Participate in Torture - Lose your License

The California Senate will be voting on a bill this week that says California regulators would notify physicians in the military that if they participate in torture, they will loose their license to practice medicine and could be prosecuted by the State.During a Senate committee hearing, there was testimony that cited the International Red Cross, military records and first-person accounts about

Tamperproof prescriptions

On May 27, 2007, Congress enacted regulations requiring the use of tamper-resistant prescription pads. This primarily affects patients covered by state Medicaid programs.

Following several meetings internally, with state agencies and with professional organizations, BIDMC elected to use tamper proof paper stock in printers which produce electronic prescriptions (not e-prescribing, which is exempt from the regulation). The new stock will be used to write all prescriptions, regardless of payer/insurer and contains the features proposed by MassHealth as "standards" for Tamper-Resistant Prescription Pads:

It has a greenish hue.

It is perforated (twice) so that up to three prescriptions can be printed on one sheet.

When photocopied, the word "VOID" will appear in multiple locations.

The backside has Rx icons printed in thermochromic ink. This means the icon will disappear when rubbed with your finger and then reappear when you stop.

We're implementing this in two phases. From April 1, 2008 to October 1, 2008, we can still use plain paper, but we've modified prescription printing as permitted by the new regulation :

“Quantity Border and Fill (for computer generated prescriptions on paper only), i.e. Quantities are surrounded by special characters such as an asterisk to prevent alteration; e.g. QTY **50** and Value may also be expressed as text, e.g. (Fifty), (optional).”

“Refill Border and Fill (for computer generated prescriptions on paper only), i.e. Refill quantities are surrounded by special characters such as an asterisk to prevent alteration; e.g. QTY **5** and Value may also be expressed as text, e.g. (FIVE), (optional).”

Here is a link to an example of our new printed prescriptions. This is live now.

We're also providing a Notice to Dispensing Pharmacies which we're attaching to prescriptions.

By October 1, 2008, we'll replace all plain paper with the tamperproof paper as required by the regulation.

This has been an effort requiring coordination among IT, providers, administration, pharmacies, and government. It's been quite complex and we're hopeful that our planning, communication, and phased implementation effort will be successful.

Medical Journal Update

Watch out for elevated triglycerides: Most patients (and physicians) are concerned about their cholesterol but triglycerides get over looked. An excellent study has shown that elevated levels of nonfasting triglycerides were associated with increased risk for death, heart attack and ischemic heart disease in both women and men. The other risks for heart disease and strokes are age, blood

Universal Healthcare? Not without Primary Care

I've written about the primary care shortage before so I am happy to see the New York Times feature it today.In Massachusetts they have mandated insurance coverage for everyone (Universal coverage) but the unintended consequence is that these newly insured people cannot find a doctor. There are not enough primary care doctors available and the ones that practice in clinics and offices are full.

Step it Up

I just read about an intriguing small study done in Sweden that worked "backwards" and showed that reduced exercise promoted chronic disorders and premature mortality.They took healthy non smoker men who took no medication and without any family history of diabetes. These people walked over 3500 steps a day (measured with a pedometer) or did more than 2 hours of exercise a week. In summary,

Mickey the Wonder Border Collie

Mickey was a rescue dog that we brought into our lives over 14 years ago. Herding was in his DNA and herd he did. Because we never had a flock of sheep, he had to find his own jobs to do. Making sure his flock (us) was safe and rounded up became his passion.They say Border Collies are the smartest breed of dogs. I believe that. Mickey could open doors, climb trees and understand moods and

Cool Technology of the Week

One of the challenges of being a CIO is the "application is slow, can you fix it" phone call. Generally, the network is blamed first, but there are many layers that all need to be examined - desktop, network, server, storage, database, active directory, internet service provider etc. For example, a complaint about email slowness can be caused by a multitude of factors.

We recently worked with our electronic health record infrastructure partner, Concordant, to do an end to end application performance analysis.

The tools they employed were:

WhatsUp Gold for Network and Server Monitoring
Windows Performance Monitor for Server and Client Monitoring
OPNET Ace for End to End Network traffic analysis
Computer Associates eHealth for Network Monitoring

The general approach they used covered three domains. They began by identifying and defining the problems from a user perspective. This helped to identify issues related to system performance versus non-technical issues that amplified the technical issues and affected user perception of performance, e.g. training, improper usage of the application. They used multiple subject matter experts to focus on the different domains to ensure they had the in-depth knowledge to evaluate each of them.

The three investigation domains and key focus areas within each domain were:

Client
End User Observation & Interviews
Client device performance analysis
Device configuration & Log review
Device specification analysis per application vendor recommendations

Network
WAN link utilization
Device performance analysis
Device configuration & Log review
Packet Loss & Latency analysis
Traffic Analysis

Infrastructure
Server and Storage performance analysis
Device configuration & Log review
Service and Process performance analysis
Device specification analysis per application vendor recommendations

The findings from the assessment did not identify a "magic bullet" issue that caused performance issues, but instead identified multiple smaller issues that combined to impact system performance.

In my experience of troubleshooting complex IT systems, I've found that the comprehensive approach outlined above works very well.

If I had to choose one simple approach to determine the cause of application performance issues, I would:

1. Check to see that the desktop, the server, and the database all have their network cards set to Auto, since performance problems are often network card duplex mismatches

2. Install OPNET agents on the client and server. More often than not, OPNET rapidly identifies root causes of application performance issues.

Based on my positive experience with OPNET, including in this particular project, I'm naming OPNET as the cool technology of the week. Now I can respond to the "application is slow" question with an OPNET answer.