I very rarely republish items on EMR and HIPAA. However, every once in a while something is so good that I think it’s worth sharing so that more people can read. The following is one such case. I loved reading Dr. Rowley’s perspective on the Japan disaster and potential radiation health risks. The article was originally published on the EHR Bloggers site. As Dr. Rowley, our thoughts are with those in Japan who are suffering amidst this terrible disaster. Hopefully the following thoughts will clarify a confusing situation.

The horrific events we have seen unfold in Japan as the result of the recent earthquake and tsunami, and subsequent instability of a large nuclear facility in the disaster zone with (at least) partial melt-down of the uranium fuel, raises questions of health risks from radiation exposure.

Granted that the West Coast of the U.S. is some 7000 miles away, and disbursement of any radiation leaked into the air in Japan, carried by the jet stream eastward, would expose people here only trivially. Even close to the reactor, as nicely illustrated by a New York Times graphichere, the amount of ambient radioactivity is less than the average annual dosage experienced from all sources by Americans in a year, though spikes in exposure can be higher. The potential for a full meltdown with much larger escape of radiation still exists, with differences of opinion as to the probability of this.

The more likely health issues related to radiation exposure from this catastrophe is from people who were nearby, and leaving the highest-risk areas (see BBC article here). Because of crippled infrastructure and shortages of food in many grocery stores in a widespread area, people have been not only leaving the area, but also leaving the country. And those exiting the country may end up in the U.S., seeking medical attention.

What should practitioners do? Are there any precedents to a situation like this?

Historical experience from 35 years ago
I am reminded of an experience in the mid 1970s, when I was a medical student at UCSF. I was part of an organizing effort that included UCSF and several local community organizations, which helped with outreach to local hibakusha – survivors of the Hiroshima and Nagasaki atomic bombs, now living in the U.S. The atomic explosions (one was uranium-based, like what is now used in nuclear power plants at much lower levels; and one was plutonium-based) killed over 200,000 people and injured 150,000 more. Many of these survivors remained in Japan, but some 30,000 of them were American-born and many returned to the U.S. (see an in-depth article that appeared in People in 1990 here). They were often Japanese-Americans visiting Japan when the war broke out, were trapped there unable to return during the war, survived the Hiroshima and Nagasaki atomic bombs, and afterwards came home. During the 1970 outreach campaign I was involved with, there were about 400 hibakusha living in the Bay Area.

Nuclear survivors were often afraid to make their history known, partly due to social stigma, and partly dueto fear of losing health insurance coverage for radiation-related illnesses – an increased risk of thyroid disease and thyroid cancer was seen in this population (long-term effect), with increased risks of multiple other cancers seen (medium-term effects), and blood and immune system suppression (acute effect).

Besides the actual health risks, there was also fear and discrimination – a stigma of being “exposed” – with the unfounded belief that those exposed to radiation were themselves radioactive, and would expose others to ill effects of this imagined “radioactivity.” It took education to overcome these mistaken beliefs.

Post-war, Japan had enacted specific government-funded programs for hibakusha, and periodically assessed their health and treated their illnesses. This included sending teams from Hiroshima that would travel to the U.S. to reach out to survivors here – this was the program I was involved in. UCSF hosted the Hiroshima team, and a variety of community groups helped reach out to hibakusha, and bring them to “Hiroshima clinic day” in San Francisco.

Modern-day lessons
In the context of history, the scale of radiation exposure, and how to take care of people significantly exposed, is nowhere near what has been seen in the past. However, the issues of exposure to radioactivity from a compromised nuclear power plant should not be minimized – the risks are real, particularly for those living nearby.

Hawaii and the West Coast of the U.S. may experience some measurable increase in background radiation levels, not unlike a solar flare, or flying in an airplane at 30,000 feet. Our instruments for detecting such radiation are very sensitive. This is not likely to be the source of impact on the health care system.

More likely, practitioners may face the issue of taking care of someone who was near the disaster zone in Japan, who has now left and is in the U.S., and is concerned about radiation exposure. There is (unfortunately) much experience in dealing with such issues at orders-of-magnitude higher levels of exposure.

