Untangled Health

Consumers Unite To Drive The Changes We Need

Tag: PHR

SalesForce as a Patient-Centered Longitudinal Care Platform | I am one happy Diabetic!

The technology facilitating Patient Centered Care arrived over ten years ago. It was all a matter of configuration!

The technology facilitating Patient Centered Care arrived over ten years ago. It was all a matter of configuration!

I am pumped!
Years ago…1997 I believe; I had a job working for DocSite: the company founded by Physiatrist John Haughton MD that became one of the premier Registry products used as the EMR community was attempting to define itself. In the DocSite product we collected measures or “clinical indicators” that were compiled around the patient and associated with an infinity of conditions. Essentially the data design allowed physicians and grant recipients to have a single patient record yet extract, analyze and report on any constellation of outcome measures without having to spend money on redundant disease registry products. Example: Blood pressure is an important measurement for diabetes and heart failure. In diabetes the measure importance is 1) how often it is done and 2) the blood pressure value. In Heart failure the same measures of process (measurement frequency) and outcome (BP value) are required but they might be different depending on the cardiovascular guideline and contrasting diabetes guideline. In the DocSite system the blood pressure recording was simply a vital sign. The rules defining threshold for compliance with guideline were defined separately and associated with multiple conditions. When the doctor generated the data for PQRI and the Cardiovascular Excellence programs a single patient outcomes dataset was generated based on the programs associated with the patient. When the patient returned to any clinician using the Docsite system the Visit Encounter Sheet displayed the current measures due, the last values and trends for each measure and gave the physician or extender a place to generate an education note. Inexpensive, simple, multi-user, modifiable for EBG and data submission automated through clerical “generate and send PQRI data”. Now, I owned some stock in the company so I am biased but quite frankly I thought the system was elegant once it received data feeds from pharma and labs!

All of us at DocSite used a Client Relationship Management cloud application in our client services department. After using it for three years or so those of us that had worked in a previous company “the forerunner of DocSite” called Cognimed all thought that Sales Force had the proper design to create a community wide care coordination and patient centered care planning tool We had built one in the 1990s and sold it and moved on with our lives.
Today I see SalesForce has entered the arena. Knowing what I know about its capabilities I hope they capture the market by landslide. Please if you thinking about building a new care management platform…dont. As a patient, I would love to see this thing as an App. in all of my clinicians hands and on my IPhone please. Check out their demo. I am sure it all does not work as advertised but I can attest to the fact that they had the correct data model ten years ago!

Reconciling data in my six health portals

Reconciling data in my six health portals

Community Care of North Carolina goes for the gold: Proving valid reduction in hospitalization among Medicaid enrollees with Chronic Disease

Heck! With health insurance we can afford a cup of coffee!

Heck! With health insurance we can afford a cup of coffee!

I have not been posting much lately due to activities with the Patient Centered Primary Care Collaborative. We are working on an analysis of accreditation standards which will ultimately be used to verify Medical Home processes, procedures and clinical outcomes. Check out their website as you consumer types will have a chance to see what others are doing for you to assure you access to the best in health care as we reform the system over the next few decades.

I am very enthusiastic these days as I am seeing the changes I have hoped for my entire life as person with diabetes since 1966. As a child my doctor was always available to teach how to master my illness and provide tips with mechanisms I could use to reduce my cost: especially when I entered college. My docs have been so cool, I can never adequately thank them. Purchasing a glucometer and testing reagents for me when I was uninsured; providing free laser therapy when my employer dumped the plan I had in favor of becoming self insured. If you want an interesting read see an old post of mine titled Physician heroes.

Today I call your attention to Community Care of NC. The organization that employed me as their clinical informatics lead back in 2002. These folks are using a model of population management and patient care that I had seen work in Massachusetts in the 1990s. To that end my wife and I moved here in 2001 to work for CCNC. They use a centralized partnership between private healthcare industry and public agencies including Medicaid, Public Health, Mental Health and Substance Abuse Services, the NC Medical Society and the local branch or thee Academy of Family Physicians.

