Conflicts of Interest 2008

In all of my jobs and activities I try to be very transparent about all I do, both good and bad. In the interest of full disclosure, I thought it would be useful to describe all my affiliations, my disclosures, and my attempts to avoid conflicts of interest.

Having just finished my tax returns, I can tell you that my income is just a W2 from BIDMC, which invoices Harvard for the time I spend there. I did this to avoid having two paychecks and FICA deducted twice.

Any income I receive from speaking engagements or consulting I donate to BIDMC to minimize conflict of interest.

In 1993, I created a family trust and all my savings/investments are managed in that trust by an independent third party. The trust does not invest in technology related stocked or bonds.

Harvard has very strict rules about working with for-profit companies. No Harvard logos can be used in association with a commercial product. No organizational endorsements are permitted i.e. "Harvard thinks this is the best product on the market!". Case studies are fine and objective comments about functionality are permissible i.e. "I tested 5 products and found product x met my specific functional criteria."

Anytime I do case studies, they are reviewed by Public Affairs at Harvard Medical School for appropriateness. Anytime I have a question about serving as an adviser or board member, I inform Corporate Compliance at CareGroup and seek permission. Here are the roles I serve in for-profit companies and the financial arrangements:

Google Health Advisory Council - For the past year, I have served as an unpaid advisor on the Google Health Advisory Council. Since several individuals working on the Council are from non-profits and share my feelings about objectivity, Google circulates a form among the group so we can specify our preferences about being paid for our time. I have not accepted any personal compensation for the meetings, phone calls, policy advice and standards work.

Healthline Medical Advisory Board - Healthline has a built a search engine that uses controlled vocabularies/ontologies in an attempt to deliver more specific search results to users i.e. it knows that brains contain neurons and thus a search on neurons also looks at diseases of the brain. I serve on their advisory board to offer suggestions about how to incorporate medical knowledge in the search process. I have not accepted any compensation. I was asked to serve as an adviser by one of my former professors, who leads the Medical Advisory Board.

Whole Health Advisory Board - Whole Health provides workplace based medical services and wellness management. They use electronic health records throughout their clinics to optimize quality and safety. I was asked to serve as an adviser by a colleague at Harvard Business School. I have not accepted any compensation.

SafeMed Board of Directors - I rarely serve on the Boards of companies, but I made an exception with SafeMed because I so strongly believe in their mission - to make decision support available to doctors, patients and payers using a web-services architecture. They are the decision support behind Google Health, informing patients about medication interactions. I have not received any cash compensation for my Board service and will receive stock options, as is typical for Board members. These options will be declared with Harvard and CareGroup and I will recuse myself from any decisions regarding purchasing of SafeMed products. At present, CareGroup uses SafeMed as part of our Blue Cross funded pay for performance initiatives and CareGroup did not purchase products from SafeMed as part of that effort.

ePocrates Board of Directors - ePocrates is handheld prescribing software that runs on Treos, Blackberries and the iPhone. Many attending physicians, residents, and medical students at Harvard download the free version of ePocrates. Since it is the most popular mobile software used by clinicians at BIDMC and Harvard, I agreed to serve on the Board of Directors. I have not received any cash compensation for my Board service and did receive stock options, as is typical for Board members. These options were declared on the Harvard and CareGroup conflict of interest statements. CareGroup and Harvard have not purchased any products from ePocrates and I will recuse myself from any purchase decisions if any product selection is done in the future.

Blackberry Advocate - In 2007, I flew to a New York City SOHO studio and spent a day speaking about the way mobile devices impact my life. It was unscripted and captured my honest feelings about life as a highly connected human. What did I do to keep my objectivity? If you go to the Blackberry website, you'll see that it calls me "John Halamka, CIO and Emergency Physician", specifically removing my institutional affiliations. I worked very hard with Harvard and CareGroup counsel to ensure all materials did not include organizational endorsements, logos, or sales literature. The Blackberry media campaign in magazines, videos, and elevators was very professionally done. I did my best to express my personal belief in the utility of wireless devices while minimizing conflicts. When I walked on the set, I was given union scale wages for the day ($100 plus residuals) as would be done for any TV appearance by an extra and I donated that to BIDMC as well as disclosed it to Harvard and BIDMC corporate compliance.

