Avoid Obesity and Let Babies Eat With Their Hands

Babies who feed themselves with their fingers chose less sugar and were less likely to become obese than spoon fed babies, according to a study in the British Medical Journal Open.  It was a small study based on recollection, but the findings were still interesting and give us clues about how children self regulate food.

When babies start eating solid food, parents often offer sweetened baby

First Aid for Car Crashes

A big crash happened right in front of me today while I was at a stop light.  The sound of crunching metal and screeching brakes is truly frightening and it was clear help would be needed.  I crossed the intersection and parked my car and ran across the street to see if I could help.  Surprisingly, the man driving the car that was hit was not hurt.  The young woman in the car that struck him

Cool Technology of the Week

I recently did an interview about distracted doctoring for National Public Radio.  Typically, when I speak on Morning Edition or All Things Considered, I travel to our local  NPR affiliate (WBUR) and use their high fidelity dedicated ISDN lines in a soundproof booth.  

This time, I used my iPhone 4S.

How does it work?   I used a free application called Report IT Live which NPR has selected to capture interviews in the field via the high fidelity microphones built into the iPhone and a high digital sampling rate.

When the interview was complete, I uploaded the file securely to NPR servers.

Here's an overview of how it works in the field.

High fidelity radio interview recording on your iPhone with all the sound quality of a studio.  That's cool!

Our Cancer Journey - Week 8

Kathy finished Cycle 3 of Adriamycin/Cytoxan, has weathered the most difficult treatment symptoms, had a positive rebound of her blood cell counts, and continued to receive an outpouring of support from the community.

Per the screen print above from BIDMC's web-based Online Medical Record, her neutrophil count increased from 3610 to 5660, ensuring she can fight infection.   Neutrophils are significantly affected by chemotherapeutic agents but Neulasta, a bone marrow stimulant, prevents cancer patients from the neutropenic nadirs that once caused multi-day hospitalizations requiring antibiotics.

Dr. Robin Schoenthaler, a Radiation Oncologist in the MGH Department of Radiation Oncology at Emerson Hospital and Director of Medical Education  at Emerson wrote to me with very helpful advice for husbands and families supporting breast cancer patients:
   
"I am a radiation oncologist at MGH specializing in the treatment of women with breast cancer and I have been following your blog (from which I heard about that very cool I-phone charger; thank you very much!) for some time.  My heart goes out to you and your wife.  I hope that things go as swimmingly as possible for you during and after the acute phase of treatment.

I have many many thoughts about what you have written; but yesterday's column which touched on the issues of 'causality' rang a real bell for me in three areas.


First off, it may interest you to know that, as far as I can find,  there are no good studies that absolutely link breast cancer (or any cancer) with stress.  Studies looking at extreme stress (eg war, famine, rape) have not shown a clear-cut link with the later development of cancers.  Studies looking at day-to-day stressors have been negative, and studies evaluating severe stressors (recent divorce, death of loved one) are extremely mixed -- some show perhaps a small link and some actually show that severe stressors are associated with a LOWER rate of breast cancer (eg the Women's Health Initiative).  This stuff is terribly hard to tease out so all we can say at the present time is that while there MAY be a link, and although there are hypothetical reasons to be concerned about a link, thus far many good studies do NOT show an absolute connection between being under stress and then getting breast cancer.


This may well be because 'cancer' is such a heterogenous disease, and it may also be related to the fact that cancers grow at such different rates, so that it's nearly impossible to say that a defined 'stressor' (and who can say exactly what stress is -- for some people it's their mother-in-law!) is linked to a very slow-growing breast cancer (or a fast one) or a lightning-fast lymphoma.  It's just too hard to connect the dots.

The second idea I would like to convey to you is that your search for a cause -- wondering if it's paints, or stress, or radicals (or for other women: fertility treatments, or living under power lines, or pesticides) is a specifically AMERICAN response to disease, or more fundamentally, why bad things happen to good people.  If you and your wife lived in India, you would probably think this disease occured because of something harmful you did in a past life prior to this reincarnation (karma, etc).  If you lived in Mexico, you might well think your wife was bound to suffer this way so she could offer it up and then sit at the right hand of Mary in heaven.

