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10 key insights on clinical partnering

by System Administrator - Tuesday, 27 January 2015, 2:26 PM

10 key insights on clinical partnering

This is the year we can increase the efficiencies of clinical trials through collaboration, innovation and enhancing quality. Where are the opportunities? How can we work differently with our partners? How can we embrace the changing technologies? How can we sustain effective clinical partnerships?

These are crucial questions and ones that we answer in our latest ebook – 10 key insights on clinical partnering.

  • Jo Sawyer, Head of External Partnerships, Novartis AG
  • Geno Gregory, Associate Director, Strategic Development, Global Phase 1 and Early Development Strategy, J&J
  • Mireille Zerola, Clinical Data Management Expert, Boehringer Ingelheim
  • Russell Svensen, Head Clinical Operations, Ipsen Pharma
  • Dave Walker, Senior Director, Clinical Development, Norgine
  • Olena Goloborodko, Senior Manager Global Contracts and Outsourcing Management, Astellas

Please read the attached eGuide

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11 Steps Attackers Took to Crack Target

by System Administrator - Monday, 19 October 2015, 5:05 PM

11 Steps Attackers Took to Crack Target

By Thor Olavsrud

Aorato, a specialist in Active Directory monitoring and protection, delivers a step-by-step report on how attackers used the stolen credentials of an HVAC vendor to steal the data of 70 million customers and 40 million credit cards and debit cards from the retailer.

Despite the massive scale of the theft of Personal Identifiable Information (PII) and credit card and debit card data resulting from last year's data breach of retail titanTarget, the company's PCI compliance program may have significantly reduced the scope of the damage, according to new research by security firm Aorato, which specializes in Active Directory monitoring and protection.

Leveraging all the publicly available reports on the breach, Aorato Lead Researcher Tal Be'ery and his team catalogued all the tools the attackers used to compromise Target in an effort to create a step-by-step breakdown of how the attackers infiltrated the retailer, propagated within its network and ultimately seized credit card data from a Point of Sale (PoS) system not directly connected to the Internet.

Many of the details of how the breach occurred remain obscured, but Be'ery says it is essential to understand how the attack happened because the perpetrators are still active. Just last week, the Department of Homeland Security (DHS) and United States Secret Service released an advisory that the malware used to attack Target's PoS system has compromised numerous other PoS systems over the past year.

Tracing the Attack Is Like Cyber Paleontology

While Be'ery acknowledges that some of the details in Aorato's account may be incorrect, he feels confident that the reconstruction is largely accurate.

"I like to think of it as cyber paleontology," Be'ery says. "There were many reports on the tools that were found in this incident, but they didn't explain how the attackers used these tools. It's like having bones, but not knowing what the dinosaurs looked like. But we know what other dinosaurs looked like. With our knowledge we were able to reconstruct this dinosaur."

In December 2013, in the midst of the busiest shopping season of the year, word began trickling out about a data breach at Target.

Soon the trickle was a torrent, and it would eventually become clear that attackers had gotten the Personal Identifiable Information (PII) of 70 million customers as well as data for 40 million credit cards and debit cards. CIO Beth Jacob and Chairman, President and CEO Gregg Steinhafel resigned. Target's financial damages may reach $1 billion,according to analysts.

Most who have followed the Target story know that it began with the theft of credentials of Target's HVAC contractor. But how did the attackers get from that initial point of penetration, at the boundary of Target's network, to the very heart of its operations? Be'ery believes the attackers took 11 deliberate steps.

Step 1: Install Malware that Steals Credentials

It started with stealing the credentials of Target's HVAC vendor, Fazio Mechanical Services. According to KresonSecurity, which first broke the story of the breach, the attackers infected the vendor with general purpose malware known as Citadel through an email phishing campaign.

Step 2: Connect Using Stolen Credentials

Be'ery says the attackers used the stolen credentials to gain access to Target-hosted web services dedicated to vendors. In a public statement issued after the breach, Fazio Mechanical Services President and Owner Ross Fazio said the company "does not perform remote monitoring or control of heating, cooling or refrigeration systems for Target. Our data connection with Target was exclusively for electronic billing, contract submission and project management."

This web application was very limited, Be'ery says. While the attackers now had access to a Target internal web application hosted on Target's internal network, the application did not allow for arbitrary command execution, which would be necessary to compromise the machine.

Step 3: Exploit a Web Application Vulnerability

The attackers needed to find a vulnerability they could exploit. Be'ery points to one of the attack tools listed in public reports on the list, a file named "xmlrpc.php." According to Aorato's report, while all the other known attack tool files are Windows executables, this was a PHP file, which is used for running scripts within web applications.

"This file suggests that the attackers were able to upload a PHP file by leveraging a vulnerability within the web application," The Aorato report concludes. "The reason is that it is likely the web application has an upload functionality meant to upload legitimate documents (say, invoices). But as often happens in web applications, no security checks were performed in order to ensure that executable files are not uploaded."

The malicious script was probably a "web shell," a web-based backdoor that allowed the attackers to upload files and execute arbitrary operating system commands.

Be'ery notes that the attackers likely called the file "xmlrpc.php" to make it look like a popular PHP component — in other words the attackers disguised the malicious component as a legitimate one to hide it in plain sight. This "hiding in plain sight" tactic is a hallmark of these particular attackers, Be'ery says, noting that it was repeated multiple times throughout the attack.

"They know they're going to get noticed in the end because they're stealing credit cards, and the way to monetize credit cards is to use them," he explains. "As we saw, they sold the credit card numbers on the black market and pretty soon afterward Target was notified of the breach by the credit card companies. The attackers knew that this campaign would be short-lived, a one-off. They weren't going to invest in infrastructure and becoming invisible because in a few days this campaign would be gone. It was enough for them to hide in plain sight."

Step 4: Search Relevant Targets for Propagation

At this point, Be'ery says, the attackers had to slow down and do some reconnaissance. They had the capability to run arbitrary OS commands, but proceeding further would require intelligence on the layout of Target's internal network — they needed to find the servers that held customer information and (they hoped) credit card data.

The vector was Target's Active Directory, which contains the data on all members of the Domain: users, computers and services. They were able to query Active Directory with internal Windows tools using the standard LDAP protocol. Aorato believes the attackers simply retrieved all services that contained the string "MSSQLSvc" and then inferred the purpose of each service by looking at the name of the server (e.g., MSSQLvc/billingServer). This is likely also the process the attackers would later use to find PoS-related machines, according to Aorato.

With the names of their targets, Aorato says the attackers then obtained their IP addresses by querying the DNS server.

Step 5: Steal Access Token from Domain Admins

By this point, Be'ery says the attackers had identified their targets, but they needed access privileges to affect them — preferably Domain Admin privileges.

Based on information given to journalist Brian Krebs by a former member of Target's security team, as well as recommendations made by Visa in its report on the breach, Aorato believes the attackers used a well-known attack technique called "Pass-the-Hash" to gain access to an NT hash token that would allow them to impersonate the Active Directory administrator — at least until the actual administrator changed his or her password.

As further evidence of the use of this technique, Aorato points to the use of tools, including penetration test tools, whose purpose is to logon sessions and NTLM credentials from memory, extract domain accounts NT/LM hashes and history and dump password hashes from memory.

Step 6: Create a New Domain Admin Account Using the Stolen Token

The previous step would have allowed the attackers to masquerade as a Domain Admin, but would have become invalid if the victim changed their password, or when trying to access some services (like Remote Desktop) which require the explicit use of a password. The next step, then, was to create a new Domain Admin account.

The attackers were able to use their stolen privileges to create a new account and add it to the Domain Admins group, giving the account the privileges the attackers required while also giving the attackers control of the password.

This, Be'ery says, is another example of the attackers hiding in plain sight. The new username was "best1_user," the same username used by BMC's Bladelogic Server Automation product.

"This is a highly abnormal pattern," Be'ery says, noting that the simple step of monitoring the users list and flagging new additions for sensitive accounts like administrator accounts could go a long way toward stopping attackers in their tracks. "You have to monitor access patterns."

He also notes that the reconnaissance actions taken in step four are another example of abnormal usage that activity monitoring can detect.

"It's very important to monitor for reconnaissance," Be'ery says. "Every network looks different, has a different structure. Attackers have to learn about that structure through queries. That behavior is very different from the normal patterns of users."

Step 7: Propagate to Relevant Computers Using the New Admin Credentials

With their new credentials, the attackers could now proceed to go after their targets. But Aorato notes two obstacles were in their path: bypassing firewalls and other network-based security solutions that limit direct access to relevant targets, and running remote processes on various machines in the chain toward their relevant targets.