Based on the hibakusha experience, monitoring of blood counts (CBCs), thyroid functions and a comprehensive metabolic panel (which includes liver function tests) are about all that is indicated. For practitioners looking to code for such encounters, the ICD9-CM codes E926.8 (exposure to other specified radiation) or E926.9 (exposure to unspecified radiation) can be used.

The larger issue is reassurance and adding the calming effect of reason on a situation of fear and rumor. Unless one ingests a radioactive substance that remains in the body, being exposed to external radiation does not render one “radioactive” and there is no risk of “contaminating” others. The levels of radiation seen, even right at the nuclear power plant during times of reactor explosions, have remained less than that experienced by someone undergoing a full-body CT scan (compare the levels in the New York Times graph here).

The impact of modern health IT
Another difference in the world since the 1970s (now-vs.-then) has been the emergence of health information technology (HIT), including web-based Electronic Health Records (EHR) systems. This kind of technology is capable of capturing clinical encounter data from practices in all settings, and identifying issues among those with radiation exposure. Reporting these findings – whether to the CDC or to Japanese health authorities – can be done more systematically, and much more quickly than was ever dreamed possible in the 1970s.

In addition, the source of the health information can be much more grass-roots. Modern web-based EHR systems are used by local ambulatory clinicians in their private practices, and not necessarily affiliated with an institution. The need for travelling teams, university-to-university, is not as much of a requirement as it was in the 1970s, given modern HIT.

Our hearts go out to those who have suffered tremendous loss and upheaval in Japan. Assisting with the rebuilding of a devastated infrastructure is something everyone who can should do. The health effects seen outside the immediate area, however, should be put into their proper perspective – those leaving the disaster area will need our help. But the risk to U.S. populations – even those on the West Coast (7000 miles downwind) – is not where our attention should be.

Robert Rowley MD
Chief Medical Officer
Practice Fusion EMR

Trent Peters from Umbrella Medical Systems added an interesting comment on my previous post about Domain Controlled Networks and HIPAA that I thought really added to my original post. Plus, Trent goes into a nice list of other benefits of having a “Management” server in an office. It gets a little technical for some of my readers I’m sure, but is valuable if you’re office is embarking on this adventure.

Here’s Trent’s comment:

This is an interesting question and can be argued either way, but again it comes down to what’s “reasonable and appropriate”. A little background, my company is a IT Consultant group that works specifically in the healthcare arena offering services to medium-sized and small healthcare organizations, we have plenty of EMR implementation experience. Over 95% of our clients are in a domain environment and we always push for an Active Directory environment if one is not present. However, in the small offices (1 – 2 providers) this can be difficult because of the initial cost and the fact it’s “server” based. Many small offices will choose a “hosted” emr solution for the low up front cost and adding on the extra 5 -7K is not a valid option as the cost outweighs the benefits (from their perspective). The other 5% simply do not have the same security and manageability as the domain environments.

Any networks Security solution is only as strong as the weakest link. While not having a domain controller doesn’t necessarily equate to not being HIPAA compliant, it sure helps secure the environment to IT best practices. We call the Domain / Active Directory server the “Management” server because it provides more functions than just AD. For instance, WSUS patch management to make sure all computers have the latest security patches and don’t have the updates that may conflict with the EMR (some EMR software are not compatible with IE8 or SQL 2005 SP3, etc), centralized backup and client folder redirection for non-EMR critical data, centralized monitoring platform for servers (hardware + software), workstations, UPS, networks, VPN, etc, centralized AntiVirus protection is also important to notify the support team of malicious software and vulnerabilities. Group Policies is a big part of the overall security that can manage (if properly configured) all aspects of the network including password policies, computer and user permission rights, power setting, audit controls, etc. There are many benefits to a DC / Management and is the choice to achieve IT best practices (I believe MS recommend 3+ computers to be on a domain environment, although this is aggressive).

