedad de temas que aborda y la actualidad de estos, esta obra es útil para profesionales de la salud, tomadores de decisiones,responsables políticos, desarrolladores de programas relacionados con la salud, y otros actores interesados en el amplio campo de la eSalud.

Estas recomendaciones importantes y otros aspectos analizados en Conversaciones sobre eSalud no sólo ayudarán a los países a desarrollar y mejorar sus planes estratégicos de tecnologías de la información y las comunicaciones en materia de salud pública, sino también fortalecerán los programas de eSalud en la Región de las Américas.

“Conversaciones sobre eSalud: Gestión de información, diálogos e intercambio de conocimientos para acercarnos al acceso universal a la salud”. Organización Panamericana de la Salud; 2014.

 Keyword(s): Conversaciones sobre eSalud

### Data-driven scheduling predicts patient no-shows

With all the advancements in health care, the medical profession still cannot get its appointment book in order.

Doctors are constantly overbooked. Patients constantly rescheduling. One day a waiting room is packed, the next it’s empty.

So when Gabriel Belfort attended a health care hackathon at the Massachusetts Institute of Technology in 2012, he challenged the coders, engineers, and clinicians there to fix that nagging issue.

“There’s a scheduling problem in medicine,” said Belfort, who at the time was a postdoctoral student studying brain science at MIT. “If you’ve had an appointment and you’ve showed up on time, you’ve probably had to wait.”

That dilemma posed by Belfort generated a very MIT proposal: What if you could use data science to determine which patients are likely to show up and which ones will be no-shows and manage office appointments around those tendencies?

“It was immediately clear to me that this is a problem that computers could solve,” Belfort said.

In short order, Belfort and an ad hoc team of nine people — students and health care professionals — at the hackathon built a prototype to prove out the concept. Then, so excited by the prospect that they could solve one of health care’s chronic pains, Belfort and three others who were strangers before that weekend launched a startup, aptly named Smart Scheduling Inc.

Here’s the gist: Smart Scheduling mines patient scheduling histories to determine who is more likely to cancel or miss an appointment. It then sends alerts to the scheduling programs that doctor offices use to book appointments.

If a patient is in a high-risk category, for instance, it prompts office schedulers to call with a reminder. If the patient cannot be reached, there is a good chance he will not show up at all. So, the doctors could then book another patient for that time slot, keeping the patient flow consistent throughout the day.

Within months of forming, Smart Scheduling attracted the interest of Healthbox, an accelerator program that invests $50,000 in promising startups and gives them free office space and mentoring. It also landed a meeting with executives at athenahealth Inc., which eventually resulted in Smart Scheduling’s becoming the first startup in the Watertown health information company’s new accelerator program. Athenahealth also made an undisclosed investment to help the company build out its marketing and sales efforts. So far, Smart Scheduling has attracted some$500,000 in early-stage investment.

And already it has two large health systems signed up as customers: Martin’s Point Health Care, which runs health centers in Maine, and Steward Health Care System, one of the biggest hospital groups in Massachusetts, where the software is being used by about 40 of its doctors offices.

Dr. Michael Callum, president of Steward Medical Group, said Smart Scheduling helps take some of the ambiguity and guesswork out of making appointments; by eliminating unexpected down time, Steward doctors systemwide are able to see 100 more patients every week.

“When you leave it to the front-desk people in the office, they are not all that good of predicting flow in terms of when patients will show up,” Callum said. “It turns out that Smart Scheduling is much better at predicting that.”

Here is what Smart Scheduling has learned about us as patients: If we are single, or under 40, we are more likely to cancel an appointment than an older or married patient. New patients miss more appointments than regulars.

In general, expecting patients to show up for the 1 p.m. slot is a bad idea. On the other hand, Wednesdays are great, as patients are not likely to cancel on those days.

So far, Smart Scheduling has developed 722 variables that it uses to make predictions, based on an analysis of millions of data points about patients from athenahealth. And the more data Smart Scheduling can crunch, the better it gets at predicting behavior

The company says that, so far, its analysis has proven accurate 70 percent of the time when predicting cancellations.

“If everybody got a better schedule, we’d all be happier,” said Ateet Adhikari, director of the Healthbox accelerator program. “The patients benefit, the doctors benefit, and the insurer benefits. A more efficient system trickles down.”

Smart Scheduling was among the first companies that Healthbox invested in when it launched in Boston in 2012. Since then, it has backed 19 health-related startups.

Smart Scheduling exemplifies a new type of health care startup; instead of going after the big issues in health care — curing cancer, for instance — they are targeting more modest changes to improve the medical experience with technology.

“Companies like Smart Scheduling are dramatically improving health care not by producing a new drug,” said Bill Aulet, director of the Martin Trust Center For MIT Entrepreneurship. “It’s by streamlining the process and getting increased efficiencies.”

Belfort has since gone on to work at a local biotech company, although he remains an adviser to Smart Scheduling. Out of the group that came together to build the original product at the MIT hackathon in 2012, only Chris Moses has stuck around full time, and is now the company’s chief executive.