Aorato says the attackers used "Angry IP Scanner" to detect computers that were network accessible from the current computer and then tunneled through a series of servers to bypass the security measures using a port forwarding IT tool.

As for remotely executing processes on the targeted servers, Aorato says the attackers used their credentials in conjunction with the Microsoft PSExec utility (a telnet-replacement for executing processes on other systems) and the Windows internal Remote Desktop (RDP) client.

Aorato notes that both tools use Active Directory to authenticate and authorize the user, which means Active Directory is aware of this activity if anyone is looking for it.

Once the attackers had access to the targeted systems, they used the Microsoft Orchestrator management solution to gain persistent access, which would allow them to remotely execute arbitrary code on the compromised servers.

Step 8: Steal 70 Million PII. Do Not Find Credit Cards

At this point, Aorato says the attackers used SQL query tools to assess the value of database servers and a SQL bulk copy tool to retrieve database contents. And here, Be'ery says, is where PCI compliance seems to have presented a big obstacle to the attackers — ultimately what may have kept them to stealing "only" 40 million credit cards and debit cards rather than 70 million, a 40 percent reduction of the incident's repercussions.

Section 3.2 of the PCI-DSS standard states: "Do not store sensitive authentication data after authorization (even if encrypted). If sensitive authentication data is received, render all data unrecoverable upon completion of the authorization process."

In other words, while the attackers had already managed to access the PII of 70 million Target customers, it did not have access to credit cards. The attackers would have to regroup with a new plan.

"Since Target was PCI compliant, the databases did not store any credit card specific data, so they had to switch to plan B and steal the credit cards directly from the Point of Sales themselves," Be'ery says.

Step 9: Install Malware. Steal 40 Million Credit Cards

The PoS system was probably not an initial target of the attackers, Be'ery says. It was only when they were unable to access credit card data on the servers they had accessed that they focused on the PoS machines as a contingency. Using the intel garnered during step four and the remote execution capabilities garnered during step seven, the attackers installed the Kaptoxa (pronounced "Kar-toe-sha") on the PoS machines. The malware was used to scan the memory of infected machines and save any credit cards found to a local file.

This step, Be'ery notes, is the only one in which the attackers seem to have used custom-written malware rather than common IT tools.

"Having antivirus would not help you in this case," he says. "When the stakes are so high, with profit in the tens of millions of dollars, they don't care about the cost of creating tailor-made tools."

Step 10: Send Stolen Data via Network Share

Once the malware obtained the credit card data, it created a remote file share on a remote, FTP-enabled machine using a Windows command and the Domain Admin credentials. It would periodically copy its local file to the remote share.

Again, Be'ery notes, these activities would have been authorized against Activity Directory, making it aware of the activity.

Step 11: Send Stolen Data via FTP

Finally, once the data arrived on the FTP-enabled machine, a script was used to send the file to the attackers' controlled FTP accounting using the Windows internal FTP client.

"The initial penetration point is not the story, because eventually you have to assume you're going to get breached," Be'ery says. "You cannot assume otherwise. You have to be prepared and have an incident response plan for what to do when you are breached. The real problem arises when malware is able to enable an attacker to penetrate deeper into the network."

"If you have the right visibility, that activity really stands out," he adds.

How to Protect Your Organization

Be'ery recommends that organizations take the following steps to protect themselves:

  • Harden access controls. Monitor and profile access patterns to systems to identify abnormal and rogue access patterns. Where possible, use multi-factor authentication to sensitive systems to reduce risks associated with theft of credentials. Segregate networks, limit allowed protocols usage and limit users' excessive privileges.
  • Monitor users' lists for the addition of new users, especially privileged ones.
  • Monitor for signs of reconnaissance and information gathering. Pay special attention to excessive and abnormal LDAP queries.
  • For sensitive, single-purpose servers, consider whitelisting of allowed programs.
  • Don't rely on anti-malware solutions as a primary mitigation measure since attackers mostly leverage legitimate IT tools.
  • Place security and monitoring controls around Active Directory as it is involved in nearly all stages of the attack.
  • Participate in Information Sharing and Analysis Center (ISAC) and Cyber Intelligence Sharing Center (CISC) groups to gain valuable intelligence on attackers' Tactics, Techniques and Procedures (TTPs).


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12 steps to the perfect health system

by System Administrator - Tuesday, 10 November 2015, 7:13 PM

12 steps to the perfect health system


By Ilene MacDonald

Recent FierceHealthcare coverage has highlighted the challenges hospitals and health systems face daily: high costsinfection control and patient satisfaction to name just a few.

And though organizations have made strides to transition to value-based care and better manage population health, overall the United States spends more on healthcare but ranks last in quality compared to 10 other industrialized Western nations.

It's hard to imagine or dream that a perfect health system could exist--one that would meet all patients' needs at reasonable costs.

So it was with interest that I recently started to read Mark Britnell's new book, "In Search of the Perfect Health System." Britnell, the former chief executive candidate for the National Health Service (NHS) in England, now serves as the chairman and partner of the Global Health Practice at auditing firm KPMG. He's spent the last five years working in 60 countries to help governments and public and private sector organizations with operations, strategy and policy.

His travels have allowed him to witness first-hand examples of great health and healthcare. Although he hasn't found a perfect health system, he writes that if he found one it would feature 12 components that take from the best practices from around the world. And it would look something like this:

1. Universal healthcare: The best, he says, is offered by the NHS in the United Kingdom. The NHS was the first in the world to create a universal healthcare system, one that is available to all citizens, regardless of whether they have the ability to pay for it.

2. Primary care: Britnell turns to Israel for the example of excellent primary care. Indeed, Israel has one of the highest life expectancy rates in the world (average age of 82) and one of the lowest shares of gross domestic product (GDP) spent on health. Primary care is supported by four health maintenance organizations that act as both purchaser and provider for preventive, primary and community services. Out-of-hours care is provided around the clock, he writes, and integrated with evening care centers, urgent care centers and home visit services.

3. Community services; For inspiration, he suggests we look to Brazil where community teams made up of doctors, nurses, nurse auxiliary and community health workers visit households every month, whether or not they demand or need it. These teams offer immunizations, chronic disease management and screenings.

4. Mental health and well-being: Australia has made the most progress in this area, according to Britnell's research, offering public funding to invest in crisis and home treatment, early intervention and assertive outreach.

5. Health promotion: The Nordic countries best address the social determinants of health, encouraging individual responsibility and fostering collective action, according to Britnell. The five countries have public health and illness prevention strategies that contribute to low smoking, alcohol consumption and obesity rates, he says.

6. Patient and community empowerment: Britnell says the world can learn about patient empowerment from Africa, which blends community activism, patient education, social marketing and behavior change to promote better health. One example is the maternity care program in Kenya, which encourages mothers and women to share experiences to help cut maternal and infant death.

7. Research and development: This is where the U.S. shines, he says, noting the number of high-impact drugs and medical devices we've developed. But he also called out the innovation of new business and care models, including Kaiser Permanente's health information and technology systems, Geisinger Heath Systems' population health management and Virginia Mason's lean manufacturing principals.

8. Innovation, flair and speed: Britnell has found inspiration for the adoption and adaption of new innovations in India, where several organizations have been able to create a hub-and-spoke model that focuses on cost effectiveness rather than cost-cutting. Examples included standardized care pathways, making it easier to shift tasks and do more with fewer staff; referral networks that channel patients to the correct settings and even hospitals manufacturing their own devices or implants when suppliers refused to reduce prices.

9. Information, communications and technology: Singapore offers great examples of the sharing of patient data via a national electronic health record that allows access to all hospitals, community facilities, practitioners and long-term care homes, he writes. This provides the country with the ability to fully analyze clinical, financial and operational data to better assess healthcare costs and outcomes.

10. Choice:  There are no out-of-network providers in France. Patients can go to any doctor or hospital they wish, he says. Patient satisfaction is particular high, he notes, as are the country's quality and outcomes.

11. FundingNo country does it better than Switzerland, which spends11.5 percent of GDP on health, according to Britnell. The country also boasts high patient satisfaction, good clinical outcomes and life expectancy of 82.7 years. But Britnell notes that the country can afford to spend so much because its economy is globally competitive and dynamic.

12. Aged care: Japan offers its citizens compulsory long-term care insurance, which offers social care to all those older than 65 based solely on need. The ability to pay is not part of the assessment process. Care offered under the plan includes home help, community-based services, and residential and nursing care. The country has also created dementia homes where groups of people live together in a supportive, home-like environment, he writes.

Wouldn't it be wonderful to live in a country that offered this type of healthcare system? Given the continued fight in the country to just provide affordable care to all, it does seem impossible. But I guess we can dream.-- Ilene (@FierceHealth)

Related Articles:




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12 Ways Secure Texting is Used in Healthcare

by System Administrator - Monday, 12 January 2015, 6:34 PM

12 Ways Secure Texting is Used in Healthcare

This infographic outlines how secure messaging is used within a healthcare organization as well as layout the benefits.