But here in America, we always, always, think it's something we did.  We think we are the cause.  We ALWAYS think we are the cause, and if only we had done x or y or z maybe this wouldn't have happened.  We like to think we are in control, us Americans (especially the engineers and computer people amongst us, despite the fact Mother Nature that is constantly showing us who rules.

I do think this is an important thing to think about -- maybe it wasn't environmental, maybe it had nothing to do with behavior, maybe it was just stone cold bad luck.  I think it changes the way one approaches disease sometimes and I offer it to you as a possibility.

The third thing I want to say to you is that you are really being a model Husband/Caretaker, and my hat is off to you and to all such wonderful men.  I call men like you 'Purse Holders' and in fact I wrote an essay in the Globe about them a couple of years ago.  If you care to read it you can find it here.

I send you my very best regards and wishes, and if you would like to further discuss these or any other breast-cancer-related issues or questions, please consider me your go-to person."

Thanks Robin, your support is much appreciated.  And you're right, since treating breast cancer is a partnership, all aspects of treatment including the driving, the listening, and the purse carrying are a shared responsibility.

On Sunday, I must fly to China to fulfill a promise I made a year ago to assist with healthcare IT design in Shanghai and Hong Kong.   My absence is timed for those treatment days when Kathy is at her best and her energy has returned.   I'll be back before the symptoms of Cycle 4 begin.    I'll write my post next week during the first time we've been apart overnight since her diagnosis in December.   As we travel the treatment path together, the experience of caring for Kathy long distance will bring new emotions.

Alternatives to Komen Foundation

Sometimes my fellow health bloggers get it so right...the best thing I can do for my readers is steer them to another blog.  And that is what I am doing.

The Blog That Ate Manhattan is written by Dr. P. and she did a great job of pointing out that we can still donate to the fight against breast cancer, now that the Komen Foundation has shown their true political leanings.  That debacle will

Two Factor Authentication

I've previously written about innovative approaches to strong identity management which we're investigating.

SAFE-BioPharma has implemented a thoughtful two factor authentication solution that leverages mobile devices and is provisionally certified as a trust framework provider for NIST level of assurance 2 and 3 by the General Service's Administration FICAM program. Their solution is cross certified with the Federal Bridge Certificate authority.  Thus, their credentials are trusted in both the Public Key Infrastructure (PKI) and non-PKI sectors for authentication to any Federal application or infrastructure.

Here's how credentials are issued per Richard Furr, Head of Global Regulatory Affairs, Policy and  Compliance, SAFE-BioPharma Association:

The applicant is nominated for a credential by a sponsoring SAFE-BioPharma member.  It is important to note here that SAFE-BioPharma is a member driven non-profit association and only members of the association can nominate applicants for credentials.  Applicants must be employees or business partners of that member. Membership in SAFE-BioPharma is limited to entities that operate in the biopharmaceutical or healthcare delivery sectors.

The nomination is made on-line by a specially trained member of the member staff who enters specific data, I.e, at least name and business e-mail address, into the registration authority system (UIS) that Verizon Business operates as a contracted infrastructure provider for SAFE-BioPharma.

The UIS generates an email to the applicant address which contains a link to the UIS and a one time password to allow the applicant to access the UIS.

The applicant completes a user profile including other information, e.g., address, telephone, last 4 digits of their social security number, date of birth, medical license number if they have one, that the UIS uses to build out their identity.

Based on the data entered by the applicant the UIS develops their identity and through a contracted data source (LexisNexis) the applicant is presented with five multiple questions to which only they should know the correct answers.  The applicant has 2 minutes to answer 4 of the 5 questions correctly.  If they fail the first time they are presented another 5 questions.  If they answer 4 correctly their identity is confirmed and they can complete the registration process.  If they fail a second time they are rolled over to a manual notary process.

