Puzzle Pieces ... Low Carb & Thyroid

So ... it' been a while, almost a human gestation period, since I reported my miraculous selenium insomnia cure.  In a nutshell, I started taking Se to see if it might help and within days I was sleeping like a baby through the night.  Although I found adding starches in somewhat difficult at first, I've also recently made clear that I'm eating a good 100g/day most days now ... at least that would be the average ... for starch.  I still eat a lot of veggies that I don't bother counting the carbs in and fruit several times a week, so probably getting about 150g perhaps up to 200 total grams of carbs these days.  

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Making forensics faster

Hola Reader,
                     There are always bigger hard drives, at least for the near future, and more devices available to individuals every day. While the everyday work flow for an individual is drastically improved, hopefully, by obtaining this additional storage and processing power it only further compounds the amount of evidence a computer forensic examiner has to go through. It's not uncommon now for a single person to have over a terabyte of data between their laptop, desktop, mobile phone, tablet, hosted email, file sharing and backup services. The question then becomes how do we keep up with the larger volumes of data without allowing each individual to take a month to process.

There are several options out there, depending on your choice of tools (encase, SIFT, FTK, Prodiscover, SMART, etc...) to really speed up the processing of the evidence so you can get full text indexes built and artifacts parsed. In most cases the answer comes down to:


1. Faster CPUs to process the evidence
2. More RAM to process the evidence
3. Distributing the workload across multiple systems (if your software permits this)
4. Faster storage to hold the evidence

In my lab we've approached this from all of these points.

1. Faster CPUs to process the evidence
We have multi cored, multi processor CPUs on our systems. What we've found is that typically, unless we are password cracking, that the I/O from the disks can't keep up with resources available. Meaning our CPUs are never maxed out. So the CPUs are not the bottleneck for getting more speed.

2. More RAM to process the evidence
We have machines with up to 49GBs of ram, under large loads we sometimes see usage into the 30GBs but again because of I/O from the disks more than enough is available. So the RAM is not the bottleneck for getting more speed.

3. Distributing the workload across multiple systems (if your software permits this)
We've tried using FTK's feature that allows multiple systems to distribute processing across them. The problem comes in that the evidence is still being stored and accessed from system. Again the issue comes up the I/O from the disks can't keep up with amount of requests being made from the additional systems now requesting data to process over the network. So distributed processing alone did not speed up processing.

4. Faster storage to hold the evidence
Here we find the greatest benefit. Initially we bought large direct attached storage RAIDs to store and process our evidence. While these systems get us I/O speeds around 100-200MBs depending on the type of disks it still wasn't enough speed to max out the CPUs and RAM. So we started looking around at other options. When you start looking at larger/faster storage systems things can get very expensive, very quickly.

If we had a very large budget we could have gone for a RAMSAN, http://www.ramsan.com/, and gotten a couple terabytes of storage at 4GBs a second read and write speeds. That kind of I/O would clearly max out most systems attached to it and easily keep up with the demands of a distribute processing system.

Unfortunately we don't have that large of a budget for storage, especially not with the amount of data that we working with. A RAMSAN 810 according to this article, start at $45,000 as of 8/23/11. So we look at the midline prosumer range of solid state storage as they are faster than similar SAS 15k drives but priced around the same in the most cases for larger sizes. Most prosumer SSD disks can go up to 300-400MBs a seconds and are connected via SATA meaning you could easily turn them into a small RAID and load your images there. However again the cost of doing this can quickly scale up depending on the amount of storage you need to hold the evidence.

Instead we have been implementing is a middle of the road approach. Instead of loading the entire evidence set into faster storage we purchased a PCI-E based SSD card from amazon with read speeds of 1.5GBs and write speeds of 1.2GBs  it has a smaller amount of storage (we opted for 240gbs) but allows the most heavy part of the processing (dealing with all the data extracted from the forensic images) to be done on the fastest storage. To accomplish this in FTK we pointed the ADTemp directory to the PCI-E SSD card and our processing speeds improved dramatically. We were able to complete a full text index of a 149GB full forensic image in 1 hour. This test wasn't even optimal as the forensic image wasn't even copied onto faster RAID storage but instead was just attached via USB3.

We've since ordered PCI-E SSD cards for all of our evidence processing servers and will post most benchmarks as we move forward in our testing and processing. I would also like to expand our SSD storage to include the evidence storage media and database media but I'm doing this one step a time to find out what parts are getting me the largest increases in speed for the dollar.