Please read the attached PDF

Related Resources:


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2014 Healthcare Innovation Report

by System Administrator - Tuesday, 13 January 2015, 1:07 PM

FierceHealthIT's 2014 Healthcare Innovation Report

This FierceHealthIT special report celebrates the advancements made by healthcare solutions providers to ensure healthcare is more affordable and accessible. The report also recognizes the winners of the 2014 Fierce Innovation Awards: Healthcare Edition.

Please read the attached PDF report.


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2014 Insider Threat

by System Administrator - Thursday, 14 August 2014, 9:22 PM


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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2015 Annual Security Report

by System Administrator - Monday, 2 March 2015, 2:28 PM

Cisco 2015 Annual Security Report: New Threat Intelligence and Trend Analysis

Despite advances by the security industry, criminals continue to evolve their approaches to break through security defenses. Attackers are realizing that bigger and bolder is not always better. The Cisco 2015 Annual Security Report reveals shifts in attack techniques, emerging vulnerabilities, and the state of enterprise security preparedness.

Please read the attached whitepaper.

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2015 global life sciences outlook

by System Administrator - Tuesday, 30 December 2014, 9:26 PM

Infographic: 2015 global life sciences outlook

Greg Reh | DTTL Global Life Sciences Sector Leader | Greg is the DTTL Global Life Sciences Sector Leade...More

The extended nature of life sciences product development mandates that sector stakeholders adopt a long-term approach to strategic planning, portfolio management, and market expansion. However, organizations must also prepare for and react to near-term challenges and opportunities. Four major trends are expected to capture the sector’s attention in 2015: searching for innovation and growth; changing regulatory and risk environment; preserving and building shareholder value; and preparing for the “next wave.” The resulting challenges and opportunities can be both global and market-specific.

Check out top life sciences sector issues for 2015 in the inforgraphic below.

Click here to download a copy of the infographic and full report.

Please read the attached infographic file.

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2016 EHR Software Pricing Guide: How to Compare EMR Systems

by System Administrator - Monday, 19 October 2015, 6:39 PM

2016 EHR Software Pricing Guide: How to Compare EMR Systems

by Software Advice

This guide is based on extensive market research and is designed to help chiropractic professionals: 

  • Learn about relevant pricing models
  • Understand common price ranges
  • Account for additional cost factors
  • Budget by desired applications
  • Compare prices of popular systems

Please download the attached whitepaper.

Below are additional offers that might interest you:

2016 Applicant Tracking Systems Pricing Guide
Simplify your ATS software evaluation process with this free download! This guide is based on extensive market research and is designed to help chiropractic professionals: • Learn about relevant pricing models • Understand common price ranges • Account for additional cost factors • Budget by desired applications • Compare prices of popular systems
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5 Key Aspects to Accurate HR Software Pricing
Simplify your software evaluation process with this 2016 HR software pricing guide! This guide is based on extensive market research and is designed to help chiropractic professionals: • Learn about relevant pricing models • Understand common price ranges • Account for additional cost factors • Budget by desired applications • Compare prices of popular systems
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2016 Payroll Software Pricing Guide: How to Compare Systems
Simplify your payroll software evaluation process with this free download!! This guide is based on extensive market research and is designed to help chiropractic professionals: • Learn about relevant pricing models • Understand common price ranges • Account for additional cost factors • Budget by desired applications • Compare prices of popular systems
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5 Key Aspects of Accurate Payroll Software Pricing
Simplify your software evaluation process with this 2016 payroll software pricing guide! This guide is based on extensive market research and is designed to help chiropractic professionals: • Learn about relevant pricing models • Understand common price ranges • Account for additional cost factors • Budget by desired applications • Compare prices of popular systems
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5 Key Aspects of Accurate Applicant Tracking Systems Pricing
Simplify your software evaluation process with this 2016 ATS software pricing guide! This guide is based on extensive market research and is designed to help chiropractic professionals: • Learn about relevant pricing models • Understand common price ranges • Account for additional cost factors • Budget by desired applications • Compare prices of popular systems
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5 Key Aspects of Accurate Learning Management Systems Pricing
Simplify your software evaluation process with this 2016 LMS software pricing guide! This guide is based on extensive market research and is designed to help chiropractic professionals: • Learn about relevant pricing models • Understand common price ranges • Account for additional cost factors • Budget by desired applications • Compare prices of popular systems
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2016 Learning Management Systems Pricing Guide
Simplify your learning management software evaluation process with this free download! This guide is based on extensive market research and is designed to help chiropractic professionals: • Learn about relevant pricing models • Understand common price ranges • Account for additional cost factors • Budget by desired applications • Compare prices of popular systems
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2016 HR Software Pricing Guide: How to Compare HR Systems
Simplify your HR software evaluation process with this free download! This guide is based on extensive market research and is designed to help HR professionals: • Learn about relevant pricing models • Understand common price ranges • Account for additional cost factors • Budget by desired applications • Compare prices of popular systems
Download This Research

Forrester Report: Security Risks Faced By Healthcare Providers Empowering Mobile Moments
This report will not only look at the drivers for remote system access but will show how some of the most mature hospitals and other healthcare providers have done it without compromising privacy and security.
Download This Research

Making the Switch: Replacing Your EHR for More Money and More Control
This whitepaper serves as a guide to identifying an under-performing EHR and replacing it with a solution that delivers results. It offers answers to a number of common questions about EHR adoption and replacement and demonstrates how the right EHR can help practices get more money and more control, freeing up physicians to focus on patient care.
Download This Research 


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25 Best Health Tech Infographics of 2014 - 1/3

by System Administrator - Thursday, 15 January 2015, 8:28 PM

25 Best Health Tech Infographics of 2014 - 1/3

Annual yearly recap of the best health tech infographics created in 2014

Over the past 12 months, HIT Consultant has covered some of the most in-depth and well designed healthcare technology related infographics in this industry. Infographics provide a great way to display complex information or research data in a visually appealing format. Themes this year covered the gamut of healthcare technology including trends transforming health IT (EHR, meaningful use), mobile healthcare, patient engagement, big data and much more.

For our annual recap, we’ve collected 25 of our favorite healthcare technology infographics of 2014 shown below based on the following criteria: 

    • Storytelling
    • Valuable information
    • Data Visualization & Design Creativity 
    • Data Sources
    • Insightful key takeaways
    • Popularity (number of social shares)

1. 10 Medical Innovations Transforming Healthcare in 2015

Illustrates Cleveland Clinic’s annual top 10 medical innovations that are likely to have a major impact on improving patient care in 2015.

2. How Wearable Technology Is Transforming Mobile Health

Created by Career Glider features statistics on how wearable technologies is transforming mobile health, including how they’re affecting the way Americans stay active and healthy.

3. ICD-10 Could Help Track Ebola Outbreak

Illustrates the public health impact of ICD-10 in supporting the biosurveillance of the eBola outbreak created by the Coalition for ICD-10 . If the ICD-10 delay was not announced back in spring, the U.S. would be able to use the ICD-10 code for the Ebola virus – A98.4 to assess the efficacy of treatment and outcomes.

4. Patient Portal Adoption: Baby Boomers vs. Millennials

Key findings from Xerox’s annual survey on the usage of electronic health records reveals differences between Millennials and Baby Boomers when it comes to online patient portals.

5. Meaningful Use Audits Could Return $33M in Incentive Payments

Meaningful Use audits could recover $33M in EHR incentives, according to data from the HHS published.

6. How Millennials Are Reshaping Digital Health

Key findings from “Healthcare Without Borders: How Millennials are Reshaping Health and Wellness” report by Communispace reveals that Millennials, dissatisfied with the current healthcare system, have developed unique POVs for managing, maintaining their health and what it means fordigital health.

7. Why Healthcare Is Moving to the Cloud

How health care entities are moving to the cloud for their data and mission-critical applications created by AIS Network

8. Rise of the Digital Patient

The digital patient is here. From pre-screening potential doctors to viewing their treatment information and tracking their fitness/health data, the digital patient is increasingly embracing mobile health to improve their well-being.

9. Wearable Fitness Trackers Adoption Trends

While the use of health and fitness tracking devices has more than doubled in the last two years, a new nationwide survey conducted byTechnologyAdvice shows that only 25.1 percent of adults are currently using either a fitness tracker or a smartphone app to monitor their health, weight, or exercise.

10. The Convergence of Big Data and EHR

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.