Once the identity is confirmed, the applicant creates an account with the UIS Identity Broker by creating a strong user name and password according to the parameters of the system.  Then, the applicant registers one or more devices that are capable of receiving a cryptographically generated one-time password, e.g., smartphone (Android or iPhone), SMS capable cell phone, iPad, other mobile tablet, landline phone capable of receiving interactive voice response, other token (RSA, OAuth, etc,) or other types of devices that can receive the One Time Password (OTP) .

Upon completion of these steps the system also generates an X.509 certificate that is downloaded to a cloud-based FIPS 140-2, level 3 certified hardware security module.  This certificate is the applicant's digital signing certificate.  It can be accessed using the 2-factor non-PKI credential that was just generated.  Upon completion of these steps the applicant digitally signs their Subscriber agreement and is ready to go.  The entire process takes about 10 minutes. It is also important to note that the last 4 of the social security number and date of birth are deleted after the initial registration process so they are never kept in the system.

Here's how actual authentication works:

1.  The use accesses an application or portal via the internet.
2.  The accessed application or portal displays a login dialog that asks for the  user name and password.
3.  The user enters their user name and password and selects the pre-registered device to which they wish their OTP to be sent.  This is the first factor of the 2-factor authentication – something the user knows.  The app or portal also generates a SAML2 request to the identity broker.
4.  The identity broker verifies that the Account is valid and uses a cryptographic algorithm to generate the OTP and send it to the selected device.
5.  The app/portal displays a dialog for the user to enter their OTP.  The user has 5 minutes to enter the OTP.  When they do, the identity broker verifies the OTP as being the one that was generated and this completes the second factor – something the user has – in this case the pre-registered device that received the OTP. Based on this successful completion, the identity broker generates a SAML2 response to the app/portal verifying the identity.

If the user needs to digitally sign a document, such as an e-prescription, they can do so using this same process to authenticate to their X.509 certificate in the cloud.  It appears that the DEA will accept this process as part of the final rule for e-prescribing controlled substances.

Since the credentials are FICAM certified, it seems reasonable that such an approach meets all compliance criteria that require strong authentication for securing protected healthcare information.

Attesting to Meaningful Use Quality Measures

I was recently asked how eligible professionals should report the Meaningful Use Clinical Quality Measures if there are zero denominators (i.e. you do not have any hypertensives, adults, or patients with 2 or more visits in the measurement period)

Here's the answer as I understand the regulations and FAQs:

1.  Report on the 3 Core measures if you can, which include
*Hypertension: Blood Pressure Measurement
*Tobacco Use Assessment and Tobacco Cessation Intervention
*Adult Weight Screening and Follow-up

2.  If any of the 3 Core measures has a zero denominator, replace them one-for-one with one of the 3 alternate core measures.   If you can’t get to 3 non-zero denominators between the core and alternate core, report on all 6 (even if it means that you have to report 6 zero denominators)
*Weight Assessment and Counseling for Children and Adolescents
*Preventive Care and Screening: Influenza Immunization for Patients ≥ 50 Years Old
*Childhood Immunization Status

3.  Regardless of the above, you MUST report on 3 of the remaining 38 Additional Set measures.  If you are reporting any zero denominators from these Additional Set measures, you must attest that you have no other non-zero denominator measures.  Essentially, you have to confirm that you’re not running away from non-zero denominator measures.

In summary, the minimal requirement is for 6 measures (3 core or alternate core, 3 additional set).  You may have to report up to 9 measures if there are zero denominators involved.  If you can’t find 3 non-zero denominators among the core and alternate core, you have to report on all 6 (even if it means that you’re reporting 6 zero denominators).  In addition, you still have to report on 3 from the remaining 38 additional set measures.  If any of these 3 additional set measures is a zero denominator, you must confirm that you don’t have a non-zero denominator for any of the remaining 35 that you’re not reporting on.
 
Micky Tripathi posted a blog about this last summer that provides additional detail.

You'll find the FAQs that address the Clinical Quality Measures here.