When it comes to physicians failing to adopt and install electronic records, I think of the Saint-Exuperty’s story of The Prince, in which a boa constrictor is trying to digest an elephant.

The story says, “”Boa constrictors swallow their prey whole, without chewing it. After that they are not able to move, and they sleep through the six months that they need for digestion.”

With electronic health records, this metaphor holds true. But it going to take five years, probably a decade if you count the last five years, for the boa constrictor, government, to digest the elephant. It may have byten off more than it can chew.

In a piece in The Health Care Blog, “ Beyond Meaningful Use: Three Five-Year Trends in the Uses of Patient Health Data and Clinical IT,” David Kibbe, MD MBA, a Family Physician and Senior Adviser to the American Academy of Family Physicians, and Brian Klepper health care market analyst and a Founding Principal of Health 2.0 Advisors, Inc., describe the essence of the digestive problem.\

All or Nothing

“Finally, we have a Final Rule on the Medicare and Medicaid EHR incentive programs. The rules and criteria are simpler and more flexible, and the measures easier to compute. But they are still an “all or nothing” proposition for physicians, who will have to meet all of the objectives and measures to receive any incentive payment.

Three HIT Trends

They then go on to describe three trends likely to take place over the next five years.

“1. The expanding uses of structured health data using XML. EHR vendors, HIE companies, consultants, and other middlemen are used to making fortunes on one-off health data interfaces between an EHR and sites of care (e.g., hospital) or service (e.g., lab).”

“2. Point-to-point sharing of health data, securely, over the Internet. Local and regional health information exchanges are proliferating, but they still face the problem of communicating beyond their own boundaries.”

“3. Platforms+modular apps+network services. Almost everyone is familiar with this model: it’s the iPhone app store and the Android Market. It’s the use of the Internet without as much dependence on the web browser, with multiple mobile devices for platforms, and with the emphasis on replaceable apps and re-useable technology that offers up data from many sources simultaneously.”

This is the kind of technocratic language most physicians, particularly those in marginal small practices, find hard to swallow and digest. This physician indigestion process reminds me of two other elephant metaphors.

The Elephant in the Room

Before resigning in frustration as the first “HIT Czar,” David Brailer observed in a 2005 in a New Times Times interview , “The elephant in the living room is what we’re trying to do is the small physician practice. That’s the hardest part, and it will bring this effort to its knees if we fail.”

The Blind Men and The Elephant

The second metaphor is the Blind Men and the Elephant. Our health care system is an elephant. Everyone feels the elephant’s parts differently. Doctors hanging on to the tail feel the system is an encircling rope, purchasers touching the leg feel it is an immovable tree, plans holding the trunk feel it is a squirming snake, and government officials riding on the head feel it as a global positioning satellite devices, capable of controlling the direction of the elephant.

Mindset – 1. an intention of inclination. 2. Deposition or mood.

Dictionary definition of Mindset

Over the next few years, the U.S. healthcare system will be in the hands of academics from Cambridge, Massachusetts. New CMS Czar Donald Berwick was a member of the Harvard Medical School faculty. Joe Newhouse, who has been the senior adviser to Medicare for as long as I can remember, holds appointments in three different schools at Harvard. David Cutler, Dean of Harvard’s Undergraduate College, seems a good bet to lead the Independent Medicare Advisory Board.

Countless of their colleagues and former students have taken key policy making positions in Washington… Whether they realize it or not, they are the vanguard of a movement bringing socialized medicine to America…The Obama administration has hired an army of academics to implement the new reforms. They bring with them the finest Cambridge pedigrees and promising ideas. They will write the first draft of the rules and academics everywhere will nod in approval at the cleverness of our colleagues.

David Dranove, “The Accidental Socialists,” The Health Care Blog, August 30, 2010

I once attended an 8-week course on health system management held at the Harvard Business School in Cambridge, Massachusetts with 60 other health care stakeholders. I was the only practicing physician. In 1994 the Hillary Clinton-led health care task force of 1200 or so contained not a single practicing physician or hospital administrator. The Obamacare team, centered in Cambridge, is about to make the same mistake of excluding health care participants on the ground.

The health reform law might be called the “Harvardization” of American health care. President Obama, a Harvard-trained lawyer inspired the reform law, weighed in when it is was in jeopardy, and pushed it across the finish line to passage. David Blumenthal, MD, a Harvard medical man, is Obama’s health information czar. Blumenthal is responsible for implementing and spending $27 billion on HIT to achieve a universal inoperative system of electronic health records.