It’s nice to be able to bundle server roles (such as SQL or FAX) in order to justify the management server, but generally it comes down to cost. We hold our HIT practices to the highest standard, so our rule is that if the organization has +5 computers, you must have a Domain Controller / Management Server in order to qualify for our full support program. We can’t justify the extra effort required to properly manage the environment without it. In those rare cases where a small organization choses to not invest in a Domain Controller when we feel it’s required, then unfortunately we wish them the best of luck and turn down their business.

I imagine that many of my readers use Twitter to find EMR information. Twitter is an interesting beast. It takes a little getting used to, but can be used in a whole number of ways. However, what people don’t realize is that you don’t have to be on Twitter and have a Twitter account to enjoy many of the benefits of Twitter.

I especially like Twitter during conferences. For example, during the HIMSS 2010 conference I would just search for the tag HIMSS2010 and found all sorts of interesting information about what was happening at HIMSS. Here’s a simple search for people talking about EMR on Twitter.

I think one of the main uses of Twitter is a way to share some of my favorite EMR links. I use this EHR and HIT twitter account to do that for some of my favorite bloggers. It’s also fun to see people’s reactions to the various items I post on that account. I guess people like what I’ve done since that account has 4232 followers of it.

At the end of the day, Twitter for me is a way for me to connect with lots of interesting people. Tomorrow, I’m going to lunch with a local CPA and blogger that I met on Twitter. It’s timely, since I’ve been looking around for a CPA. So, we’ll share lunch, I’ll teach him about blogging and we’ll see if his CPA services are a good fit for my needs.

Beyond that I’ve connected with so many people on Twitter. I’ve gotten free tickets to shows in Las Vegas. I’ve gotten free graphic design work. I’ve seen some of the latest breaking news before CNN and the likes are broadcasting it. I’ve found side work on Twitter. Plus, I’ve gotten hundreds of questions answered by my smart twitter friends.

Obviously, I’m a pretty big fan of Twitter. In fact, many of you likely found this blog through Twitter. I love Twitter because it can be used in so many ways. How do you use Twitter?

Also, if you want to connect to my personal twitter account (which also does quite a bit of EMR related content), I’m @techguy.

I got an email from EHR TV telling me that the video I did with them was posted online. I mostly talk about my EMR selection book, but thought my readers might enjoy seeing Lindsay Pine from EHR TV. If you haven’t see EHR TV before, you should go check out their EMR industry videos. Eric and his team put a lot of hard work into the videos.

I also did a short interview with the people over at MedicExchange talking about my EMR selection e-Book as well. They’re another interesting entrant into the EHR and healthcare IT world of video news coverage.

Lots of amazing content out there. In fact, I’m thinking I’m going to do a post soon about some of my favorite places to read EMR and healthcare IT related content. Feel free to post yours in the comments.

I’ve often seen people compare the adoption of IT in healthcare with the banking industry’s adoption of IT. Many have wondered why the banking industry (and so many other industries) has adopted IT when healthcare is still sitting here with such low adoption levels. As I’ve thought about the difference, one thing is very clear. Both healthcare IT and banking have/had major challenges in order to implement IT in their industry. Many people have argued that healthcare IT is just more complicated or complex than other industries. There’s no doubt that healthcare IT has some unique challenges. However, I’m not sure they’re any harder than other industries. Resistance to change is a universal characteristic regardless of industry.

So, why has the banking industry adopted IT more quickly than healthcare?

I believe the major difference is that in banking the consumers demanded that banks use IT. How many of you would have gone to a bank if they didn’t provide you access to an ATM? Kind of funny to think about no? Well, ATM cards would have never been possible if it weren’t for IT. The same could be said for online banking. I know that when I moved and was searching for a new bank I wanted to make sure that it had great online banking. Luckily, now online banking is pretty much ubiquitous.

Now let’s think about healthcare. Do you choose a doctor because they use an EMR? Do consumers only go to healthcare providers who will share their patient record electronically? For the vast majority of people this just isn’t the case. Luckily, the PHR movement is going strong. Plus, the day will come when consumers demand online bill pay for their doctors. The time will come when we want to schedule appointments electronically with doctors. We’re going to demand that we get our script refills electronically. We’re going to only go to those doctors who provide e-visits. All of these things will require a great healthcare IT infrastructure and things like an EMR.