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by System Administrator - Thursday, 15 January 2015, 8:46 PM


Annual yearly recap of the best health tech infographics created in 2014

Over the past 12 months, HIT Consultant has covered some of the most in-depth and well designed healthcare technology related infographics in this industry. Infographics provide a great way to display complex information or research data in a visually appealing format. Themes this year covered the gamut of healthcare technology including trends transforming health IT (EHR, meaningful use), mobile healthcare, patient engagement, big data and much more.

For our annual recap, we’ve collected 25 of our favorite healthcare technology infographics of 2014 shown below based on the following criteria: 

    • Storytelling
    • Valuable information
    • Data Visualization & Design Creativity
    • Data Sources
    • Insightful key takeaways
    • Popularity (number of social shares)

11. ACO Trends to Watch

12. How Mobile Medical Apps Are Poised to Revolutionize Healthcare

Infographic created by global science, technology and product development services company Sagentiaillustrates how mobile medical apps are poised to revolutionize healthcare. 

13. Top Physician Information Sources by Mobile Device

Key findings from Wolters Kluwer Health’s 2013 Physician Outlook Survey conducted by Ipsos of more than 300 practicing primary care physicians.

14. Apple HealthKit vs. Google Fit: A Developer’s Perspective

Infographic created by True Vault, a HIPAA compliant database as a service provider illustrates how Apple HealthKit stacks up against Google’s Fit digital health platform from a developer’s perspective. It also highlights Samsung’s SAMI (Samsung Architecture Multimodal Interaction) ecosystem and their new sensor-filled watch “Simband.”

15. Embracing Cloud in Healthcare

Key findings from HIMSS Analytics inaugural Cloud Survey on embracing the cloud in healthcare.

16. How Android is Transforming the Medical Devices Market

How the Android platform is improving healthcare using new technologies and apps to enhance the quality of medical care.created by Hughes Systique Corporation

17. The Rise of HIPAA Violations

Illustration provides a picture of the regulatory landscape along with the type of complaints, breaches and fines that occur due to HIPAA violations created by TrueVault

18. Top Digital Health Consumer Activities of U.S. Households

Nearly 60% of U.S. broadband households own some kind of personal health and wellness device, such as a digital weight scale or glucometer, and new designs and form factors, such as smart watches, have generated considerable consumer interest.

19. The Average Health IT Salary is $89,879 in 2014

The average health IT salary is $89,879.43 with 30 percent also receiving an average bonus of $31,100.52, according to the new 2014 Health IT Salary report conducted by

20. The Inefficient State of Supply Chain in Healthcare


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by System Administrator - Thursday, 15 January 2015, 8:58 PM


Annual yearly recap of the best health tech infographics created in 2014

Over the past 12 months, HIT Consultant has covered some of the most in-depth and well designed healthcare technology related infographics in this industry. Infographics provide a great way to display complex information or research data in a visually appealing format. Themes this year covered the gamut of healthcare technology including trends transforming health IT (EHR, meaningful use), mobile healthcare, patient engagement, big data and much more.

For our annual recap, we’ve collected 25 of our favorite healthcare technology infographics of 2014 shown below based on the following criteria: 

    • Storytelling
    • Valuable information
    • Data Visualization & Design Creativity
    • Data Sources
    • Insightful key takeaways
    • Popularity (number of social shares)

21. The Rise of Clinical Mobility in Healthcare

Examines how clinical mobility solutions — critical to clinical workflows — are making data more readily available, improving workflow and efficiency, and enhancing the patient experience, both inside the hospital and beyond created by created by CDW Healthcare 

22. 25th Annual HIMSS Leadership Survey

Key findings from the 25th Annual 2014 HIMSS Leadership Survey, which highlights the journey of health IT over the past 25 years. The Survey examines a wide array of topics crucial to healthcare leaders including IT priorities, issues driving and challenging technology adoption and IT security.

23. State of Mobile Technologies in Healthcare Today

Key findings from HIMSS Analytics 3rd Annual Mobile Survey, which examines the mHealth landscape and examines the use of mobile devices in provider patient care improvement initiatives.

24. Intersecting Trends in HIT: Population Health Management & Business Intelligence

Illustrates how population health management and business intelligence tools are playing a bigger role in the changing HIT landscape created by CDW Healthcare

25. Rx for Doctor Disconnect

According to the U.S. Department of Health and Human Services, nearly 90% of physicians are using smartphones, but only a tenth of our hospitals are offering a secure texting solution at their facilities. Infographic highlights the doctor disconnect trend by exploring the key issues and risks contributing to poor physician engagement created by Voalte

26. HIMSS: The State of Healthcare Innovation 2014

Key findings from the 2013 Healthcare Provider Innovation Survey with select U.S. hospitals, academic medical centers, children’s and ambulatory care centers to understand the current state of innovation within provider organizations by HIMSS and AVIA.


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29% of Broadband Households Own A Connected Health Device

by System Administrator - Thursday, 18 June 2015, 7:03 PM

29% of Broadband Households Own A Connected Health Device

29% of U.S. broadband households own a connected health device and 12% of U.S. broadband households own multiple connected health devices, according to market research firm Parks Associates. The report, Digitally Fit: Products and Services for Connected Consumers examines the current adoption and usage of connected health devices with analysis of multiple nationwide surveys of U.S. broadband households. Global revenues from connected fitness trackers is also expected to increase from over $2 billion in 2014 to $5.4 billion by 2019. 

The research firm will address new partnerships between device manufacturers and health insurance providers, as well as other key issues in the growing connected health market, at the second-annual Connected Health Summit: Engaging Consumers, September 9-10, at the Omni San Diego Hotel.

“The adoption rate for fitness trackers and GPS watches has increased, while the adoption rate for other connected health devices has been more stable, said Harry Wang, Director, Health & Mobile Product Research, Parks Associates. “Fitness trackers stand out as one of the more successful product categories thanks to the release of better products and major marketing campaigns.” 

Additional Parks Associates mobile research finds: 

– 50% of U.S. broadband households use an online health tool to communicate with their doctor, access personal health data, or fill prescriptions 

– Smart watch sales will exceed 100 million units in 2019 

– Over 80% of U.S. mobile subscriptions will be 4G LTE by 2018 

– 19% of smartphone owners find a master health app that aggregates data from all health apps very appealing. 

Featured image credit: vernieman via cc 



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3 growth areas for patient engagement in healthcare

by System Administrator - Monday, 5 October 2015, 5:46 PM

3 growth areas for patient engagement in healthcare

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3 long-term healthcare changes on the horizon

by System Administrator - Monday, 27 April 2015, 11:12 PM

3 long-term healthcare changes on the horizon

Leaders share what industry will look like in 5-15 years

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3 tips for getting along with Dr. Google

by System Administrator - Wednesday, 6 May 2015, 3:22 PM

3 tips for getting along with Dr. Google

Physicians can use online health information for more productive visits


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4 factors for successful value-based care

by System Administrator - Tuesday, 10 November 2015, 7:02 PM

4 factors for successful value-based care

By Ron Shinkman

Society of Actuaries provides road map to aid transition away from fee-for-service

New research from the Society of Actuaries has identified several factors that will help ensure a provider's successful transition to value-based care.

The report, "Navigating The Transition To Value-Based Care," concluded that the payment models must include:

  • A reasonable method to determine patient costs

  • An equitable process for allocating quality incentives among participating healthcare providers 

  • A well-designed provider network aimed at fostering cost savings

  • The most efficient healthcare delivery system within the specific market  

However, the society also noted it was difficult to observe and draw conclusions from many examples of value-based care.

"The authors found that it is neither easy nor transparent to see how these organizations interact or coordinate results, even for those well-versed in U.S. healthcare," the report said. "In addition, methods of reporting results of payment reform studies were not necessarily methodologically rigorous, which made it difficult to reach definitive conclusions on whether specific reported payment reform models were successful."

The U.S. healthcare sector is struggling to make progress with value-based payment initiatives. Many providers have made little progress with their initiatives, and seem to be hesitant to ditch the time-honored fee-for-service model. And while some progress has been made in reducing the levels of "low-value care" that are being delivered, many providers have dropped out of the Pioneer Accountable Care Organization program, noting that they have struggled to meet the performance and financial goals that have been delineated by the Centers for Medicare & Medicaid Services.


To learn more:

Related Articles:



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5 Best Practices to Make Healthcare Innovation Partnerships Work

by System Administrator - Thursday, 4 September 2014, 11:30 PM

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.


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5 Digital Health Trends Reshaping Healthcare

by System Administrator - Wednesday, 8 July 2015, 10:06 PM

5 Digital Health Trends Reshaping Healthcare

Healthcare executives expect that, within the next three years, their industry will need to focus as much on training machines as they do on training people, according to one finding from a new report by Accenture. The Accenture 2015 Healthcare IT Vision is based on a survey of doctors, consumers and healthcare executives and] highlights emerging technology trends that will affect the health industry in the next three to five years.