The monumental, sprawling, massively-bureaucratic health reform effort rests on a set of Harvard mindsets. According to John Naisbitt, author of Megatrends (1982) and Mind Set!(2006),” Mindsets are the ground on which rain (information) falls. Mindsets are how we receive information. That is the key.”

Harvard reformers, mostly economists or academic technocratic experts, believe free market health insurance is imperfect and inequitable. Unregulated insurers leave too many individuals uninsured. Other individuals choose not to buy insurance. Still others “free-ride” off of taxpayer subsidized charity.

In the rarified academic heights of Cambridge , the solution to these societal ills is to tightly regulate the private insurance market and deploy “rational” technocratic mechanisms, perfected and directed from Washington, to create a more perfect health system.

Dranove, an economist at Kellogg School of Management in Chicago, says, “The preferred Cambridge solution is a combination of greatly expanded government insurance and a tightly regulated private insurance market. This is the essence of Obamacare.”

This mindset, when coupled with political power, transforms Harvard health reformers into high-minded social carpenters with hammers. Anything or anybody that doesn’t suit their fancy and fit their concepts looks like a nail.

Hammer for-profit health plans. Hammer fee-for-service doctors. Hammer hospitals that live off Medicare and Medicaid. Hammer anyone who needs profit to survive. Hammer the free-market crowd who believes in individualism, innovation, and free markets. Hammer anything and everybody that disagrees with you to nail down your concepts.

What are the Harvard health reform mindsets?

• Academic and government experts know better than people themselves what is good for them.

. You can trust government, but you can’t trust markets.

• Equality of results and health care equity, with expansion of coverage, is paramount.

• Standardize and homogenize health plans into one-size-fits-all plans that offer comprehensive and coordinated care.

. The power if centralized government transcends the power of individual states.

• Make all health plans and all states comply with federal mandates and regulations.

• Health care is too important to be left to consumers, doctors, hospitals, and private markets.

• Health care technologies should, and must be, be assessed by government before and after introduction into the market.

• The practice of medicine is a rational, measurable science and its technologies and outcomes must be managed by outside experts.

• All physician and hospital practices must be digitized so they can be monitored and paid-for-performance based on evidence.

• You cannot depend on health care stakeholders or competition or markets, or consumers spending their own money, to be self-regulating.

• Big Government and Big Academe know best.

These precepts rest on progressive Harvard mindsets, on faith in government experts to do the job of reform, on the ability of experts to analyze and to manage complex systems, on sophisticated technocratic analysis, and on more analysis and rule-writing is as the most equitable solution to social breakdowns.

The two regimens were equivalent in terms of treatment failure in this retrospective cohort study. Quinolones were associated with more diarrhea. Mortality was not evaluated.

I don’t like to stray too far off course from discussions of heart disease and related issues in this blog. But the question of bone health comes up so often that I thought I’d discuss the strategies available to everybody to stop, even reverse, osteoporosis.

Coronary atherosclerotic plaque and bone health are intimately interwoven. People who have coronary plaque usually have osteoporosis; people who have osteoporosis usually have coronary plaque. (The association is strongest in females.) The worse the osteoporosis, the greater the quantity of coronary plaque, and vice versa. The two seemingly unconnected conditions share common causes and thereby respond to similar treatments.

Incredibly, rarely will your doctor tell you about these strategies. Your doctor orders a bone density test, the value shows osteopenia or osteoporosis, and a drug like Fosamax or Boniva is prescribed. As many people are learning, drugs like this can be associated with severe side-effects, such as jaw necrosis (death of the jaw bone), a dangerous and disfiguring condition that leads to loss of teeth and disfigurement, followed by reconstructive surgery of the jaw and face. These are not trivial effects.

Note that drugs are approved by the FDA based on assessment of efficacy and safety, NOT proven equivalence or superiority to natural treatments.

In order of importance (greatest to least), here are strategies that I believe are important to regain or maintain bone health. Indeed, I have seen many women increase bone density using these strategies . . . without drugs of any sort.

1) Vitamin D restoration–Vitamin D is the most important control factor over bone calcium metabolism, as well as parathyroid function. As readers of this blog already know, gelcap forms of vitamin D work best, aiming for a 25-hydroxy vitamin level of 60-70 ng/ml. This usually requires 6000 units per day, though there is great individual variation in need.