Once consumers start demanding these services, we’ll finally see the tipping point for IT adoption in healthcare.

I’m attending the Consumer Electronics Show in Las Vegas today. It’s one of the nice little advantages of living in Las Vegas. The first year I attended there wasn’t much healthcare presence at all. Each year it seems like there’s more and more. The largest healthcare vendors at CES are PHR vendors and medical device ones. Then of course we have the big booths like Microsoft and Intel. I’ll be interested to see how HIMSS 10 compares to CES. The pace of technology is amazing. For example, check out this picture of a video wall at the Intel booth that’s touch screen. It’s not hard to imagine one of these in a hospital or doctor’s office:

UPDATE: I found this video of the display that demonstrates what it can do even better.

Traffic at EMR and HIPAA usually slows down on the weekend and so I try to keep my weekend posts just a little bit lighter than the rest of the week. Often that means I talk about some technical thing since at the end of the day I’m just a techguy.

Don’t worry though, I’m not planning on getting really technical here. There are plenty of technical blogs out there for that discussion.

Instead I just want to highlight what might be the most important thing you set up when implementing an EMR: your EMR backup. However, the problem with backing up your EMR is that it’s not like something you buy on TV where you simply “set it and forget it.” Well, I guess you can, but you do so at great risk.

Do you know how often your EMR backs up?
Where is your EMR backup saved and what happens if that place dies?
Do you know that it indeed did back up your EMR?
Have you ever tried to restore your EMR backup?
Is there space for your EMR backup? Will there be space as your EMR backup grows?

I could keep going for a while, but that should get you started down the path to ensuring that not only your EMR is backing up, but that you’ll be able to restore your EMR if the need ever arises. Any IT person worth their salt knows that a backup is only good if you are able to restore it. Unfortunately, the only way to know if you’ll be able to restore it is to do it.

I’ll save the discussion of disaster recovery for another time. However, becoming familiar with your EMR backup is one of the best investments you can make in your practice. In fact, the future of your practice might just be riding on it.

I’ve mentioned a blog partnership that I created with the website EMR and EHR. In fact, you’re certain to notice the striking similarities between the 2 websites. I expect over time that will change to some extent. Although, things have gone well here so why mess with something that’s working right?

Well, I’m really happy to announce that Dr. Jeff has joined on with me and will be piloting the EMR and EHR blog. He’s a passionate guy with some strong opinions about EMR and I hope he doesn’t get shy now that he’ll be sharing those opinions about EMR in public. You can read more about Dr. Jeff on the EMR and EHR About us page. I’ll be posting occassionally on that blog too, but I expect to have a number of good blog “sparring” matches between Dr. Jeff’s blog, EMR and EHR, and this blog, EMR and HIPAA.

Dr. Jeff’s already got 2 blog posts up:
Big Government, Healthcare IT, Our Healthcare System and the Economy – A look at some of the changes happening with government and healthcare.
A Patchwork Quilt of Unique EMR Software – A short discussion of a Big National Data Bank of Healthcare Information

Let’s make Dr. Jeff feel welcome by heading over to the site and posting some good comments on his posts. Also, those who want to hear a doctor’s perspective on EMR can subscribe to EMR and EHR by email or RSS feed.

In a recent comment, Steven suggested that an EMR and HIT in general might be necessary because the volume of medical knowledge is so large and complex that it’s too complex for the human mind. Here’s a short section of his comment:

Another set of reasons to adopt EMR, and sooner rather than later, are the reasons that are beyond the horizon. With the rate of change continuing to accelerate in the health care industry, along with our body of medical knowledge, I see a day where a person’s care plan is simply going to be too complex for a human brain alone to work out all the contributing factors. Sometimes I think we’ve already reached that point and haven’t quite realized it yet.

I absolutely love this concept of the body of medical knowledge being “too complex” for us to work it all out on our own. The idea that we need good clinical decision support systems, EMR and other technology we might not have even developed is really intriguing to me. Reminds me of my previous post about not knowing the true benefits of EMR.