84% of health executives surveyed agree or strongly agree that healthcare industry will need to focus as much on training machines – such as using algorithms, intelligent software and machine learning – as they do on training people in the next three years. In fact, most of those surveyed (83 percent) agree that provider organizations, driven by a surge in clinical data, will soon need to manage intelligent machines as well as employees.

The Accenture Healthcare IT Vision 2015 report reveals five key digital health trends reshaping the healthcare industry:

1. The Internet of Me: Your healthcare, personalized Welcome to the era of personalized healthcare defined by meaningful and convenient individual health experiences.

2. Outcome Economy: Hardware producing healthy results New intelligence is bridging the digital enterprise and the physical world. It’s about more than technology; it’s about delivering results.

3. Platform Revolution: Defining ecosystems, redefining healthcare Healthcare IT platforms capture data from disparate sources (e.g., wearables, phones, glucometers), and connect it to provide patients and caregivers a holistic and real-time view of your health.

4. Intelligent Enterprise: Huge data, smarter systems, better healthcare A data explosion, accompanied by advances in processing power, health analytics and cognitive technology, is fueling software intelligence. Medical devices and wearables can now recognize, “think” and respond accordingly.

5. Workforce Reimagined: Collaboration at the intersection of humans and healthcare As the digital revolution gains momentum, doctors and healthcare workers are now using machines to be more efficient, provide better care and take on increasingly more complex tasks.

These trends clearly prove that digital health is dramatically influencing the healthcare industry today, and it will continue to do so for decades to come. The infographic shown below illustrates these five key findings from the report (attached image).

“As the digital revolution gains momentum, doctors and clinicians will use machines to augment human labor, personalize care and manage more complex tasks,” said Kaveh Safavi J.D. M.D., who leads Accenture’s health business. “The digital revolution is also creating a data goldmine that can spark medical breakthroughs and improve individualized treatment plans.”


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5 hábitos saludables podrían reducir 80% de los infartos

by System Administrator - Thursday, 9 October 2014, 10:42 AM
Conductas de bajo riesgo

5 hábitos saludables podrían reducir 80% de los infartos

La alimentación saludable, junto con hábitos de vida de bajo riesgo y ausencia de adiposidad abdominal puede prevenir la gran mayoría de episodios de infarto de miocardio en hombres.


 Alimentación y hábitos de vida de bajo riesgo en la prevención primaria del infarto de miocardio en hombres.


El objetivo de este estudio fue analizar el beneficio de la alimentación y los hábitos de vida saludables sobre la incidencia del infarto de miocardio (IM) en hombres. Se efectuó un seguimiento de 11 años a una cohorte de 20721 hombres de 45-79 años.

Las conductas de bajo riesgo fueron:

  1. Alimentación saludable
  2. Consumo de alcohol moderado
  3. Actividad física
  4. Ausencia de tabaquismo
  5. Ausencia de adiposidad abdominal.

Durante ese tiempo se comprobaron 1361 casos nuevos de IM. La combinación de conductas saludables sólo presente en el 1% de los hombres, pudo prevenir el 79% de los episodios de IM.


La incidencia y la mortalidad de la enfermedad coronaria (EC) disminuyeron en muchas regiones del mundo, pero la carga de enfermedad aún es grande. Aunque los tratamientos farmacológicos para el descenso de los lípidos y de la hipertensión son eficaces para disminuir los episodios coronarios, la observancia de hábitos de vida saludables sigue teniendo un impacto notable. En contraste con los tratamientos farmacológicos, las estrategias no farmacológicas para contribuir a la prevención de la EC no tienen el riesgo de efectos colaterales.

Para la incidencia de EC, hasta el 77% - 82% de los episodios se atribuyeron a la falta de observancia de hábitos de vida de bajo riesgo, que para las mujeres consisten en 5 opciones saludables. En los hombres de los EEUU, el riesgo atribuible correspondiente fue del 62%, y del 57% entre los que recibían medicamentos para la hipertensión o la hipercolesterolemia.

En este trabajo se estudió el beneficio de combinar alimentación y hábitos de vida saludables sobre la incidencia del infarto de miocardio (IM) en una gran cohorte prospectiva de hombres suecos sanos.

Se estimó la carga de EC que podría haber sido evitada si todos los hombres hubieran cumplido con una dieta saludable, consumo de alcohol moderado, actividad física, supresión del tabaquismo y hubieran evitado la adiposidad abdominal. Se efectuó un análisis aparte de los hombres con hipertensión e hipercolesterolemia.


En 1997, todos los hombres nacidos entre 1918 y 1952 residentes en dos provincias de Suecia central recibieron un cuestionario que incluía 350 preguntas sobre su alimentación y otros factores de sus hábitos de vida (la tasa de respuestas fue del 49%). Esta gran cohorte es representativa de los hombres suecos de 45 a 79 años en cuanto a la distribución por edad, el nivel educativo y la prevalencia de sobrepeso.

Tras la exclusión de los que tenían antecedentes de enfermedades que podrían haber causado cambios en la alimentación y los hábitos de vida, quedaron 20721 hombres para el estudio. Se efectuó un análisis aparte de 7139 hombres con hipertensión e hipercolesterolemia.

Evaluación de los factores alimentarios de hábitos de vida

La alimentación se evaluó mediante un cuestionario semicuantitativo autoadministrado, con preguntas sobre 96 alimentos (Food Frecuency Questionnare). La alimentación saludable se identificó según la Puntuación de alimentos recomendados (PAR) (Recommended Food Score), ideada en 2000 por Kant et al. como una manera sencilla de definir la calidad de la alimentación separando los alimentos saludables de los menos saludables, sobre la base de los conocimientos actuales y las recomendaciones alimentarias.

La PAR es un excelente factor pronóstico de mortalidad e incluye los alimentos con efecto favorable sobre la salud cardiovascular, como frutas, verduras, legumbres, frutas secas, lácteos descremados, granos enteros y pescado. Se asignó una puntuación de 1 (hasta un máximo de 25) para ≥ 1 porción por semana de cualquiera de 3 productos lácteos descremados, pan crocante y pan integral, mientras que para los restantes alimentos la frecuencia de consumo fue por lo menos 1 - 3 veces por mes.

Se consideró que aquéllos con puntuación en el quintilo más alto (puntuación 23 - 25) tenían una alimentación saludable variada (alimentación de bajo riesgo). En un análisis post hoc, sólo el quintilo superior se asoció con disminución estadísticamente significativa del riesgo de IM. La puntuación de alimentos no recomendados (Non-Recommended Food Score) se basó sobre 21 alimentos, entre ellos las carnes rojas procesadas, las papas fritas, las grasas sólidas, el queso no descremado, el pan blanco y los cereales refinados y diversos alimentos dulces.

El grupo de bajo riesgo con respecto al alcohol comprendió los hombres que consumían cantidades moderadas de alcohol (10 - 30 g/día).

Se consideraron el tabaquismo, la actividad física y la adiposidad abdominal como los tres principales factores de bajo riesgo no alimentarios modificables. Se consideró que la actividad física de bajo riesgo CV incluía tanto actividad física como caminata y ciclismo diarios y un ejercicio semanal más vigoroso.

De esta manera, el grupo de bajo riesgo estuvo compuesto por hombres que no fumaban, que caminaban o practicaban ciclismo durante por lo menos 40 min/día y hacían ejercicio más vigoroso por lo menos 1 hora por semana y tenían una circunferencia abdominal <95 cm.



Durante una media de 11 años, se comprobaron 1361 casos nuevos de IM. Globalmente, fue más probable que los hombres con alimentación de bajo riesgo tuvieran mayor nivel educativo, no fumaran y no vivieran solos.

Cada factor de los hábitos de vida se asoció inversamente y, tras el ajuste mutuo, para los otros elementos del perfil de bajo riesgo, independientemente del riesgo de episodios coronarios.

Esta disminución del riesgo correspondió al 18% para la alimentación saludable, al 11% para el consumo de alcohol moderado, al 36% para la ausencia de tabaquismo, al 3% para la actividad físicay al 12% para una circunferencia abdominal normal.

En total, el 8,7% de los hombres combinaron la alimentación de bajo riesgo con el consumo moderado de alcohol. La media de su consumo diario fue de 5 porciones de verduras y frutas, 4 de granos enteros (o de salvado) y el consumo semanal de 2,2 porciones de pescado.

La mediana de consumo de alcohol en este grupo fue de 17 g/día. En relación con el grupo de alto riesgo, que no cumplió los criterios de ninguno de los 5 factores de la alimentación de bajo riesgo ni de los hábitos de vida, esta conducta alimentaria y de consumo moderado de se asoció con una reducción del riesgo de IM del 35%.