Paul Henry (@phenrycissp on twitter) has already taken this a step further by putting all his pieces onto SSD SATA storage and integrating in the PCI-E SSD card for his temporary directory. His new issue is finding test images large enough to show meaningful results since its' processing so quickly So if you have a test image 100GBs or larger, please let him know!

Drug Discovery and Reductionism for Physicists ... And Others

Having worked both in health IT and in pharma drug discovery, I read numerous pharma-related blogs.

From the blog of medicinal chemist Derek Lowe, "In the Pipeline" about reductionism in drug discovery. I believe the observations are more widely applicable to health IT, and to medicine itself. Emphases mine:

--------------------------------

March 6, 2012

Drug Discovery for Physicists

Posted by Derek

There's a good post over at the Curious Wavefunction on the differences between drug discovery and the more rigorous sciences. I particularly liked this line:

The goal of many physicists was, and still is, to find three laws that account for at least 99% of the universe. But the situation in drug discovery is more akin to the situation in finance described by the physicist-turned-financial modeler Emanuel Derman; we drug hunters would consider ourselves lucky to find 99 laws that describe 3% of the drug discovery universe.

That's one of the things that you get used to in this field, but when you step back, it's remarkable: so much of what we do remains relentlessly empirical. I don't just mean finding a hit in a screening assay. It goes all the way through the process, and the further you go, the more empirical it gets. Cell assays surprise you compared to enzyme preps, and animals are a totally different thing than cells. Human clinical trials are the ultimate in empirical data-gathering: there's no other way to see if a drug is truly safe (or effective) in humans other than giving it to a whole big group of humans. We do all sorts of assays to avoid getting to that stage, or to feel more confident when we're about to make it there, but there's no substitute for actually doing it.

There's a large point about reductionism to be made, too:

Part of the reason drug discovery can be challenging to physicists is because they are steeped in a culture of reductionism. Reductionism is the great legacy of twentieth-century physics, but while it worked spectacularly well for particle physics it doesn't quite work for drug design. A physicist may see the human body or even a protein-drug system as a complex machine whose understandings we can completely understand once we break it down into its constituent parts. But the chemical and biological systems that drug discoverers deal with are classic examples of emergent phenomena. A network of proteins displays properties that are not obvious from the behavior of the individual proteins. . .Reductionism certainly doesn't work in drug discovery in practice since the systems are so horrendously complicated, but it may not even work in principle.

And there we have one of the big underlying issues that needs to be faced by the hardware engineers, software programmers, and others who come in asking why we can't be as productive as they are. There's not a lot of algorithmic compressibility in this business. Whether they know it or not, many other scientists and engineers are living in worlds where they're used to it being there when they need it. But you won't find much here.

--------------------------------

I personally like the conclusion of Dr. Lowe's source article at Curious Wavefunction:

... All this can only be a good augury if it means that more physicists are going to join the working ranks of drug discoverers. And it will all work out splendidly as long as they are willing to occasionally hang their reductionist hats at the door, supply pragmatic solutions and not insist on getting answers right to twelve decimal places.

The reductionistic ideas prevalent in medicine today, where EHRs and Watson-like computers are supposed to be able to work miracles real soon now, is likely worse than reductionism in drug discovery, as they lead to the current mess with EHR's (see for instance this article) and threats to patients.

-- SS

AMA News Article Offers Incomplete (and Thus Misleading) Advice on the Legal Risks of EHRs and other Clinical IT

An article was published in the AMA News by Alicia Gallegos, AMA Medical News staff, entitled "Legal risks of Going Paperless." While it is not clear if these are the official views of the AMA leadership, the article is interesting nonetheless.

It should perhaps have been entitled "Some of the Legal Risks of Going Paperless, excluding the ones that make the health IT industry look bad:"

Legal Risks of Going Paperless
AMA News
March 5, 2012

Electronic medical records are meant to save time and money, but they also can create liability issues for doctors.

By Alicia Gallegos, amednews staff.

Defense attorney Catherine J. Flynn knows how electronic medical records can overwhelm — and often change — the course of a medical liability lawsuit.