Improving patient flow in the doctor’s office is just the first step, Moses said. “The next step,” he added, “is to try to figure out who are the sickest patients and who the ones are that need to be seen first.”

 Keyword(s): Data-drivenschedulingpredictspatientno-shows

### The Apple Watch & Digital Health: 3 Must-Ask Questions

The tech world is still digesting Apple’s big announcement. Some believe Apple’s watch is the Second Coming. Others are disappointed that it does not look cooler. Left-handed people are up in arms that the device is not designed to be worn on the right hand.

My opinion: plenty of people will buy the Apple Watch and it will dramatically improve over time. Apple’s great at getting people to desire its devices (remember what they said about the iPad?) and does a good job of tweaking its designs.

#### Design Critiques Aside, Are We Focusing Enough on the Bigger Picture Beyond the Device?

But, I’ve always maintained that focusing on form factor, pre-loaded

applications and other surface features of Apple’s devices obscures the larger strategic reality. Apple is playing the long game and working to develop a device-software-data ecosystem that will keep its products relevant and necessary over the long-term. As others have noted, Apple’s foray into health illustrates how it is playing the long game quite clearly. (I’ll talk more about this in a bit.)

One need only look to the entertainment industry and the evolution of the iPhone software ecosystem to understand what Apple is trying to achieve. In music, Apple developed (for a time) a digital ecosystem that was second-to-none. In order to experience hassle-free music downloads, access the latest music on-demand and more you needed to have an iPod (and later the iPhone). Apple’s products went from nice-to-have to essential.

One of the reasons the iPhone did so well was Apple’s decision to open up the app development process to third parties. Inventive innovators developed applications that filled in the gaps in terms of functionality that many complained about when the iPhone and iPad were first introduced. Want a certain feature? There’s an app for that.

#### What Are the Key Health-Related Questions We Need to Answer About the Apple Watch?

Now, let’s look at what Apple is doing in health. Earlier today, I sent a somewhat breathless message to people on my email list announcing the Apple Watch. I received a number of responses to my message.

Some people wondered whether Apple would be able to solve the consumer engagement issue associated with many wearable devices. Earlier this year, Endeavour Partners put together a now-famous white paper that outlined how most people stop using wearable devices, trackers and other tools after an initial honeymoon period. So, the engagement issue is a big one.

But one of Apple’s strengths is its demonstrated ability to develop partnerships and tap into a vast and talented developer ecosystem that makes its devices more useful and relevant without the company having to invest in a large amount of R&D. In time, people will develop digital health applications that do a great job of harnessing the strengths of the Apple Watch while minimizing its drawbacks (and making it more sticky).

Other people contacted me to take aim at the digital divide — especially the fact that the Apple Watch is expensive. Well, only time will tell whether Apple will shift its pricing strategy. But, it’s done a good job of working with carriers and incentivising them to subsidize the iPhone, which has helped it reach people across economic segments. In addition, Apple is partnering with a range of health insurance firms, hospitals and others. I have to imagine that part of the reason for this activity is to encourage these powerful players to subsidize the cost of the Apple Watch and other tools — especially if they (or the software running on them) can be proven to help improve health outcomes and boost consumer engagement with their health.

#### The Elephant in the Room: Will Health Consumers Use a Wearable Like the Apple Watch?

The most pressing issue, however, is the adoption question. This goes beyond economics. If consumers decide the device is not very useful or adds anything to their lifestyle that will merit its long-term use, the Apple Watch is doomed. Companies like Pebble have succeeded in creating a long-term user base. Samsung and Google have already introduced watches that have gained limited traction. The jury is still out as to whether the Apple Watch will go much beyond power users.

From a digital health perspective, there’s evidence that some groups of consumers, including people with heart disease are not very interested in connected health devices, as this essay by Mark Bard of the Digital Insights Group suggests. But, it’s worth repeating that the issue of adoption may come down to a simple question: are these devices useful? Frankly, many current wearables are less then useful and require a lot of work and mental energy to optimize. (This is changing, however as this report [available via subscription] suggests.)

Yet, there is certainly a strong willingness among the most digitally active health consumers to use wearables, as our research suggests. These are ePatients or people who regularly use digital tools (i.e., Web, social media) for health.

Below is a chart illustrating some of our ePatient data.

We asked ePatients to tell us whether they would be willing to use a wearable device with the ability to track and monitor their health status. A slight majority of all ePatients said they would be very willing to use these devices. In addition, I looked at our data by socioeconomic status and found something interesting. Interest was greatest among the most affluent, but remained relatively strong across income groups. For example (as shown above) about 49% making between $31,000 and$40,000 annually were willing to use this type of device.

Related: Rise of the ePatient Movement

Now the question remains: would they be willing to use an Apple Watch? I’m not sure. But, this data does suggest that — for the company that gets wearables right — there is a significant opportunity in health.