En el análisis final, los autores investigaron el efecto combinado de todas las prácticas de bajo riesgo. 

El perfil final completo de bajo riesgo, con los 5 factores, cumplido por el 1% de la población del estudio, se asoció con un 86% menos de riesgo de IM que el grupo de alto riesgo sin factores de bajo riesgo.

El riesgo atribuible poblacional estimado para el perfil completo de bajo riesgo en relación con los restantes hombres de la población del estudio fue del 79%. Esto sugiere que 4 de 5 episodios coronarios podrían haber sido evitados si todos los hombres hubieran observado conductas de bajo riesgo.

En otro análisis se evaluó la asociación entre las conductas de bajo riesgo y el riesgo de IM entre 7139 hombres con hipertensión e hipercolesterolemia al inicio del estudio con 765 nuevos casos comprobados de IM.

Las tasas de incidencia estandarizadas para la edad y los índices de riesgo descendieron al agregar cada factor de bajo riesgo. La diferencia de tasas absoluta entre ningún factor de riesgo versus 5 factores de bajo riesgo fue de 778 casos por 100000 años-persona, similar a la de hombres sin hipertensión ni hipercolesterolemia.


En este estudio de cohortes prospectivo de hombres sanos, se observó que la alimentación de bajo riesgo junto con el consumo moderado de bebidas alcohólicas se asoció con el 35% de reducción del riesgo de IM primario en relación con hombres del grupo de alto riesgo (i.e., hombres que no tenían ninguno de los 5 factores de bajo riesgo).

Los hombres que combinaron esta alimentación de bajo riesgo y el consumo moderado de alcohol con hábitos de vida de bajo riesgo (no fumar, actividad física y evitación de la adiposidad abdominal) tuvieron un riesgo 86% menor. El efecto favorable de combinar la alimentación, los hábitos de vida y un peso corporal saludable puede prevenir aproximadamente hasta 4 de 5 casos de IM en esta población sana. El descenso de los riesgos con el mayor cumplimiento de conductas de bajo riesgo se observó también en hombres con hipertensión e hipercolesterolemia.

En esta cohorte de hombres sin antecedentes de enfermedad cardiovascular (ECV), hipertensión, hipercolesterolemia o diabetes al inicio del estudio, la reducción observada en la incidencia de IM asociada con alimentación saludable junto con el consumo moderado de alcohol fue similar a la de un estudio español reciente que analizó la dieta mediterránea, complementada con aceite de oliva o frutos secos. En el 29% de pacientes sin ECV, pero con alto riesgo cardiovascular, la dieta mediterránea combinada disminuyó significativamente el riesgo de ECV en relación con una dieta control.

Al contrario de los alimentos saludables, el consumo de alcohol no se puede recomendar sin reservas para reducir la ECV. Aunque su consumo moderado puede proteger de la ECV, el abuso de alcohol es uno de los 3 factores de riesgo más importantes de la carga global de todas las enfermedades.

Riesgos atribuibles poblacionales similares se observaron en mujeres estadounidenses (82%) y suecas (77%), así como en hombres de los EEUU (62%). En el presente estudio, sólo el 1% de la población integró el grupo de bajo riesgo. Recientemente se observó muy baja frecuencia (0,1% - 2%) de “salud cardiovascular ideal,” según la definición de la American Heart Association en las muestras nacionales de ese país.

Esta definición incluyó 4 (excluyó el alcohol) de 5 opciones de hábitos de bajo riesgo junto con cifras favorables de colesterol total, glucosa en ayunas y presión arterial. Programas dirigidos a los hombres para aumentar la proporción de los que adoptan conductas de bajo riesgo podrían ser de gran impacto sobre la carga de enfermedad.

Es de gran importancia que estos hábitos de vida sean modificables y los cambios prospectivos de hábitos de alto riesgo a otros de bajo riesgo se asociaron con disminución del 27% de la incidencia de ECV. Es, sin embargo evidente que una prevención amplia sólo se podrá alcanzar inhibiendo el inicio y el establecimiento de cualquier conducta de alto riesgo y asegurándose de que las conductas de bajo riesgo ideales se introduzcan tempranamente y continúen durante toda la vida.



Este estudio indica que una alimentación saludable, junto con hábitos de vida de bajo riesgo y ausencia de adiposidad abdominal pueden prevenir la gran mayoría de episodios de infarto de miocardio en hombres.


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disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990- 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2013; 380: 2224–60.
34. Lloyd-Jones DM, Hong Y, Labarthe D, et al. Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association’s strategic Impact Goal through 2020 and beyond. Circulation 2010;121:586–613.
35. Yang Q, Cogswell ME, Flanders WD, et al. Trends in cardiovascular health metrics and associations with all-cause and CVD mortality among US adults. JAMA 2012; 307:1273–83.
36. Bambs C, Kip KE, Dinga A, Mulukutla SR, Aiyer AN, Reis SE. Low prevalence of “ideal cardiovascular health” in a community-based population: the heart strategies concentrating on risk evaluation (Heart SCORE) study. Circulation 2011; 123:850–7.
37. Capewell S, Lloyd-Jones DM. Optimal cardiovascular prevention strategies for the 21st century. JAMA 2010; 304:2057–8.
38. Mozaffarian D, Afshin A, Benowitz NL, et al. Population approaches to improve diet, physical activity, and smoking habits: a scientific statement from the American Heart Association. Circulation 2012; 126:1514–63.



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5 Ideas to Raise Your Patient Centricity Profile

by System Administrator - Thursday, 12 March 2015, 12:36 PM

5 Ideas to Raise Your Patient Centricity Profile

a new publication from BBK Worldwide – offers a unique look at how to apply the construct of patient centricity to recruitment and engagement at-large. This valuable guide offers quick tips, practical advice and industry insights designed to inspire you to continue to raise your organization's patient centricity profile.

Download your free copy today and gain valuable insights on how to adopt a patient-centric approach and impact:

  • Strategy & Planning
  • Patient Advocacy
  • Branding & Advertising
  • Prescreening Patients
  • mHealth & Technology

Please read the attached whitepaper.

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5 Must-Track Metrics for Practice Profitability

by System Administrator - Monday, 11 August 2014, 5:35 PM

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
      • Ensure your practice secures reimbursements in a timely manner
      • Identify missed revenue opportunities, and more.

Please read the attached whitepaper


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5 optimistic healthcare trends for 2015

by System Administrator - Friday, 30 January 2015, 4:52 PM

5 optimistic healthcare trends for 2015

Innovation, physician engagement are positive indicators, according to Aegis Health Group

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5 ways to close common medical device vulnerabilities

by System Administrator - Tuesday, 12 May 2015, 11:58 AM

5 ways to close common medical device vulnerabilities

VA CIO Stephen Warren offers tips for addressing device security threats

By Brian Eastwood

The U.S. Department of Veterans Affairs is no stranger to cyberattacks. In March, roughly 1.2 billion cyberattacks targeted the VA network, CIO Stephen Warren said at the Medical Informatics World conference in Boston. That's a sharp increase from 330 million attacks in November.

Amid all that activity, the VA saw a sharp drop in protected health information breaches in March, with 383 veterans the victim of a PHI breach in March compared to 891 in February, FierceHealthIT previously reported.

Admittedly, the VA benefits from a level of security that not all healthcare organizations have--namely, the Department of Homeland Security's control points, known as Trusted Internet Connections, as well as advanced security measures that even Warren doesn't know about.

That said, the VA has taken several steps to shore up security in a common point of vulnerability: Medical devices. With criminal attacks now the leading cause of healthcare data breaches, according to a recent Ponemon Institute report, organizations would be wise to address five key threats posed by medical devices.

Windows XP: Microsoft stopped supporting this operating system more than a year ago. Connect a device running XP to the Internet and it will be compromised within seven seconds, Warren said. Keep these devices offline.

Irreplaceability: Those devices running Windows XP remain in use because organizations believe they are too costly to replace. But the cost to mitigate a data breach can exceed $2 million, according to Ponemon, and Anthem faces damage control costs in excess of $100 million following its February cyberattack. The VA replaces medical devices regularly--as of March 5, only two devices across the 152 medical centers in the entire VA system represented a liability, Warren said.

No antivirus or antispyware software: Push the market to change this, Warren said. If you plan to replace devices regularly, it's in a manufacturer's best interest to protect those devices better. If you still have devices without software to detect vulnerabilities, meanwhile, make sure clinical staff know why these devices pose such a threat, he said.

No software updates: The VA pushes patches to its devices "multiple times a day" to ensure they remain protected against the latest threats, Warren said. Again, if devices cannot be updated regularly, they should remain offline.