In one of her cases, a New Jersey doctor being sued for medical negligence has been accused by a plaintiff’s attorney of modifying a patient’s electronic history. A printing glitch caused the problem, Flynn said, but the accusation has meant extra time and defense costs. Computer screen shots were reviewed, more evidence was gathered and additional arguments were made.

“This has taken a life of its own, and we’ve done virtually no discovery on the medical aspects of the case,” she said. “The cost of the e-discovery alone is in excess of $50,000.”

This is a variation on the theme of plaintiff's lawyers being the cause of EHR problems as I wrote at "Plaintiff's Trial Lawyers Are to Blame for EHRs That 'Tattle' on Doctors - And Harm Patients."

System breaches. Modification allegations. E-discovery demands. These issues are becoming common courtroom themes as physicians transition from paper to EMRs, legal experts say. Not only are EMRs becoming part of medical negligence lawsuits, they are creating additional liability.

Missing is the problem that is most important of all: health IT system defects, poor user interfaces, unreliability, data loss, etc. causing or contributing to medical malpractice that results in patient harm or death. (An example that I personally observed and reported to the FDA MAUDE database is here; there are numerous others in this blog.)

Data breaches are among the most common reasons that electronically stored information lands doctors in court, said Lisa Gallagher, senior director for privacy and security at the Health Information and Management Systems Society, which advocates health information technology

Most common perhaps (a big problem unto itself), but not the most clinically significant problem. Yet the AMA article goes on about this issue for many paragraphs; it's the prime focus of the article.

A 2011 ruling in New York highlights how e-discovery creates a burden for doctors.

During a lawsuit against St. Luke’s Hospital Roosevelt Center, a debate arose about whether the plaintiff should be allowed access to screen shots from a doctor’s computer. Joan Bowman, who sued the hospital for wrongful death on behalf of her husband, wanted to see a computer template used to aid physicians in diagnoses. The hospital said the request was overly broad and oppressive.

But the Supreme Court of the State of New York ordered the release of the screen shots.

“Defendant doctors testified that they utilized these materials in coming to their diagnosis,” Judge Alice Schlesinger wrote. “It is not a stretch to allow counsel to see and understand these materials.”

At this article’s deadline, the hospital’s attorney had not returned messages seeking comment.

The case sets a precedent, said Susan Dennehy, Bowman’s attorney.

“If others want to see screen shots from records, I think they’ll rely on this case,” she said. “It was important to see where the template led you if you put in an inaccurate chief complaint.”

Note the "spin" about the "burden for doctors" of eDiscovery. To the pundits and voluntary adopters: you have gotten what you asked for. To the non-pundit clinicians forced to use health IT: I hate to say this, but you've gotten screwed.

The article then offers a laundry list of how to avoid EHR-related liability:

... As the number of electronic medical records increases, so do certain legal risks, medical liability experts say. Common mistakes doctors make with EMRs and how attorneys recommend that physicians reduce their liability risks:

Mistake: EMRs allow users to move quickly through patient records, but cutting and pasting information makes it easy to paste incorrect information.
Recommendation: Refrain from copying and pasting EMR data, and be cautious when moving from one patient’s record to the next.

Mistake: Computer programs can help doctors make a differential diagnosis, but the templates don’t often include every possible symptom and corresponding medical condition.
Recommendation: Doctors should not become overly dependent on electronic diagnosis aids. Electronic systems are no substitute for hands-on diagnosis.

Mistake: Because EMRs allow physicians to move through patient charts much more quickly than paper charts, attorneys are noticing that some doctors are not being thorough when writing notes electronically.
Recommendation: Physicians should keep meticulous electronic notes on each patient and take time to document each chart.

Mistake: Some practices can fail to safeguard electronic patient data.
Recommendation: Practices should encrypt all information on computer devices and have policy that discourages employees from taking portable devices out of the office.

Mistake: A system may not clearly indicate changes to records.
Recommendation: Physicians should install systems that show transparency when modifications are made and/or have a program lockout period where no more modifications can be made to a record.

Mistake: Doctors may fail to follow notification requirements in the event of a data breach.
Recommendation: Be clear on what your state law requires when a data breach occurs, and make sure employees follow the rules immediately.

Mistake: Doctors may destroy or delete electronic records when a lawsuit is possible.
Recommendation: If doctors suspect they are being sued, they must preserve all electronic data related to the patient in question, including emails, phone messages and computer records.