#### The Bottom Line: Only Time Will Tell if the Apple Watch is a Hit, or Flop

Recent news reports make it clear that Apple is doing its best to develop a suite of indispensable products (in health and beyond), partnerships that will help it make its health data useful and relevant to medical professionals and learning the regulatory ropes. But, only time will tell whether the Apple Watch will be successful or a rare (for Apple) flop.

What’s clear is that the wearables arena is continuing to evolve, especially in health. For those willing and able to get it right, the rewards are potentially massive.

Fard Johnmar is a digital health futurist, researcher and co-author of the #1 bestselling book, ePatient 2015: 15 Surprising Trends Changing Health Care. He is also founder of Enspektos, LLC, a globally respected innovation consultancy providing original research, strategy, analytics and more to health executives, organizations and others.

Take your digital health knowledge to the next level by enrolling in a unique and free 5-part email course.  You’ll receive little-known, but vital insights, original research and analysis that’s critical to your success. Click here to learn more and enroll

The Apple Watch & Digital Health: 3 Must-Ask Questions by Fard Johnmar

 Keyword(s): Apple WatchDigital Health

### The Value Digital Health Brings To The Healthcare Ecosystem

What is Digital Health?

Digital health is the convergence of the digital and genetics revolutions with health and healthcare. As we are seeing and experiencing, digital health is empowering us to better track, manage, and improve our own and our family’s health. It’s also helping to reduce inefficiencies in healthcare delivery, improve access, reduce costs, increase quality, and make medicine more personalized and precise.

The essential elements of the digital health revolution include wireless devices, hardware sensors and software sensing technologies, microprocessors and integrated circuits, the Internet, social networking, mobile and body area networks, health information technology, genomics, and personal genetic information.

The lexicon of Digital Health is extensive and includes all or elements of mHealth (aka Mobile Health), Wireless Health, Health 2.0, eHealth, Health IT, Big Data, Health Data, Cloud Computing, e-Patients, Quantified Self and Self-tracking, Wearable Computing, Gamification, Telehealth & Telemedicine, Precision and Personalized Medicine, plus Connected Health.