2) Vitamin K2–If you lived in Japan, you would be prescribed vitamin K2. While it’s odd that K2 is a “drug” in Japan, it means that it enjoys the validation required for approval through their FDA-equivalent. Prescription K2 (as MK-4 or menatetranone) at doses of 15,000-45,000 mcg per day (15-45 mg), improves bone architecture, even when administered by itself. However, K2 works best when part of a broader program of bone health. I advise 1000 mcg per day, preferably a mixture of the short-acting MK-4 and long-acting MK-7. (Emerging data measuring bone resorption markers suggest that lower doses may work nearly as well as the high-dose prescription.)

3) Magnesium–I generally advise supplementation with the well-absorbed forms, magnesium glycinate (400 mg twice per day) or magnesium malate (1200 mg twice per day). Because they are well-absorbed, they are least likely to lead to diarrhea (as magnesium oxide commonly does).

4) Alkaline potassium salts–Potassium as the bicarbonate or the citrate, i.e., alkalinizing forms, are wonderfully effective for preservation or reversal of bone density. Because potassium in large doses is potentially fatal, over-the-counter supplements contain only 99 mg potassium per capsule. I have patients take two capsules twice per day, provided kidney function is normal and there is no history of high potassium.

5) An alkalinizing diet--Animal products are acidic, vegetables and fruits are alkaline. Put them together and you should obtain a slightly net alkaline body pH that preserves bone health. Throw grains like wheat, carbonated soft drinks, or other acids into the mix and you shift the pH balance towards net acid. This powerfully erodes bone. Therefore, avoid grains and never consume carbonated soft drinks. (Readers of this blog know that “healthy, whole grains” should be included in the list of Scams of the Century, along with Bernie Madoff and mortgage-backed securities.)

6) Strength training–Bone density follows muscle mass. Restoring youthful muscle mass with strength training can increase bone density over time. The time and energy needs are modest, e.g., 20 minutes twice per week.

Note that calcium may or may not be on the list. If on the list at all, it is dead last. When vitamin D has been restored, intestinal absorption of calcium is as much as quadrupled. The era of force-feeding high-doses of calcium are long-gone. In fact, calcium supplementation in the age of vitamin D can lead to abnormal high calcium blood levels and increased heart attack risk.

These are benign and easily incorporated strategies. They are also inexpensive. I challenge any drug to match or exceed the benefits of this combination of strategies. Keep in mind that strategies like vitamin D restoration provide an extensive panel of health benefits that range far beyond bone health, an effect definitely NOT shared by prescription drugs.

“It’s a reflex that’s built into the brain circuits,” she said in an interview. “At its core biological basis, it’s unfair to criticize men for that initial unconscious circuitry.”In light of this, male ogling must henceforth be considered genetic destiny rather than anti-social creepiness.I guess it’s how you process it in your neocortex afterwards that counts.Via Instapundit.

A paragraph in the August 29 WSJ opens:

“Forced with mounting debts from the new health-care law, many loal governments are leaving the hospital business, shedding public facilities that can be the caregiver of the last resort.”

Surely this is an unexpected and undesirable consequence of Obamacare, which was passed with the good intentions of covering the uninsured and Medicaid population, which flock to these hospitals for desperately needed care.

The WSJ article goes on,

“More than a a fifth of the nation’s 5,000 hospitals are owned by governments and may drown in debt caused by rising health-care costs, a spike in uninsured patients, cuts in Medicare and Medicaid, and payments on construction loans sold in fatter times.”

Local public hospitals foresee an expensive future because of new health-care requirements for such expensive items and services such as electronic medical records and other information technologies, tracking and enforcing quality of care of their physicians and hospital personnel, and coordinating care for its patient populations many of whom lack public transportation, phone access, and housing.

To make matters worse, many small hospitals in smaller communities are the economic engines and only health care facilities of their towns and surrounding regions.

Source: Suzanee Sataline, “Cash-Poor Governments Ditching Public Hospitals,” WSJ, August 29, 2010

I watched several shows this past weekend remembering Katrina, and virtually none of the coverage focused on Mississippi. Mississippi didn’t just get hit with some wind and some flooding; it got hit by a tsunami. Entire towns were literally wiped off the face of the earth. Storm winds tore through all of southern Mississippi for 150 miles wreaking havoc, cutting off power and killing people. In Jackson, where I live, 150 miles north of the coast, many people were without power for weeks. Gasoline was rationed. Days after the storm, I traveled to Pascagoula, Ms, which was 100 miles east of the epicenter, to help some friends save some of their belongings. It was a war zone. Attached is a picture of the coast of Pascagoula with nothing left but rubble. However, as you can see from the picture, the storm did not dampen the spirit of the Americans living there. There were American flags everywhere, and the people were upbeat, courageous and working together. My friends gathered around a broken spicket in the neighborhood for water to drink and shower. They lived in their drive ways and barbequed. There was no fussing about their predicament. There was true American grit. I came away humbled by their spirit. So, remember New Orleans, but remember Mississippi too. Home of the brave!