Missing is this, as is well-covered by almost 8 years of posts on this blog, and elsewhere:

Big mistake: Doctors and hospitals buy and implement experimental technology approved by nobody, of uncertain quality to the point of losing or corrupting data, often with glass-tube black-and-white TV user interface modernity. Such technology is "errorgenic", i.e., it promotes "use error", can mislead, and can promote medical errors.
Recommendation: Hold off until the industry has gotten its act together.

Also missing from the AMA News article is the fact that physicians and hospitals use health IT at their own risk, even if the IT is "certified."

This article is clearly pregnant with omissions and spin that reveal a pro-health IT bias.

-- SS

Kode Rahasia dan Penting di Handphone Nokia

Unik Informatika - Ternyata, dalam handphone kita yang ber-merk Nokia, memiliki beberapa kode-kode yang penting, mungkin banyak orang yang masih belum mengetahuinya atau malahan ada orang yang tau tapi tidak mengamalkannya (kirain amal, pake diamalkan segala ? :D).

Ya, kode-kode itu mungkin akan sangat berguna bagi pengguna handphone Nokia jika mereka tau detail yang kan mereka dapatkan jika mereka bisa menggunakan kode ini secara optimal.

Nah, berikut adalah kode-kode yang tersembunyi dan penting di handphone Nokia anda :

1. *#06# untuk menampilkan nomor IMEI.

2. *#0000# untuk menampilkan versi firmware yang kita gunakan pada handphone kita.

3. *#9999# untuk kode alternatif jika kode *#0000# tidak berjalan.

4. *#8110# untuk menampilkan versi firmware di Nokia 8110.

5. *#21# untuk melihat pengalihan untuk semua panggilan yang ada di 'All Calls'.

6. *21*nomor tujuan# untuk mengalihkan semua panggilan ke nomor yang dituju.

7. *61*nomor tujuan# untuk mengalihkan panggilan ke nomor yang dituju untuk panggilan  tidak terjawab saja.

8. *67*nomor tujuan# untuk mengalihkan panggilan ke nomor yang dituju untuk panggilan ketika handphone kita sedang sibuk.

9. *#61# untuk melihat nomor panggilan karena tidak dijawab.

10. *#62# untuk melihat nomor pengalihan karena diluar jangkauan.

11. *#67# untuk melihat nomor pengalihan karena sibuk.

12. *2820# untuk menampilkan alamat IP Bluetooth.

13. *#30# untuk menampilkan nomor pribadi.

14. *#43# untuk melihat status 'Call Waiting'.

15. *#73# untuk mereset timer ponsel dan skor game.

16. *#2640# untuk melihat kode pengamanan ponsel anda sendiri. 

17. nomor urut phoneboook# untuk mengkases cepat ke nomor seseorang.

18. *#7760# untuk melihat kode pabrik.

19. *#7780# untuk merubah settingan handphone ke default setting atau seperti semula.

20. *3370# untuk menaktifkan fungsi EFR (Full Rate Codec), untuk suara kualitas terbaik tetapi pemakaian baterai menjadi sangat boros,

gunakan tombol yang sama untuk mereset kembali.

Demikian saja, terima kasih atas kunjungannya.

5 Akibat Kurang Tidur

Unik Informatika - Tidur adalah sebuah aktivitas yg harus dijalani, minimal orang dewasa tidur 6 jam lah sehari, jadi apa yang terjadi jika tubuh kita kurang tidur?

hahaha..bisa beragam kejadian bisa terjadi, jangankan melakukan aktivitas yang berat, kadang aktivitas yang ringan pun akan menjadi sangat berat,

jadi ga ada untungnya kita bergadang semalam suntuk..(kecuali ada bola, lebih-lebih sih milan yang maen), dewasa ini semakin banyak orang yang suka bergadang,

mungkin ada juga sebagian untuk kebaikan nya sendiri, semisal lembur di kantor, ya mereka lembur untuk memenuhi biaya hidup mereka, jadi jangan lah kita kurang tidur, karena akan banyak efek yang terjadi bila tubuh kita kurang diistirahatkan.

Berikut adalah ciri-ciri orang yang kurang tidur, apakah bisa kita cek dari mukanya? kita cek saja :

1. Mengantuk sepanjang hari.

Efek pertama jika kita kurang tidur adalah kemungkinan kita akan mengantuk sepanjang hari ketika kita melakukan rutinitas kita sehari-hari,

mungkin manusia mempunyai banyak cara untuk menghalangi mereka agar tidak mengantuk, salah satunya adalah meminum kopi atau kafein, itu mungkin hanyalah bersifat temporer,

tidak untuk jangka waktu yang lama.