Be sure to join the Digital Health group on LinkedIn

The Value Digital Health Brings To The Healthcare Ecosystem by Fred Pennic

 Keyword(s): Value Digital HealthThe Healthcare Ecosystem

### 3 Keys to Maximizing the ROI of Your EHR

A 2013 study from the University of Michigan School of Public Health finds that practices that implement an EHR without a laser focus on enhancing revenue and cutting costs are likely to lose more than $43,000 over five years. In other words, 73% of those surveyed failed to see a ROI. The financial implications of EHRs are about more than Meaningful Use (MU) checks, after all.That said, whether a medical practice wants to purchase an EHR, switch out its current solution – or simply get the most out of existing investments – there are three levers for maximizing the ROI of your EHR solution: #### 1. Choose a product that can enhance, not erode, profitability The American Academy of Family Physicians (AAFP) 2012 EHR User Satisfaction survey reflected that only 38% of respondents were highly satisfied with their EHR systems. Productivity declines were a primary source of dissatisfaction – and, in turn, lower ROI. Four attributes in particular help physicians make the most of their investment in an EHR system: high usability; capabilities for both charting and tasking; integration with practice management; and cloud-based delivery. #### 2. Optimize implementation for faster time to value For practices considering a new or replacement EHR, the next major element to tackle is optimizing the implementation and training process to accelerate time to value. Implementing a system as complex as an EHR can bring with it unforeseen expenses. And while Meaningful Use incentive programs are meant to help remedy that expenditure, some experts argue the money covers only a fraction of the system’s actual cost.The key is to strategically tackle the EHR implementation process by focusing on two key things: 1) Ensuring strong EHR integration into existing workflows, and 2) Making EHR implementation a team effort. #### 3. Attack Meaningful Use in a way that maximizes payments Meaningful Use (MU) attestation is a more nuanced process than industry observers often give it credit for. Not surprisingly, the first hurdle is pursuing Meaningful Use dollars with an incomplete knowledge of its requirements. CareCloud’s Meaningful Use expert, Michael Pepe, explains this succinctly: “In an obvious sense, ‘misstepping’ any MU measure can cost you the incentive payment, especially at the end of the reporting period of that year. For instance, improperly educating your staff will cost you in lost revenue because their time is being taken by completing tasks that have no meaning.” There are two areas that doctors and their staffs can strategically target to ensure the best possible chance at attesting for Meaningful Use dollars: 1) Treating Core Measure 15 carefully and 2) Minimizing the potential for negative audits. Download the CareCloud report to learn why Meaningful Use attestation is only one of the steps involved in seeing a return on your EHR investment. Please read the attached whitepaper  Keyword(s): ROIEHR #### Health Tech Entrepreneur Hardships ### DoctorBase CEO Talks Health Tech Entrepreneur Hardships Right now, innovations and the companies that create them are abounding in HIT. But that doesn’t mean that cracking the code to HIT success is all that easy. Even an experienced entrepreneur like John Kim says that healthcare is a difficult space for startups. And he should know. He started one. In April 2010, Kim cofounded DoctorBase, a developer of a cloud-based communications platform that offers mobile engagements to patients for providers. The San Francisco, CA-based company seems to be steadily growing as its platform moves into small and mid-level health organizations. Kim said he knew that the idea for DoctorBase was a solid one, having had previous success with his startup Five9and its development of virtual call center software. Still, it hasn’t been all smooth sailing for DoctorBase. Kim admits encountering his fair share of snags in the healthcare space, which have since humbled him. As a result, we at HIT Consultant wanted to sit down with Kim and talk about his successes and stumbles as an health tech entrepreneur, and how they are helping him shape the future of DoctorBase as its Cofounder and CEO: Let’s start with talking about DoctorBase and how the company came to fruition: What was the inspiration and thought process behind forming the company and devising the patient-doctor communications technology? In 2010 we saw the power of marketing automation software that was starting to become adopted by mainstream businesses, and we knew eventually, it was going to find its way into healthcare. We’re seeing that without marketing automation, patient engagement doesn’t operate efficiently at scale or get adoption from either providers or patients. Marketing automation is the secret sauce to effective patient engagement; so being better at healthcare marketing automation than anyone else has always been our focus. What was it about DoctorBase that made you think it was a project worthy of pursuing? What elements stuck out to you about the technologies that were going to give you an edge on the competition? Our first customer (the office manager for a doctor’s office named Linda) sent me a 2 word email in all caps. “LOVE IT.” That’s when we knew we were onto something. You have had notable success with launching multiple startups outside of the healthcare space. Tell me a briefly about what those experiences compare to DoctorBase: What’s been the greatest departure or change in approach that you had to adapt to when it comes to the HIT space? The toughest lesson for me was also the most humbling one. Based on the moderate success of my previous SaaS company Five9, I thought that we would walk into healthcare IT and “revolutionize it.” What we found, and are still learning, is that healthcare is actually a byzantine network of different industries, and not all of them are governed by traditional business rules or economic forces. From a technical or product perspective, we now push thousands of messages per day between providers and patients, and in healthcare you just can’t have “routine scheduled downtime maintenance” like you can with many B2B SaaS companies. The goal for the margin of allowable error is always nearing zero in healthcare. What are/were some of the key challenges that you have encountered with launching DoctorBase? We face a three pronged challenge each day: 1. How do you get patients engaged with their doctor and their medical staff without over-burdening the medical providers? 2. How do we make the lives of the medical office staff easier? 