These are all my for-profit company activities. I hope my attempt to isolate any conflicts of interest sound reasonable to you. The only companies from this list that I have mentioned in my blog are Google and SafeMed. For my Google entry on February 28, 2008, I specifically mentioned my Advisory Council service. Regarding my SafeMed entry of November 12, 2007, I began my Board service on February 1, 2008, so this entry is my declaration.

If there is anything I can do to adhere to other best practices, ensuring my objectivity, let me know!

Health Information Confusion

Thanks to J.S. for today's funny.

Physicians are Sleep Deprived

When patients complain about insomnia or difficulty staying asleep, I must admit I have no personal point of reference to what they are experiencing. I can fall asleep within minutes of my head hitting that nice soft pillow. I can doze off in a movie, sitting around with a group of friends or reading medical journals. The American College of Chest Physicians has now published results of a

Cool Technology of the Week

This week, the Massachusetts Health Information Exchange, MA-SHARE, went live with secure sharing of clinical summary records from provider to provider at Beth Israel Deaconess Medical Center, Lahey Clinic, Northeast Health Systems and Boston Children's using the recently recognized national standards harmonized by HITSP.

Here's how it works.

When a patient registers for care, their primary care giver is captured by the registration clerk. We store the National Provider Indentifier of the clinician.

When a patient is discharged from the hospital or the emergency department, a comprehensive clinical summary is automatically prepared in Continuity of Care Document format including medications, diagnoses, procedures, and all followup issues.

This electronic document is sent via SOAP/HTTPS to a hospital-hosted gateway. That gateway uses the National Provider Identifier to look up the primary care giver's institutional affiliation in our statewide provider index. The summary is then routed to the gateway of the receiving institution via the internet via SOAP/HTTPS. Once it arrives, it is routed to the clinician's Electronic Health Record, Fax machine, or secure Email box.

The end result is that we are ensuring appropriate followup, medication reconciliation, and communication among physicians using a standards-based electronic document and the internet. Further details are available in this overview.

In Masssachusetts, we exchange 100 million HIPAA transactions per year via our New England Health EDI Network (NEHEN) gateway. Massachusetts was recently recognized as the #1 e-Prescriber in the country and part of our accelerated adoption has been our use of an e-Prescribing Gateway. Now the secure summary exchange gateway is live. All three of these gateways are built on the same application platform, which is running at hospital systems and payers throughout the state. There are no transaction fees, and no charges to the patient. The software is developed and maintained via contributions from provider and payer organizations which derive value from its use. In the case of secure document exchange, we can eliminate mailing discharge summaries and ED notes, saving hospitals like BIDMC $100,000 per year.

National standards, the internet, and a business model for health information exchange in production. That's cool!

Medicare Fraud - Or Just a Mistake?

I hate waste and fraud as much as the next guy but are "Medicare coding mistakes" really the most pressing activity for our government to go after? Private audit companies, hired by Medicare, will begin scouring mountains of medical records in doctors' offices and hospitals to see if health care providers made a mistake in coding and billing Medicare. Intent to fraudulently bill does not need

Antibiotics - Truths you may not like

Some blogs are so good I want to repeat it for my readers. Thanks to Distractible mind for this one. Patients don't like to hear it but here is the real truth about antibiotics and YOU:Common myths about infections and antibiotics Much attention has been given to the fact that antibiotics are given too often. The reason for this concern is that the overuse of antibiotics can create resistance

Buying Great Sake

On occasion, I'll write blog entries about my avocations - rock and ice climbing, playing the Japanese flute, drinking green tea, winemaking, mushroom hunting and finding the perfect Sake.

Today's entry is about buying Sake, which can be very confusing.