2. Tubuh mudah sakit.

Perbaikan sistem kekebalan tubuh dapat diperkuat saat orang tidur.

Kurang istirahat dapat membuat daya tahan tubuh melemah, sehingga mudah terinfeksi virus maupun bakteri. Biasanya penyakit yang paling mudah menyerang orang yang kurang tidur adalah influenza.

3. Otak tulalit.

Membuka beberapa website dalam waktu 5 menit atau mengecek email berkali-kali padahal tak ada pesan masuk,

menandakan Anda kesulitan fokus dan berkonsentrasi. Karena saat kurang tidur, sel-sel otak pun akan kurang waktu untuk regenerasi sehingga kinerjanya tidak akan maksimal dan memori kita pun akan berkurang.

4. Sering tidak makan siang.

Kurang tidur bisa mengakibatkan perubahan hormonal yang meningkatkan nafsu makan atau malah sebaliknya,

merasa perut selalu kenyang. Hal ini terjadi karena terganggunya jam biologis yang mempengaruhi suasana hati tidak normal.

Ini sebabnya mengapa ada orang-orang yang jadi gemuk atau kurus akibat kekurangan tidur.

5. Pembicaraanya tidak nyambung.

Orang yang kekurangan waktu tidur biasanya kesulitan untuk konsentrasi saat berbicara dengan lawannya.

Akibatnya, apa yang diomongin dengan apa tanggapannya suka 'ngaco'.

sumber : Forum Indowebster

Another Health IT Mythbuster: Doctors order more X-rays, not fewer, with computer access

This piece is in the Washington Post about a just-released piece in Health Affairs (at this link) by Danny McCormick, David H. Bor, Stephanie Woolhandler and David U. Himmelstein of Harvard Medical School.

(Woolhandler and Himmelstein have written on such topics before, such as in the Nov. 2009 article “Hospital Computing and the Costs and Quality of Care: A National Study”, Amer J Med 123:1; 40-46.)

In the abstract of the new article, the researchers note:

Giving Office-Based Physicians Electronic Access To Patients’ Prior Imaging And Lab Results Did Not Deter Ordering Of Tests

Health Aff March 2012 vol. 31 no. 3 488-496

Abstract

Policy-based incentives for health care providers to adopt health information technology are predicated on the assumption that, among other things, electronic access to patient test results and medical records will reduce diagnostic testing and save money.

To test the generalizability of findings that support this assumption, we analyzed the records of 28,741 patient visits to a nationally representative sample of 1,187 office-based physicians in 2008. Physicians’ access to computerized imaging results (sometimes, but not necessarily, through an electronic health record) was associated with a 40–70 percent greater likelihood of an imaging test being ordered. The electronic availability of lab test results was also associated with ordering of additional blood tests.
The availability of an electronic health record in itself had no apparent impact on ordering; the electronic access to test results appears to have been the key. These findings raise the possibility that, as currently implemented, electronic access does not decrease test ordering in the office setting and may even increase it, possibly because of system features that are enticements to ordering. We conclude that use of these health information technologies, whatever their other benefits, remains unproven as an effective cost-control strategy with respect to reducing the ordering of unnecessary tests.

The WaPo offered these observations in their article:

Doctors order more X-rays, not fewer, with computer access

By Lena H. Sun, Published: March 5

In the debate over the high cost of health care, federal policymakers have always claimed that one way to cut costs is for doctors to use electronic medical records and other information technology. Doing so, they say, avoids duplication and saves money.
But new research suggests that may not be the case.

Doctors who have easy computer access to results of X-rays, CT scans and MRIs are 40 to 70 percent more likely to order those kinds of tests than doctors without electronic access, according to a study to be published in the March issue of the journal Health Affairs.

This is not surprising to me. Click a button, order an test, click a button, get the results. What could be easier?
What the pundits failed (and continually fail) to take into account is the social context of health IT. It is not used on a robotic assembly line. There are incentives, both proper and perverse (e.g., "defensive medicine", profits, patient demands) that figure into how any IT will "play out" in healthcare.
Making the blanket statement that "IT in healthcare will save money" without solid, sustained evidence (as opposed to the anecdotal evidence that now exists), while simultaneously ignoring contrary evidence is simply promoting an industry-created meme, a.k.a. wishful thinking.