3. How do we get healthcare providers to collaboratively engage in meaningful ways that go beyond simple point-to-point email? Furthermore, how have those challenges changed your perspective on the HIT space? Were there assumptions or expectations you had that yielded different results? Many, many experts told us that medical professionals would not build their own social network on our platform or answer patient questions for free on their downtime. With thousands of our doctors answering patient questions for free on our platform (even though this new feature is just seven weeks old), our users have proven that the critics were wrong. Ultimately, all credit goes to the doctors and mid-levels who answer consumers – the critics just underestimated their compassion. Amidst all of this reshuffling of the healthcare economic cards, healthcare providers are healers by calling – nothing is going to stop them from helping people. Would you say that the consumer mentality is different in healthcare? Which part is the trickier piece of the puzzle, appealing to providers or to patients? Naturally, you are selling to providers, but you have to make sure you have a product that patients will use. Has that been part of the challenge at all? Here’s the tricky part of healthcare economics (and I’m part of this American sentiment as well so guilty as charged): When we’re healthy, we want to pay for the equivalent of cheap, federally subsidized cafeteria food. When we’re seriously ill, we want the hospital with the Louis Vuitton suite. That’s a tough challenge. What about the fact that DoctorBase started with a strictly mobile offering? Did that create unforeseen challenges? We started as a desktop offering that was forced to move to a dual-mode delivery platform that was heavily based on mobile experiences. If one thinks about it : A) Office staff are on Wintel desktop computers during their work hours. B) Doctors are on both desktop and mobile (heavily iOS) during work hours (for many doctors, all waking work hours are potential work hours). Also, throw in a high adoption rate of iPads amongst doctors. C) Patients can be heavily Android depending on the geographic area. We’ve seen in some of our neighborhoods that Android devices can be over 70% of the patient population on our platform. Building a seamless user experience with singularity of purpose-as-per-role is a constant puzzle, challenge and joy to work on with a three user interface – patient, provider and staff. We are starting to get marketing agencies and practice management consultants using our platform on behalf of their clients, so that may be another user base we need to learn from and address. However, this was totally unexpected as a user base even as of last year and we’re still learning about their needs as more healthcare organizations employ the professional services of agencies and consultants. How has tackling these challenges changed the way you view the company and product offerings? What about the consumers? DoctorBase has nearly doubled each year over the lifespan of our last four years, and we did it without VC funding. Healthcare has both humbled me and taught me to have more of a long term view on both the company and how our product innovations spread their influence over time. Now having experienced some of these challenges firsthand, why do you think it’s so difficult to build a successful health-tech startup as an entrepreneur? There are so many reasons why health-tech is so difficult for entrepreneurs, but I’ll list the top three in descending order of importance: 1. The biggest challenge is what Jason Lemkin of Saastr refers to as “VC Overhang.” In healthcare this is especially true, where you have companies that after raising several million dollars need a sizable exit in an industry where the potential M&A companies have more conservative valuations than VCs. 2. Lack of integrations kill nearly any good health IT ideas. Integration into existing EHR, billing, and PMS systems are a must if one’s idea is going to actually scale. We know this is especially difficult for a young startup, so our CTO has been documenting our APIs in the hopes that one day the increasing amount of Y Combinator, TechStars and Rock Health companies asking DoctorBase to license our integration libraries (we integrate to over 27 different EHR and PMS systems) can do it in a safe, affordable manner. 3. The patient owns the data. The doctor owns the patient (relationship). The office manager owns the office. Building an organizational culture that respects these fundamental truths was a lot harder than one might think. Are there unique challenges to consider when garnering funding, or creating an appropriate yet scalable business model in the HIT space? If so, what are they? Additionally, How do you ensure that you are growing your business at the right pace and what risk do your run when it comes to premature scaling? Most of the money in healthcare is in the services of delivering care -not technology. It’s a wonderful time to be raising money for your health-tech venture because there is an ocean of money out there right now, but both investors and developers have to be aware that there are very few potential bIllion dollar ARR companies in digital health currently. It’s important for entrepreneurs not to over-promise their investors, prepare their team for the long journey across the desert, and drink lots of fluids along the way. If you build your culture right, it will be an amazing road trip and the scale issues will resolve themselves simply because your team will help you pilot and adjust along your maze-like journey. As a result of all you have learned, where is DoctorBase today? What important changes have you made and what direction is the company headed in as a result? Deloitte released a study showing that 2014 was the breakout year for secure messages between providers and patients, and there’s potential legislation next year with bi-partisan support that would allow doctors to be reimbursed by Medicare for accepting patient messages. By being amongst the first platforms to gain traction in engaging providers, admins and patients in meaningful, collaborative and time-efficient ways, DoctorBase will be at the forefront of how healthcare access will be defined – and paid for. What is the critical lesson here for ambitious health-tech entrepreneurs? Walt Disney once said, “My best product goes home each night.” Similarly, in health-technology it’s all about the team. We just hired Joshua Angeles from ZocDoc to be our first VP of Sales – the energy his team brings to the office is infectious, both to our engineers and support team. From a product perspective my focus is on the next version of our platform, called PANDA Black – a culmination of 4 years of learning, mistakes and discoveries. I will wake up in the middle of the night and start working on it again because I