The basic concept being that we won’t know the real benefits of EHR adoption until we have a platform for smart people to be really creative. Think about the Apple iPhone. If you look at the creativity that’s come out of the iPhone platform, it’s amazing. However, we would have never seen all this creativity until the platform was adopted in a broad way.

I believe that being able to managing and delivering all the medical knowledge out there is going to be one of those long term benefits we can’t realize until we have broad EMR adoption.

I found this article which described a number of the offerings that Dell has offered to help Healthcare IT. I’m sure this could sound a lot like a sales pitch for Dell. It’s not intended to be a sales pitch for Dell. In fact, most of the solutions are being offered through Dell partners like Symantec, VMWare, Citrix, etc. I’d caution that you should look around since you can certainly find the exact same products from other sales channels than Dell. As always, it’s best to look around when purchasing any of the products described below.

What I did find interesting was all of the various types of packages that Dell and its partners are trying to offer to healthcare IT. My big question for you, is how can we ever keep up with all these cool technologies?

The following are snippets of the article linked above. I’ll add my commentary in italics below each section.

Dell Mobile Clinical Computing Solution

Among the new offerings announced is Dell Mobile Clinical Computing Solutions. This lets physicians access patients’ records from any terminal using smart cards and Symantec’s (Nasdaq: SYMC) Workspace Corporate product for single sign-on and secure authentication.

This capability is not entirely new, however. Sun Microsystems (Nasdaq: JAVA) has offered roaming capabilities using smart cards and single sign-on access through its Sun Ray technology, both in the U.S. and worldwide, for several years now. U.S. Sun Ray customers in the healthcare field include Denver Health, which provides healthcare for a quarter of all residents of Denver, Colo.

Smart Cards are interesting to talk about and interesting to see in action, but I just personally have never been fond of trying to manage smart cards. They’re expensive and prone to be lost. Can someone else make the case for them? I’d be interested to hear it.

On-Demand Desktop Streaming

Another element of Dell’s new lineup is On-Demand Desktop Streaming. This is for stationary environments where data management and security are critical. Virtual disk images will be streamed to desktops. This enhances security because users get a new, pristine image every time they boot up.

While Dell partners with VMware (NYSE: VMW), Microsoft (Nasdaq: MSFT) and Citrix (Nasdaq: CTXS) for virtualization, it’s likely that Citrix has been picked for this solution, as it is based on streaming images to the desktop.

On demand desktop streaming is a really cool concept. I think that in the next 2 years, the thin client on the desktop will become a major reality. Of course, I think this really only applies to large scale implementations that can benefit from the savings of virtualization and thin clients. Small offices will still be buying the regular old desktops. I don’t know what Dell will do, but I see VMWare becoming the dominate player in this space and Citrix losing some of its hold.

Virtual Remote Desktop

Virtual Remote Desktop offers centralized control and management of end-user devices while enabling personalized end-user desktops, access from any device — whether within our outside the corporate firewall — and session mobility, where a single desktop session can follow the user from one device to another.

The solution was developed in collaboration with Citrix. It consists of Citrix XenServer Dell Edition; Citrix Desktop Delivery Controller; Citrix Secure Gateway; and Citrix Provisioning Server.

This sounds like the idea of taking the desktop to your mobile phone. The mobile phone is getting there now with 3G speeds. I’d like to see this work. I’m afraid it’s still not going to be as nice as using a desktop.

Dell, Perot and the Cloud

In addition to Mobile Clinical Computing, Dell is teaming up with Perot Systems to provide virtualized desktop, storage, server and electronic health records on-premise, hosted off-site or in secure private clouds.

Perot also works with other major vendors in healthcare IT, such as IBM (NYSE: IBM) , HP (NYSE: HPQ) and Sun. “We’re vendor-agnostic,” Moss said. “We work with whatever’s best for the client.”

I don’t know anything about Perot systems, but it sounds interesting. I might have to learn more. Anyone else ever used Perot systems before that can tell me what it’s like?