“On average, this is comparing doctors who had electronic medical records and those who didn’t,” said lead author Danny McCormick, a physician and assistant professor of medicine at Harvard Medical School.
Researchers say the findings challenge a key premise of the nation’s multibillion-dollar effort to promote the widespread adoption of health information technology.
“This should give pause to those making the argument,” McCormick said. Instead of saving money, that effort could drive costs higher, he said.
For the study, researchers at the Cambridge Health Alliance, a health system in Cambridge, Mass., and the City University of New York analyzed data from a 2008 federal government survey. The data included information collected from 28,741 patient visits to 1,187 office-based doctors. The information included the type of doctor, their office computerization and the tests ordered at each visit. About half of the doctors’ offices surveyed had computerized access to results of X-rays and other imaging tests.
Researchers found that doctors who did not have computerized access ordered imaging tests in 12.9 percent of visits, while doctors with electronic access ordered imaging in 18 percent of visits, a 40 percent greater likelihood. Doctors with computerized access were even more likely — about 70 percent more likely — to order advanced imaging tests, such as PET scans, which experts said are most commonly used to detect cancer, heart problems, brain disorders and other central nervous system disorders.
The study found the results hold true even after taking into account other factors, such as patient demographics, doctor specialty and physician self-referral.

Unfortunately, nothing up to and including HIT-related patient deaths will give pause to health IT pundits pushing national rollout. They have too much skin in the game in the health IT bubble, psychologically (link) and financially.

The pundits need to be opposed by medical and legal professionals in an organized, systematic fashion until such time as this industry follows the National Academies' direct recommendations on getting health IT "right."

... Researchers were not able to determine why physicians ordered the imaging tests, or whether in those cases, physicians had looked at patients’ prior chest X-rays. Nor were they able to assess whether the increased imaging helped or harmed patients.

That needs to be followed up upon, obviously. Will it? Probably not.

At some flagship hospitals with customized health information technology systems, for example, doctors get specific feedback about diagnostic tests that can result in ordering fewer tests.

Note the word "can." (After decades there is no rigorous, unopposed proof, yet we are embarking on a national rollout with penalties for non-adopters?) This rationalization is both the "it will be better in version 2.0" and wishful thinking combined.

Michael Furukawa, a health economist in the Office of the National Coordinator for Health Information Technology, the administration’s health IT czar, said the researchers’ focus was not deep enough to support the study’s conclusions.
“The data are sound, the methods are appropriate, but the focus is limited,” he said. “They only looked at one piece of health IT.”

"But the focus is limited?"

So what?

That was all they intended to look at, and the result was concerning. Moving the goalposts is not a valid refutation of research.

On the other hand, coming from a political office that clearly does not understand how to conduct qualitative research and creates political promotion pieces masquerading as "research", such a statement is not surprising. See "ONC: "The Benefits Of Health Information Technology: A Review Of The Recent Literature Shows Predominantly Positive Results" at this link, where essential research methodologies were thrown under the bus for publication in Health Affairs.

At least the deviations from rigorous research methodologies were admitted:

“... Our findings must be qualified by two important limitations: the question of publication bias [e.g., bias in evidence selection - ed.], and the fact that we implicitly gave equal weight to all studies regardless of study design or sample size.”

Unfortunately, the media, politicians, financial decisionmakers and others are likely not to really comprehend, in-depth, the full significance of that sentence.

I can only imagine the reaction to such an excuse made by pharma for the mainstreaming of a risk-prone drug.

I personally take with the greatest of skepticism anything coming from ONC, an increasingly politicized government office in my observation.

You should, too, in my opinion.

-- SS

Gentiva's Odyssey Healthcare Settles Again, Signs Yet Another Corporate Integrity Agreement

The Milwaukee Journal-Sentinel reported a legal settlement worth noting.  Here are the basics:

One of the nation's largest providers of hospice care has agreed to pay $25 million to settle a Medicare fraud case initiated after a former company nurse in Milwaukee filed a whistle-blower suit.

It was the second such settlement in six years for Odyssey Healthcare Inc., which paid the federal government $12.5 million in 2006 after another Wisconsin-based employee sued.