can’t sleep, and often notice half of my engineering team is still on Slack (our group messaging application). We’re just loving it. The team is everything. Is there any one thing you wish you had done differently from the beginning? More importantly, is there anything that you definitely being doing differently as DoctorBase moves forward? I wish that we had found a co-founder from day one with a deep background in building great customer service teams. We had to find one later, and it cost us big time. Are the elements that made this project worth pursuing, have they changed at all, or have they still held true? It’s wise to follow Steve Job’s adage to “build useful things,” but in health-technology, those useful things better be monetizable relatively quickly and with a sizeable total addressable market to boot. DoctorBase CEO Talks Health Tech Entrepreneur Hardships by Erica Garvin  Keyword(s): Health TechEntrepreneur Hardships #### Seguridad Móvil ### ¿Cuáles son las mejores herramientas de seguridad para la colaboración móvil? Mario de Boer Estamos hablando de colaborar en equipos con los cuales usted puede no haber tenido una relación preexistente. ¿Va a forzar su MDM con todos esos dispositivos? Bueno, eso no va a funcionar, ¿no? La gestión de todos esos dispositivos no va a funcionar en esa situación. Si soy malware, y me estoy ejecutando en este dispositivo, ¿puedo acceder a los datos que viven en el contexto de otra aplicación? En general, estos dispositivos son bastante seguros. La única manera de hacerlo es con rooting, jailbreaking u obteniendo de otro modo acceso privilegiado al dispositivo. Bueno, ¿adivinen qué? Si soy tan inteligente, entonces puedo escribir malware que rompa los niveles privilegiados de ese dispositivo y probablemente puedo desactivar el anti-malware también, ¿verdad? Así que el anti-malware realmente no va a ayudarle con la protección de sus datos. Afortunadamente, muchos de los dispositivos móviles modernos tienen muy buena protección de datos y control de acceso en el propio dispositivo. Nosotros [también] tenemos soluciones de contenedores, tenemos gestión de aplicaciones móviles y tenemos cada vez más soluciones empresariales como soluciones corporativas para compartir archivos que hacen un muy buen trabajo protegiendo los datos que se almacenan en estos dispositivos móviles. Pero idealmente, el usuario o empresa deberían ser capaces de proteger los datos en sí, no solo las aplicaciones, a través del control de gestión de derechos –que dicta quién puede ver o modificar la información que usted comparte y quién no– y hacer la protección de datos a nivel local, justo en el propio dispositivo móvil. Lo que realmente me gustaría es proteger los datos en sí y no preocuparme por las aplicaciones. Usando la gestión de derechos, por ejemplo. Si no podemos usar eso, entonces tenemos que depender de, por ejemplo, la sincronización de archivos corporativa y compartir eso que se ejecuta en el dispositivo para hacer el control de acceso y la protección de datos local en el propio dispositivo. Créanme que estas soluciones son cada vez mejores y mejores en hacer eso. Y olvídese de la gestión de todo el dispositivo, ya que no va a funcionar en la colaboración móvil. #### Mueva el entorno de colaboración móvil a la nube En primer lugar, utilizamos servicios en la nube no solo para evitar la apertura de su red interna, sino también porque muchas de las soluciones en la nube están realmente bien equipadas para soportar dispositivos móviles, para soportar múltiples grupos de usuarios de diferentes organizaciones y para estar disponible de manera muy fiable. El riesgo, por supuesto, es que se pierde el control. Usted tiene que renunciar a parte de su propio control y cambiarlo por confianza. [Pero] la mejor conclusión es evitar el uso de las redes internas por completo. Ir a la nube con su entorno de colaboración. Las soluciones en la nube remedian el riesgo de dar acceso remoto... la única cosa de la que tiene que cuidarse en este caso es que intercambie los riesgos de dar más acceso a las aplicaciones generales con tener confianza. #### Asegure las aplicaciones ofreciendo alternativas a los usuarios Asegúrese de que tiene alternativas empresariales para aplicaciones de colaboración que tengan una facilidad de uso que realmente coincida con las soluciones que la gente tiene de forma gratuita. Suena difícil de hacer, ¿verdad? ¿Cómo puedo coincidir con la usabilidad de Dropbox? Bueno, sí puede porque usted es una empresa. Puede ofrecer a sus usuarios una solución que no solo sincronice y comparta archivos, sino que sincronice y comparta archivos y además dé acceso a carpetas internas importantes, y dé acceso a su entorno de SharePoint, y se integre con su información de presencia. Usted puede hacer una solución mucho mejor que las soluciones gratuitas. Así que esa es una oportunidad. También puede, nuevamente… utilizar el control de gestión de derechos para controlar los datos en sí. Ahora controlo el acceso a esos datos independientemente de la aplicación que utilizo. Ya se trate de sincronizar y compartir archivos corporativos o simplemente almacenamiento en la nube o correo electrónico, no me importa... Y puedo cambiar la política en cualquier momento que quiera. De la presentación de Mario de Boer sobre "Cinco Mayores Problemas de Seguridad en la Colaboración Móvil”, en la Conferencia Catalyst de Gartner en San Diego. De Boer es un analista de Gartner en el equipo de Estrategias de Seguridad y Manejo de Riesgos para los Profesionales Técnicos. Sus principales áreas de interés son seguridad de punto final y dispositivos móviles, seguridad del navegador web y seguridad de las redes sociales, correo electrónico y colaboración. Cuenta con más de 15 años de experiencia en la industria en las áreas de seguridad, riesgo y temas de cumplimiento, trabajando para empresas, organizaciones gubernamentales y empresas de consultoría. Link: http://searchdatacenter.techtarget.com  Keyword(s): Seguridad Móvil #### Healthcare IT Startups # What's Hot, Not in Healthcare IT Startups By Brian Eastwood Healthcare attracts much interest from startups. It's not surprising, really. Most incumbent electronic health record (EHR) vendors are too busy to innovate, says Matthew Holt, co-chair of Health 2.0; they must focus on meaningful use and ICD-10 instead. Providers grapple with similar problems, plus the emerging challenges of accountable care and changing business models. Healthcare startups, then, find themselves in a market mirroring the tech landscape of the late 1990s, when companies developed core enterprise products to fill gaps left by Microsoft. Look at America's healthcare industry today – poised to exceed$3 trillion in 2014, with much of that money spent on chronic yet preventable conditions – and it becomes clear just how many gaps there are.