Sake is made from rice, water, Koji (Aspergillus Oryzae, a starch dissolving mold), and yeast. It is not a distilled beverage and is generally between 15% and 17% alcohol. Sake takes approximately one month to brew, followed by a six month aging period and is meant to be consumed soon after purchase. Try to buy a sake bottled within the last year. There is no such thing as a vintage Sake.

Interpreting a Sake label can be challenging. The most important elements reflect the addition of alcohol and the processing of the rice. You'll find one of two designations about alcohol

Honjozo - Sake to which a small amount of distilled alcohol is added
Junmai- No added alcohol

Premium sake is brewed with special Sake rice in which the starch component (the shinpaku or "white heart") is concentrated at the center of the grain, with proteins, fats, and amino acids located toward the outside. With increased milling, sake makers can remove the fats, proteins, and amino acids that lead to unwanted flavors and aromas in the brewing process. Ginjo-shu (premium Sake) has at least 40% or more milled away. Daiginjo (super premium Sake) has at least 50% or more milled away. Sake bottles list Seimaibuai, the amount of the rice grain left after milling.

Another important element is the level of dryness. The Sake Meter Value (Nihonshu-do) is the specific gravity of a Sake. It indicates how much of the sugars created from the starches in the rice were converted to alcohol, and how much remained to contribute to sweetness. By historical convention, the higher the number, the drier the Sake. What is the range? In theory, it is open-ended. In practice, + 10 or so is quite dry, -4 or so is quite sweet, and +3 or so is neutral.

Acidity affects how the flavor spreads, and also the sensation of sweet and dry. The range is quite narrow, with 0.7 being low and 2.0 being quite high. 1.2 or so is average.

Good Sake is made from special Sake rice. There are dozens of types of Sake rice, which is different from eating rice, but only a handful that are truly worth remembering. The most important of these is Yamada Nishiki.

Yeast mainly affects fragrance, and then flavor. There are dozens of yeast strains, each with its own subtly different characteristics, mostly affecting fragrance, but also flavor. Learning to discern the characteristics of the various yeast strains is part of the fun of learning about Sake.

Other elements you may find on the label are

Amakuchi -Sweet in flavor
Jizake - Sake from smaller sake breweries
Karakuchi - Dry in flavor
Nigori - Unfiltered sake which has a white milky color
Yamahai - Sake brewed in a way that allows wild yeasts to grow. This is rarely done since the aroma is "gamey".

My favorite Sake is Wandering Poet, a Junmai Ginjo made by Rihaku Shuzo, Shimane Prefecture. Brewed slowly at low temperatures using traditional brewing techniques and Yamada Nishiki rice with 45% milled away, it has a well-rounded flavor, extraordinary fragrance, and a clean finish.

Let's analyze the label:
*Junmai Ginjo means no alcohol added and at least 40% of the rice grain has been milled away. I tend to prefer Junmai Ginjo instead of Junmai Daigingo, because the Ginjo has more intense flavor and character. I tend to eat a lot of raw/unrefined foods and I prefer my sake a little less refined.
*Sake Meter Value/Nihonshudo +3 means that this is neither overly dry nor sweet
*Alcohol 15.2% means that it is relatively low in alcohol for a sake
*Acidity 1.6 means that it is a crisp sake, relatively high in acid, that goes well with food
*Seimaibuai 55% means that 45% of the rice grain has been milled away
*Yamada Nishiki means that a premium rice has been used
*Yeast # 9 means that a specific strain of yeast was used. Many ginjo yeasts are #9-based strains which creates a great fragrance and a consistent fermentation.

Sakes are available at many liquor stores throughout the US, but often they are from inexpensive American producers. The best Sakes are available online and from a few regional specialty stores that import fine Sake. Interestingly Trader Joes often has fine Junmai Ginjo type Sakes at a great price.

Sake should be served chilled, not warmed. Warming is only done with inferior Sakes to hide the impurities.

So drop by your nearby Trader Joes, pickup a bottle of a Junmai Ginjo Sake and serve it chilled. You'll have a great Sake experience.