Email access: Even with all of the above protections in place, medical devices remain vulnerable if people use them to check personal email--which they will do if administrative restrictions forbid them from doing so on any other computers in the building, Warren said. Give clinical staff as well as device repair contractors a place to check email, and take that opportunity to shore up email security.

Related Articles:


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56% of Americans Want Connected Health Devices to Monitor Their Health

by System Administrator - Thursday, 15 January 2015, 9:09 PM


56% of Americans Want Connected Health Devices to Monitor Their Health

  • It would keep track of my health information accurately – 30%
  • It would allow me and my doctor to see trends and patterns – 29%
  • It would give me peace of mind to know how I’m doing – 24%
  • It would allow my doctor to be “in the know” to prevent surprises during appointments – 19%
  • It would allow my doctor to monitor my health 24/7 if necessary – 18%
  • Internet of Things is the future of medicine – 11%
  • The whole world is connected so it makes sense for devices to be connected – 10%
  • It’s difficult to enter the information into an app – 3% 

Most Popular Vital Signs

The most popular vital sign Americans wanted monitored was blood pressure, with 37 percent of Americans wanting to monitor that with connected devices followed by:

  • Weight – 33%
  • Chronic conditions (hypertension, diabetes, etc.) – 25%
  • Sleep – 23%
  • Physical activity – 22%
  • Diet – 19%
  • Vision – 18%
  • Medicine – 16%

Nearly half of Americans (48 percent) are concerned about their blood pressure, with one in four Americans (25 percent) concerned about either having a stroke or developing hypertension.  Over one in five Americans (23 percent) are worried about heart attacks.

Americans Prefer Companies with Healthcare Experience

A majority of Americans (53 percent) say they would want connected health devices/apps to come from a company with healthcare experience for the following reasons:

- Medical expertise is important to me (26 percent)

- I want to know I can trust the company making the device or app (25 percent)

- Companies with medical experience will know what information will be trusted by my doctors or important to my doctors (18 percent).

Survey Methodology

This survey was conducted online within the United States by Harris Poll on behalf of A&D from December 17-19 2014 among 2,024 adults ages 18 and older. This online survey is not based on a probability sample and therefore no estimate of theoretical sampling error can be calculated. 

Featured image credit: 15216811@N06 via cc



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7 digital resolutions for hospitals

by System Administrator - Thursday, 8 January 2015, 2:56 PM

7 digital resolutions for hospitals


by Jenn Riggle

It's the beginning of 2015 and time for people to take a closer look at their lives and make resolutions for the coming year. It's also a good time for hospitals to take another look at their social media and digital initiatives and determine what's working and what's not.

The good news is that U.S. hospitals have embraced social media. In fact, 99.41 percent of the 3,371 U.S. hospitals have ongoing social media initiatives, according to a recent reportfrom the Journal of Medical Internet Research. But are they using the right channels and achieving the results they want?
Here are some social media resolutions for hospital marketers for the coming year:

  • Make your website work for you: Your website is your most important digital property because it's the first place people go to learn about your organization and the services you provide. However, websites are no longer the online brochures they were in the 1990s. They need to be searchable and updated on a regular basis to remove stale and outdated content. A good resource to help you know where to focus your efforts is your site's Google Analytics, which will tell you which pages get the most views and how long site visitors spend on each page.
  • Make your content easier to find: It's not enough to create compelling content, people need to be able to find it. You may have a beautiful, informative website, but are you making the most out of Search Engine Optimization (SEO)? This is important, but can be a time-intensive task. Or have you spent a lot of time creating compelling videos and posting them on YouTube, but wonder why they may not attract viewers? A simple way to fix this is by not just posting key words, but by posting the entire videotranscript.
  • Reach the right people: Research shows that hospitals tend to post generic content or information about employee-related issues and achievements. While this approach helps build critical mass by engaging hospital employees (which is especially important when launching social media programs), it won't help turn people into patients. It's important to know your audience and know what topics interest them, which will help increase followers and stimulate engagement.
  • Give the people what they want: Not only is this the name of a great album by the Kinks, it's a good social media mantra for hospitals. Your site's Google Analytics will help you identify whether people are coming to your site to learn about your heart and vascular program or maternity services, or simply want directions to your hospital. This information will help you identify topics for future blogs and social media posts and will help ensure that you continue to provide content that interests people.
  • Focus on what works: Hospital marketing departments are stretched thin and it's often difficult for staff to find enough hours in the day to do their work and manage all of their organization's social media properties. Rather than having a mediocre presence in multiple social media channels, focus your efforts on a couple of major channels. Or create an educational social media campaign that encourages people to take control of their own health, such as getting a mammogram or having a colon cancer screening.
  • Listen to what people say: One of the most important parts of social media engagement is listening to what people say. The challenge is to keep up with the channels as they evolve. For example, Yelp is where people go to get restaurant reviews--but patients also use it to review the care they receive at their local hospital. It's important to hear what people say and respond to their concerns. It's amazing how listening to people and addressing their concerns can help turn a detractor into an advocate.
  • Be part of the bigger conversation: In addition to listening to patient comments, hospitals should listen to the issues and concerns that other organizations in their community, including other hospitals, talk about. Listening to others allows you to be more relevant and become part of the bigger conversation.

Jenn Riggle is a PR and communications consultant who lives in Dallas.


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7 ways the cloud can elevate your practice

by System Administrator - Monday, 11 August 2014, 4:37 PM


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.

Please read the attached whitepaper.


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8 Ways to Stop IT Alert Fatigue

by System Administrator - Monday, 11 August 2014, 2:32 PM

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.

Please read the attached whitepaper


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by System Administrator - Friday, 1 August 2014, 11:57 PM


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


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91% of Physicians Practice Defensive Medicine

by System Administrator - Monday, 11 August 2014, 5:08 PM

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


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; 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

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:
  • B. Sonny Bal, MD, JD, MBA, can be reached at Missouri Orthopaedic Institute, 1100 Virginia Ave., Columbia, MO 65212; 573-882-6762;
  • Lawrence H. Brenner, JD, can be reached at P.O. Box 787, Carrboro, NC 27510; 919-929-5597; email:
  • 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;
  • 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:
  • 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:
  • Jeffrey Segal, MD, JD, can be reached at Medical Justice, P.O. Box 49669, Greensboro, NC 27419; 336-691-1286;
  • 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;
  • David Teuscher, MD, can be reached at Beaumont Bone & Joint Institute, 3650 Laurel Ave., Beaumont, TX 77707; 409-838-0346;
  • Neil Vidmar, PhD, can be reached at Duke University School of Law, Room 3183, Box 90360, Durham, NC 27708-0360; 919-613-7090;
  • 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:
  • Disclosures: Archdeacon, Bal, Brenner, Choma, Jimenez, Leflar, Sohn, Teuscher, Vidmar and Weinstein have no relevant financial disclosures; Segal is a shareholder in Medical Justice.





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¿Pueden los enfermos hacer lo que les pedimos que hagan?

by System Administrator - Monday, 13 July 2015, 11:29 PM

¿Qué es la "carga de tratamiento"?

Autor: Frances S Mair, professor of primary care research, Carl R May, professor of healthcare innovation Fuente: BMJ 2014;349:g6680 Thinking about the burden of treatment

¿Pueden los enfermos hacer lo que les pedimos que hagan?

Asistimos a enfermos del siglo XXI con un sistema pensado para la epidemiología del siglo XIX. Cómo sobrevivir con enfermedades crónicas a la fragmentación y a la falta de coordinación en el cuidado de los más vulnerables.

"¿Puede usted realmente hacer lo que yo le estoy pidiendo que haga?"

Los sistemas de salud a lo largo del mundo deben enfrentar un incremento de la demanda y de los costos. El incremento de la expectativa de vida ha sido acompañado por una explosión de enfermedades de largo plazo (crónicas) y por la multimorbilidad.1

Los clínicos están trabajando con sistemas heredados que fueron desarrollados para tratar problemas del siglo XIX –aportar respuestas especializadas a enfermedades agudas e infecciones-. Al mismo tiempo la práctica cotidiana ha sido influenciada por un modelo centrado en la enfermedad que no refleja el panorama de la realidad de la práctica clínica actual, en particular la ubiquidad de la multimorbilidad.2

El resultado de ellos es la fragmentación, la pobre coordinación de los servicios de salud para aquellos más vulnerables y sus necesidades –pacientes con múltiples condiciones crónicas-3.

Los profesionales actuales que se ocupan del cuidado de la salud enfrentan no solo interacciones enfermedad / enfermedad, sino fármaco / fármaco y fármaco / enfermedad en poblaciones con multimorbilidad así como las consecuencias evidentes de las desigualdades socio-económicas.