Efforts to fill those gaps vary. Put another way: Some markets are hotter than others. To gain some clarity, Health 2.0, StartUp Health and Rock Health – all of which work closely with healthcare entrepreneurs – discuss where they see the most and the least action. Their assessment of startup activity in 15 key areas of healthcare follows.

(Note: We talked general trends, not hard and fast numbers. Also, the "hot," "warm" and "cold" labels were determined by CIO.com and are subjective. Finally, companies and products are mentioned solely to provide examples, not to offer endorsements.)

#### Hot: Sensors and Connected Devices

Wearable tech gets the runway treatment and just about every major hardware maker sells a smartwatch. Healthcare's interest, though, turns to sensors and devices with more specific purposes. AdhereTech makes smart pill bottles to note the time and location pills were taken and send reminders about missed doses; this improves medication adherence. Cohero Health does something similar with inhalers. Many diagnostic devices plug into smartphones, too, increasingly making Dr. McCoy's medical tricorder less science fiction and more reality. "There are entire new businesses being formed around these sensor-enabled and connected devices," says Unity Stoakes, president and co-founder of StartUp Health.

#### Hot: Home Healthcare

Where would prefer to spend your golden years: At home or in an assisted living facility? That single question explains the high interest in home healthcare services, from doctors on demand (Medicast) to a caregiver marketplace (CareLink) to wearable sensors that monitor everyday behavior and send alerts is anything is amiss (CarePredict). "They're making it much more efficient and easier to stay in the home," Stoakes says, adding that interest isn't limited to Baby Boomers. Meanwhile, Holt notes that, while such devices are largely for consumers, they're increasingly becoming part of the overall health system.

#### Hot: Big Data and Analytics

Connected devices create data. So, too, do electronic health record (EHR) systems, other clinical apps, billing systems, pharmacy records – the list goes on. "This market is emerging to make sense of the data and make it useful and meaningful and actionable," Stoakes says. Healthcare analytics case studies (examples here and here) target many aspects of hospital operations, from reducing readmissions to cutting costs to making sense of bundled patients (Aver Informatics) and lab data (Medivo) to quickly getting the right antibiotics to patients with bacterial infections (LuminaCare). Also of interest, thanks to healthcare reform: Price data transparency, which shows providers, payers, employers and employees what they will (or, as the case may be, will not) pay for particular procedures.

#### Hot: Population Health Management

Healthcare still doesn't have all the data necessary to make business decisions – but it has more than it used to, as data sets from payers and the Centers for Medicare and Medicaid Services are now more readily available. This provides an "entry point" for companies aiming to go beyond mere data aggregators to more complete solution providers, says Teresa Wang, strategy manager at Rock Health. Population health management primarily identifies and targets an institution's most at-risk patients, examining ways to offer preventive care or outreach that helps patients stay healthy and out of the emergency room. Much of this can be automated, from reporting to patient education to appointment or test reminders.

With health insurance companies often seen as the Bad Guys responsible for spiraling healthcare costs, it's little surprise that there are opportunities for startups to help payers trim management and administration costs. Desired functionality includes business process automation, prescription administration, health information exchange and claim adjudication – and, of particular interest in a post-reform world, with a growing number (and complexity) of health plans for a growing number of buyers, benefit plan and member eligibility management. Oh, and don't forget analytics.

#### Warm: Patient-Facing Tech

Here there's some disagreement. Technology such as patient portalswearable technologyand fitness trackers "haven't seen big successes yet," StartUp Health's Stoakes says; they don't integrate with clinical workflows and struggle to save money, add revenue or save time for providers.

Rock Health, on the other hand, ranks "healthcare consumer engagement" among its emerging themes of 2014. Such technology receives funding, Wang says, because it helps address healthcare reform's stated goal of streamlining the industry. It also ties into the "evolution of the accountable care organization," Health 2.0's Holt says, as it makes patients more informed participants in a more coordinated healthcare process.

#### Warm: Video

Recent Deloitte research says one in six doctor visits will be virtual this year in the United States and Canada. Established vendors exist in this market – namely, WellDoc and American Well – but activity persists, with Grand Rounds and Doctors on Demand (advised by "Dr. Phil" McGraw and funded by Sir Richard Branson) among the firms (and big names) getting in on the action.

For all that's happening, though, Holt admits that a lot of the companies are doing the same thing, or at least something similar. Stoakes, for his part, says StartUp Health still expects activity around video-enabled health interactions but adds, "We thought it would have happened by now."

#### Warm: Digital Therapy

This broad market segments address chronic conditions, such as diabetes, hypertension or obesity, which are better treated with more continuous monitoring of a patient's condition than the status quo of infrequent in-person doctor visits. This involves sensors and apps – or, in the case of Proteus Digital Health, a small sensor in each pill a patient swallows – but also a more direct connection to a physician than a smartphone app or wristband. The idea is to use software to deliver better clinical outcomes, Wang says: "It makes healthcare much more accessible." The digital therapy market has grown 20-fold since 2011, Wang says, albeit from a small benchmark.

#### Warm: Physician Search

Health 2.0 Research Analyst Kim Krueger has tried a few physician search tools, with limited success. It's a novel idea, and one on which many companies hope to capitalize, but it remains "an area that's very complex [with] not a lot of abstraction at the moment," Holt says. At issue: Looking for a doctor is a "very complex algorithm," one that must incorporate a physician's diagnostic history, a patient's personal preference and a variety of other factors that, for many reasons, aren't readily available or publicly reported.