Also,

Medicare provides a benefit meant to cover hospice care for the terminally ill. It covers 24-hour in-home nursing service only during limited crisis periods. But from 2006 to 2009, Odyssey practiced a pattern of enrolling and recertifying non-terminal patients, and billing for continuous care that wasn't necessary or reasonable, according to the False Claims Act suit filed in 2008 but just unsealed Thursday.

As is usual in such cases, Odyssey's parent company denied that it did anything wrong:

Odyssey, which operates in 26 states, is now part of Atlanta-based Gentiva Health Services, which runs hospice offices in West Allis and Burlington. Gentiva officials declined to comment, but referred to an announcement it posted on its investor relations website last month.

'Gentiva cooperated fully with this investigation, which covered a period prior to our acquisition of Odyssey, and the settlement is consistent with our efforts to instill Gentiva's culture of compliance throughout the company,' said John Camperlengo, general counsel and chief compliance officer.

The statement said the firm is proud of the care its thousands of hospice clinicians provide, and of Gentiva's efforts to ensure strict compliance with all regulatory requirements.

The Implications of the Need for a New Corporate Integrity Agreement

However, there are some disturbing aspects of this case that require a bit more explanation. First, as noted by the Associated Press (in a story available here from the Dubuque [Iowa] Telegraph-Herald),

Besides agreeing to pay the $25 million settlement, Odyssey entered a five-year corporate integrity agreement with the federal government.

Now corporate integrity agreements are not known for their effectiveness. In fact, as we noted in this blog post, according to Gentiva's 2010 annual report, its Odyssey subsidiary had been subject to a corporate integrity agreement arising from its 2006 settlement, one which was apparently not effective in preventing its misbehavior from 2006 to 2009.

However, corporate integrity agreements do serve as markers for the need to improve the integrity of the corporations who need to make them. In this case, why would Gentiva be asked to sign such an agreement if its integrity were already beyond reproach? So Gentiva's current "culture of compliance" is open to question.

The Implications of "Enrolling and Recertifying Non-Terminal Patients"

A quick read of the Journal-Sentinel and Associate Press stories above might give the impression that what Odyssey did wrong involved a billing technicality, admittedly, one that allowed it to collect more money that that to which it would otherwise be entitled.

This story actually goes beyond the issue of fraud, and raises important concerns about patient care.

The enrollment  by a hospice of patients who are actually not terminally ill could have serious adverse effects on such patients. As we noted in this post, hospices are meant for patients with very limited life expectancies. The goal of hospice is to provide comfort and palliation, not active treatment of illnesses. So if patients who actually do not have such severely limited life expectancies are admitted to a hospice, they might be denied therapy that could actually make them feel better, or even cure acute illnesses or prolong their lives. For example, a hospice patient who developed an open wound might not get maximal wound therapy, as in an example (allegedly involving a different commercial hospice provider) in the post above.

So it is possible that Odyssey's enrolling and re-certifying of non-terminally ill patients could have lead to failure to provide some of these patients with the care they should have had. Whether this did or did not occur in individual cases, and what adverse effects may have been produced is not clear from the coverage of this case.  

Summary

As I wrote in 2011, .... There has been a lot of blather from politicians in the US about "death panels" in debates about health care reform. Many such politicians seem worried that the US government has or will have death panels under the new health care reform legislation. We have criticized that legislation for not addressing many important health care problems. No one, however, has convincingly demonstrated how its provisions would convene "death panels."


Wendell Potter argued in his book, Deadly Spin, (see this post) that for-profit insurance companies had their own "death panels." The Bloomberg article strongly suggests that for-profit hospices may also act like death panels. In search of more revenue, for-profit hospices may enroll patients who are not at the end of life, but then provide them only "comfort care," so that if they develop new conditions that are treatable, they are likely to die in the absence of treatment.

I am waiting for the politicians who so enthusiastically condemned the supposed "death panels" to be found in health care reform legislation to condemn for-profit hospices for behaving like death panels.

In my humble opinion, the case discussed above are the strongest argument yet that we need to reconsider our headlong rush to turn health care, particularly the direct care of patients, over to relatively unregulated, for-profit corporations. The cases above suggest that the pursuit of revenue ahead of patients' welfare by such organizations may lead to sick and dead patients.