Mientras tanto, los pacientes, sus familias y sus redes sociales extendidas experimentan no solo la carga de síntomas sino la carga de tratamientos.4 Este es un fenómeno emergente y poco investigado. Ha recibido una atención creciente en los últimos tiempos y el interés se ha centrado en definir y comprender mejor este concepto.
Algunos de los componentes centrales de la “carga de tratamiento” han sido evaluados por revisiones sistemáticas5 6  y estudios cualitativos.7 8 9

Los resultados muestran que los pacientes y los cuidadores de salud ponen con frecuencia bajo enormes demandas a los sistemas sanitarios. Tales demandas pueden incluir cambiar sustancialmente su comportamiento y la vigilancia de la conducta de los demás con el fin de adherirse a las modificaciones de estilo de vida recomendados.

Los pacientes o sus cuidadores a menudo tienen que controlar y manejar sus síntomas en casa, lo que puede incluir la recolección y la introducción de datos clínicos. La adhesión a los regímenes de tratamiento complejos y la coordinación de múltiples medicamentos también pueden contribuir a la carga de tratamiento.10

Para asegurar su acceso a los servicios los pacientes a menudo se enfrentan a complejos sistemas administrativos y a la necesidad de hacer frente a los sistemas de salud y a la falta de coordinación de la atención social que puede añadir un suplemento más a la carga.

La carga continúa aumentando a medida que los sistemas de salud desplazan de una lista cada vez mayor de las responsabilidades de gestión y tareas a los pacientes y a sus cuidadores. Este es un trabajo real, que requiere de un considerable esfuerzo por parte de los pacientes, sus cuidadores y de sus redes sociales extendidas. Para muchos esto puede ser abrumador, es mucho tiempo, requiere de un alto nivel de alfabetización aritmética y, a veces, de un conocimiento técnico. A menudo también se requieren destreza manual y habilidades prácticas.

Las personas que están socialmente aisladas, que tienen bajo nivel de educación, bajo nivel de alfabetización en salud, que se deterioran cognitivamente, que no hablan el idioma local, o que tienen dificultades sensoriales o físicas es poco probable que prosperen en tales contextos.

Tampoco las personas que no tienen estos problemas disponen del tiempo suficiente. A las personas que tienen tres trabajos para pagar el alquiler les puede resultar difícil adherir a los requerimientos de las múltiples guías clínicas. Estas personas tendrán dificultades para cumplir con las recomendaciones de tratamiento, arriesgando con ello obtener malos resultados y desperdiciar los recursos sanitarios cada vez más escasos.

Un primer paso para la disminución de la carga del tratamiento es el desarrollo de métodos para medir esa carga. Dichos instrumentos deben incluir algo más que los efectos secundarios del tratamiento. Tienen que incluir los efectos perturbadores que la adherencia al tratamiento tiene para la vida laboral (por ejemplo, tener que ir varias veces a las clínicas para pruebas) y para la vida social (por ejemplo, tener que reducir las actividades debido a los efectos secundarios del tratamiento).

Los costos ocultos son también un problema los costos, para acudir a las citas clínicas, tomar tiempo fuera del trabajo, y el pago de todos o algunos de los tratamientos deben ser tenidos en cuenta. Además, el esfuerzo necesario para aprender las habilidades de autocuidado, tales como la forma de administrarse a sí mismo o a otras personas dependientes las inyecciones regulares, deberían ser incluidos.

Por último, hacer frente a los problemas causados por la discontinuidad y la atención fragmentada, así como por el potencial de la carga psicosocial de ser medicalizado y ser convirtido en un paciente deben ser considerados. El trabajo preliminar se ha comprometido a desarrollar las escalas y las medidas de carga de tratamiento, pero es necesario seguir trabajando acerca de la capacidad de los individuos para hacer frente a una determinada carga.1112


La carga del tratamiento impuesto por la prestación de servicios de salud podría convertirse en un barómetro clave de la calidad de la atención. Sin embargo, tendrán que diseñarse instrumentos e intervenciones adecuados para tener en cuenta las diferencias entre los sistemas de salud y las combinaciones de condiciones, así como los gradientes de la capacidad individual para hacer frente a esa carga.13 Así que, aunque la evidencia indica que la carga de tratamiento tiene muchas características genéricas, también es probable que difieran entre, por ejemplo, Nebraska y Norfolk y entre el astrocitoma y el asma.

No toda la carga de tratamiento es irrazonable o evitable. Por ejemplo, la polifarmacia puede ser necesaria para controlar los síntomas de varias condiciones o para reducir el riesgo de exacerbaciones de la enfermedad o de eventos adversos a largo plazo.

Alguna carga tratamiento puede ser circunstancial y transitoria, en relación con una crisis aguda específica. Por otra parte, la carga puede ser mejor tolerada por las personas que están bien equipadas y que sean resistentes que por los que no lo son. Los métodos para predecir con precisión los que están en mayor riesgo de ser abrumados por la carga de tratamiento todavía no están disponibles, pero un punto de partida razonable pueden ser asumir que todo el mundo está en riesgo.

Hemos argumentado anteriormente acerca de la "medicina mínimamente impertinente o disruptiva": enfoque centrado en la atención al paciente que haga hincapié en las preferencias individuales, que tenga en cuenta la multimorbilidad, y que busque reducir la carga de trabajo para los pacientes y sus cuidadores.14

Las intervenciones que pongan en práctica la medicina mínimamente impertinente y que ataquen la carga del tratamiento necesitará proporcionar una atención coordinada centrada en la persona en lugar de la enfermedad y aportar el máximo apoyo posible. Mientras esperamos, las medidas fiables y validadas de la carga de tratamiento, una pregunta simple del médico puede ser suficiente: "¿Puede usted realmente hacer lo que yo le estoy pidiendo que haga?"

  1. Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet 2012;380:37-43.
  2. Guthrie B, Payne K, Alderson P, McMurdo ME, Mercer SW. Adapting clinical guidelines to take account of multimorbidity. BMJ2012;345:e6341.
  3. Payne RA, Abel GA, Guthrie B, Mercer SW. The effect of physical multimorbidity, mental health conditions and socioeconomic deprivation on unplanned admissions to hospital: a retrospective cohort study. CMAJ2013;185:E221-8.
  4. May CR, Eton DT, Boehmer K, Gallacher K, Hunt KJ, MacDonald S, et al. Rethinking the patient: using burden of treatment theory to understand the changing dynamics of illness. BMC Health Serv Res2014;14:281.
  5. Sav A, King MA, Whitty JA, Kendall E, McMillan SS, Kelly F, et al. Burden of treatment for chronic illness: a concept analysis and review of the literature. Health Expect2013;15:351-9.
  6. Gallacher K, Morrison D, Jani B, Macdonald S, May CR, Montori VM, et al. Uncovering treatment burden as a key concept for stroke care: a systematic review of qualitative research. PLoS Med2013;10:e1001473.
  7. Bohlen K, Scoville E, Shippee ND, May CR, Montori VM. Overwhelmed patients: a videographic analysis of how patients with type 2 diabetes and clinicians articulate and address treatment burden during clinical encounters. Diabetes Care2012;35:47-9.
  8. Sav A, Kendall E, McMillan SS, Kelly F, Whitty JA, King MA, et al. “You say treatment, I say hard work”: treatment burden among people with chronic illness and their carers in Australia. Health Soc Care Community2013;21:665-74.
  9. Gallacher K, May C, Montori VM, Mair FS. Understanding patients’ experiences of treatment burden in chronic heart failure using normalization process theory. Ann Fam Med2011;9:235-43.
  10. Gallacher K, Batty GD, McLean G, Mercer SW, Guthrie B, May CR, et al. Stroke, multimorbidity and polypharmacy in a nationally representative sample of 1 424 378 patients in Scotland: implications for treatment burden. BMC Med2014;12:151.
  11. Eton DT, Ramalho de Oliveira D, Egginton JS, Ridgeway JL, Odell L, May CR, et al. Building a measurement framework of burden of treatment in complex patients with chronic conditions: a qualitative study. Patient Relat Outcome Meas2012;3:39-49.
  12. Tran VT, Montori VM, Eton DT, Baruch D, Falissard B, Ravaud P. Development and description of measurement properties of an instrument to assess treatment burden among patients with multiple chronic conditions. BMC Med2012;10:68.
  13. Shippee ND, Shah ND, May CR, Mair FS, Montori VM. Cumulative complexity: a functional, patient-centered model of patient complexity can improve research and practice. J Clin Epidemiol2012;65:1041-51.
  14. May C, Montori VM, Mair FS. We need minimally disruptive medicine. BMJ2009;339:b2803.


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