#### Warm: Clinical Trials

Clinical trials are expensive. Not coincidentally, they also rely on a lot of paper – for patient-reported outcomes as well as clinical outcome assessments. Seems like an easy place to get started, as Wang puts it. Digital solutions (either through smartphones or tailor-made devices) could be used in all phases of the clinical trial, from design to recruitment to monitoring to maintenance to post-trial market reporting. There's interest, Wang adds – but, as with digital therapy, this particular market segment has received less absolute funding than some of those previously discussed.

#### Cold: Gamification

Standalone gamification apps faded from view as the industry learned that getting healthy isn't a game. "You need something that will sustain behavior change," Wang says. That said, the concept of game mechanics, along with excitement about its potential, has found its way into tools for patient engagement and wellness, Holt says. (Think of programs that offer coupons, discounts and other rewards for participants who consistently make healthy choices.) Gamification has also emerged on the provider side as a motivator for continuing medical education, Krueger adds.

#### Cold: Enterprise Wellness

Employee wellness programs have had pockets of success, but many struggle, including those that offer free or discounted fitness trackers. The problems mirror those of many other types of patient engagement. Not only must the technology be right; the marketing, the motivating factors, the incentives (tangible or otherwise), the rewards and the lasting value all have to be right as well. What's more, the firms that operate in the enterprise wellness market are well-established and "relatively dominant," Wang says. Not surprisingly, this tempers startups' interest.

#### Cold: Personal Genomics

The cost of mapping the human genome has dropped from $100 million in 2011 to less than$5,000 today. Inexpensive, readily available genomic research could fundamentally change diagnostics, predictive analytics and drug development. However, aside from 23andMe and despite an influx of venture capital, there's a "So what?" factor attached to personal genomics, Holt says. (It doesn't help that 23andMe drew the ire of the FDA, which says it provided results that weren't "analytically or clinically validated.") Patients' persistent struggle to share information with providers, physicians' reluctance to trust third-party data and cash-strapped providers' unwillingness to pass up revenue from pricey tests may all play a part here.

#### Cold: Personal Health Records

Google Health rests in peace, Microsoft HealthVault languishes and patient portals stillhaven't caught on. Blame poor design, Holt says, as well as the inability to connect to enterprise systems. (Such negligence is understandable; after all, patients use portals or PHRs much less frequently than, say, social media sites.) Consumer health data platforms could be the answer, he adds, as could data utility layers from fitness device makers, who have plenty of personal health data on hand.

Holt spoke to CIO.com before Aetna scrapped CarePass and Apple told developers not to store health data in iCloud. Neither development bodes well for any startup aiming to help patients take control of their personal health information.

#### Cold: Social Networks for Doctors

There's Doximity and Sermo, yes, but that's about it. Plus, while they let physicians connect with, securely message and pose questions to each other, they don't connect physicians to current or prospective patients. At a broader level, though, it may not matter. Physicians tend to shy away from social media, in large part because the risks associated with healthcare social media are broad, ranging from HIPAA to reputation management. It's a shame, too, because patients are all over social media, and they often get bad health information as a result.

#### Cold: Electronic Health Records

Thanks to meaningful use, EHR implementation has, for the most part, already happened, Wang notes. It's therefore a mature market – and a crowded one, with several hundred vendors (from boutique shops to the \$1.7 billion Epic Systems) in the United States alone. Startups very well may be tempted to dip their toe in the water; poor usability, workflow and interoperability suggest that the EHR market is poised for disruption, as do reports indicating that 40 percent of practices want to switch EHR vendors. Incumbents don't go down easily, though – even if, as Stoakes says, today's EHR systems are "still completely broken."

 Keyword(s): HealthcareIT Startups

by John Lynn

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 15 blogs containing almost 6000 articles with John having written over 3000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 13 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit.

It seems like I have a little trend of leadership posts going on. This one goes along the lines of my previous post where I talked about Surpassing Expectations. The next leadership concept that I want to talk about comes from Brad Feld and he calls it Negative Maintenance.

Here’s how Brad describes it from his perspective:

There are days that I’m high maintenance. Everyone is. But if you subscribe to my “give before you get”, or #givefirst, philosophy, you are constantly contributing more than you are consuming. I’ve talked about this often in the context of Startup Communities, but I haven’t really had the right words for this in the context of leadership, management, and employees in a fast growing company.

I think that this description applies just as well to healthcare organizations. We all know the Hospital CIO who takes more than he gives. The hospital CIO that makes a project 10 times harder than it needs to be with the exact same (or sometimes worse) results. Hopefully you’ve also known leadership that makes your life easier. They remove roadblocks. They clearly articulate the path forward. They make the work easier as opposed to harder.

The same applies to anyone on a project team. There are those people on a team that are high maintenance, no maintenance, and negative maintenance. The highest performing teams are those that have a team full of negative maintenance people.

What kind of team member are you?

#### Are women flourishing in IT? Find out by downloading the Women in techology report from Computer Weekly and Mortimer Spinks.

• The average number of women in technology teams is 12%, down from 15% last year
• 71% of men have asked for a pay rise compared to 61% of women
• 94% of people are happy to be working in technology