I cannot see how for-profit direct patient care can be made safe for patients without intense government regulation. If any of those vocal advocates of "free market" health care (in the absence of any good explanation of how health care can ever be an ideal free market, see this post) can explain to me how for-profit hospices can be made safe for patients without such regulation, I would welcome their attempts.

Meanwhile, this just calls out for legislative and legal investigation, and urgent policy changes.
 
By the way, the case above also shows how the current approach used by the government to address misbehavior in health care does not work.  We have noted previously how these legal settlements often only lead to financial penalties imposed on companies, not individuals, which diffuses their impact, and provides no disincentives to future bad behavior by individuals.  Sometimes corporate integrity agreements are added, but as in the current case, they also seem not to deter future bad behavior.   So, I further conclude, de rigueur, to really deter bad behavior, those who authorized, directed or implemented bad behavior must be held accountable. As long as they are not, expect the bad behavior to continue. Real health care reform needs to make health care leaders accountable, and especially accountable for the bad behavior that helped make them rich.

sorry for being MIA...we had a rough weekend.  we lost our sweet doggie barron.  we got barron right after warren and i got married and moved into our first home, seven and half yrs ago.  it is not fun being  a grown up and making painful decisions.  it is equally not fun to have to tell little taylor that barron is in heaven.  we know he's safe and sound and no longer in pain.  he will forever be in our hearts and is definitely missed in our little household.  we love you "B"....

Courses and Conferences on Health Care Ethics, Corruption, Marketing

Two courses and two conferences of interest to Health Care Renewal readers are coming soon.

Short Course: Why Do Physicians Not Make Rational, Evidence Based Decisions?


A full-day course at the 14th Biennial European Meeting of the Society for Medical Decision Making on Sunday, 10 June, 2012 in Oslo, Norway. Taught by bloggers Dr Roy Poses and Dr Wally Smith, the course will address both the effects of cognitive psychological limitations and of external influences by vested interests leading to less than optimal decisions.

A full description of the course is here.
 
Online Course: Corruption in the Health Sector

A 30 hour online course given by the U4 Anti-Corruption Resource Center, offered in collaboration with the Boston University School of Public Health.  The course is "on causes and consequences of corruption in the health sector; vulnerabilities in drug supply systems, informal payments, and strategies to minimise the problems." 

A full description is here. 

Conference: Deception, Incentives and Behavior

A two-day conference given by the Rady School of Management, University of California - San Diego, on 20-21 April, 2012 in San Diego, California, USA.  This will be a multidisciplinary meeting to facilitate "research of deception and related unethical behavior in the fields of economics and psychology/judgment and decision making (JDM)."

The conference web-site is here. 

Conference: Third Annual PharmedOut Conference on How Patient Harms May Result from Industry Promotion

A two-day conference given by PharmedOut at Georgetown University in Washington, DC on
14-15 June, 2012.  The conference will focus on the how industry promotion may lead to under-use, over-use, or mis-use of drugs and devices.

The conference web-site is here.

Mother’s Day

Mother’s Day Sunday 18th March
Make your Mother’s Day with jewellery from Kit Heath!

Here are some of our favourites that we think will make the perfect gift for your Mum!

Ring O'Roses Earrings £55

Ring O'Roses Necklace £70

Ring O'Roses Bangle £150

 
As well as treating your Mum to a gorgeous piece of jewellery from Kit Heath what else will you be doing to make her day extra special – ironing, washing up, making her a cup of tea?!






What about baking her some of these amazing Macaroons from the website Pink Whisk?

The guys here at Kit Heath have had a go and here are the results!
Not bad for us girlies who do more surfing than baking (saying that there where a few misshapes along the way - Laura blew up her Mum’s 26 year old mixer and Lys had few stern words with her husband whilst at a critical part of Macaroon making)!

Well done to Becky who persevered and presented us with a plate of perfect Macaroons to brighten up our Monday morning (your Mum is in for a treat)!

(A Doodle Cloth is coming your way for your efforts kindly sent in by www.stitchdesignworks.co.uk)



Have you seen what people have been saying about us? Take a look here!

http://sfrproductreviews.wordpress.com/2012/03/04/kit-heath-simple-inspired-sterling-silver-jewellery-by-a-quintessential-british-designer/

http://wishfulwonderings.blogspot.com/2012/03/kit-heath-review.html?spref=tw

http://www.discontentedmother.blogspot.com/2012/03/looking-for-perfect-gift-for-little.html?m=1