Maybe so.

In Washington, there are still way too many people who cannot get over how important they are. And do you want to know why they think they’re important? Because they make policy! To the rest of America, making policy is a form of intellectual masturbation; To Washingtonians, it is productive work. They love to make policy. They can come up with a policy on anything, including the legal minimum size of the hole in Swiss cheese.

Dave Barry, Hits below the Beltway: a Vicious and Unprovoked Attack on Our most Cherished Political Institutions, Random House, 2001

We live in an age of extremism. As those on the far left might say, “Extremism in defense of social justice is no laughing matter.” Or, as Barry Goldwater actually said, “Extremism in defense of liberty is no vice.”

Be careful about extremes. As politicians say in arid Arizona when the creeks run dry, “Don’t jump from one ex-stream to another.”

But fear not about extremes of government. Abraham Lincoln observed, “No administration,by any extreme of wickedness or folly, can very seriously injure the government in the short space of four years.” Maybe not, but when you spread it out over ten years, as Obama has done with health reform, there is cause for alarm.

Even with these things said, I should note the following. Health policy is a serious matter. Policy wonks are deadly serious people. Doctors take their profession seriously. Patients go to doctors with serious concerns. And as every serious politician knows who wants to make his mark on history knows, health reform is much too serious to be entrusted to doctors.

The two lists I am about to share with you, therefore, are dangerous. Why? Because they are full of puns, the lowest form of humor.
____________________________________________

One, I am about to print a series of doctor puns on health reform.

Don’t blame me. Blame the doctor who sent them to me.

• Allergists voted to scratch it.

• Dermatologists advised the government not to make any rash moves.

• Gastroenterologists had a gut feeling about it.

• Neurologists thought the Administration had a lot of nerve.

• Obstetricians felt they were all laboring under a misconception.

• Ophthalmologists considered the idea shortsighted.

• Pathologists yelled, “Over my dead body!”

• Pediatricians said, “Oh, Grow up! “

• Psychiatrists thought the whole idea was madness.

• Radiologists could see right through it.

• Surgeons decided to wash their hands of the whole thing.

• The Internists thought it was a bitter pill to swallow.

• Plastic Surgeons said, we don’t want to lose face.

• Podiatrists thought it was a step forward,

• Urologists said the whole idea was as painful as passing a kidney stone.

• Orthopedists said the idea was broken and cast aside.

• Anesthesiologists thought the whole idea was a gas.

• Cardiologists didn’t have the heart to say no.

• Proctologists were neutral, leaving the entire decision up to the “a– holes” in Washington.
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Two, I am about to reprint a previous blog of mine containing puns on why we should take old doctors seriously because they never diee.

• Old Internists never die, they just lose their differentials.

• Old Family Physicians never die, they just keep it in the family.

• Old Orthopedic Surgeons never die, they’re just get cast aside.

• Old Cardiologists never die, they just lose heart.

• Old Heart Surgeons never die, they just get bypassed.

• Old Urologists never die, they just spring a leak.

• Old Pathologists never die, they just get disembodied.

• Old Anatomists never die, they just become disorganized.

• Old Endocrinologists never die, they just make their Last Gland Stand.

• Old Hospitalists never die, they just walk down their last corridor.

• Old Pulmonologists never die, they just breathe their last.

• Old Fertility Experts never die, they just breed their last.

• Old Obstetricians never die, they just can’t deliver anymore.

• Old Surgeons never die, they just can’t cut it anymore.

• Old Plastic Surgeons never die, they just do a final life-suction.

• Old Gastroenterologists never die, they just disappear up their own fundamental aperture.

• Old Neurologists never die, they just lose their nerve.

• Old Psychiatrists never die, they just lose their minds.

• Old Physiatrists never die, they just can’t rehab themselves anymore.

• Old Radiologists never die, they just lose their images.

• Old Dermatologists never die, they just shed their skins.

• Old Ophthalmologists never die, they just make spectacles of themselves.

• Old Allergists never die, their immune systems reject them.

• Old Nephrologists never die, their machines fail and they lose their metabolic balance.

• Old Physician Executives never die, they just cross the Great Divide to the Other Side.
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Closing

I close with this little ditty.
Let not those onthe far left deride,
let not those on the far right divide,
but let voters in the center decide,
aided by a little humor on the side.

Here he is at the Restoring Honor rally.Via Gateway Pundit.