The central teams keep improving patient targeting and clinical outcomes analysis using a variety of statistical sources and deliver regionalized community information from 12 different 501c3 Community Care Networks. The individual Networks then put care coordinators, case managers, pharmacists and administrative staff in place to create local flavors of patient centered care. All have guiding physician committees and other staff who collaborate with subspecialists as well as local hospitals. The net result is a care continuum surrounding the sickest individuals where the team focuses on goals set by the patient, their family and the team. They have been doing this for fifteen years now and I can attest to the fact that they are one of only a few Patient Centered Medical Home Networks in the country that are using a web-native care plan accessible to all on the patient team as well as multiple other physician practice improvement web apps totally focused on education, assessment of each doctors population and measurement of patient outcome.

This week they published the proof in the pudding. After long struggles against threats to defund the program they survived. They are now audited in full and have demonstrated hospital utilization rates falling at 10% per year in the chronic disease population. We are talking HUNDREDS of MILLIONS of DOLLARS in savings folks on top of hugely improved clinical outcomes and patient satisfaction with their sense of well-being.

I have always said that I needed a lot of help in my life. Since I knew how to assemble a care team for myself I figured I may as well help others do the same. Today, in 2015 we have the mechanisms in play to reconnect patients with their physicians. Please step up and teach your docs about your needs, wants and struggles as it will take us a while to walk out of the woods.

nc hospitalization trends under CCNC

Proper Nutrition Boosts Recovery for Cancer Remission Patients

Jillian McKee
Complementary Medicine Advocate

When a physician, surgeon, or oncologist pronounces a person is officially in remission from cancer, there is much cause to celebrate and to feel victorious.  Fighting the disease and the accompanying side effects, such as those of mesothelioma, is no easy feat. The battle for good health can take a significant toll on a person’s mind and body.  While being in remission is good news, many people who reach this stage often feel exhausted, sore, ill, and drained of all sources of energy.  Nutrition can play a big role in helping a person get back to feeling vital and energized once again.

Plan Healthy Menus in Advance for Fast and Nutritious Meals on the Go

While many people are aware that eating healthy foods is an ideal way to return to full health, preparing healthy meals often is time-consuming and this can be an obstacle for numerous people.  When people are recovering from cancer, they are usually in the process of trying to return to a normal routine of going back to work or taking care of family and other responsibilities.  Shopping for healthy foods and cooking them for each meal is time-consuming and often seems much harder than simply grabbing a fast food hamburger on the go.

One solution is to set aside one day each week where a few hours will be spent grocery shopping and then preparing healthy meals and freezing them for later. Fresh vegetables such as broccoli, spinach, kale, bell peppers, collard greens, and squashes can be washed and chopped and put into freezer bags.

Lean cuts of meat can be marinated and cooked and then placed in the freezer in freezer bags as well.  When it comes time to prepare a quick meal, simply pull out the desired foods from the freezer and place them to steam or in the oven for a few minutes for a simple and healthy heal on the go.  Fresh fruit purchased once a week will typically last through the week if it is kept in the refrigerator

Taking Control of Weight Management Increases Good Health

It is not uncommon for people who have battled cancer to have either gained or lost a lot of weight.  Taking control of weight management by incorporating a healthy diet into a daily schedule is a great way to get back to feeling rejuvenated and filled with energy.  Consumption of nutritious foods also leads to people gaining strength, an important part of beginning a regular exercise regiment intended to increase physical health.

The American Cancer Society has provided several online articles on nutrition that helps cancer patients, whether in remission or battling cancer, to learn which foods provide the most physical benefits.  Reviewing this list is a great way to begin committing to a new and improved diet.

New Comment On Self-Management Responsibility

A snapshot of my PHR s data-store homepage MS HealthVault

Jeffrey Harris • Sandy, I enjoyed your comment and want to tease out a couple of points:
If best healthcare is measured by vital measures such as infant mortality, number of quality adjusted life years between age 65 and death and social perception we really don’t provide the best healthcare. For existence: I have a brother-in-law who has been hospitalized for syncope and loss of bladder-bowel function in addition to anxiety and right-sided hemiparesis three times in the last eight weeks. Discharges are always premature with an inconclusive diagnosis while all symptoms and signs point to micro vascular injury to his brain. He has fallen at home and been taken to ER a total of six times. The hospitals treating him are two well-known academic medical centers who keep avoiding the commitment of concluding his dx. I argued for IP rehab but Blue Cross denied the admission due to his inability to participate in three hours of therapy each day. At this point he is living at home alone with his son who has significant developmental disability.

What has happened in my opinion is the staffs of each facility see a 375lb man with 100 pack year history of smoking and wash their hands of going the extra mile. I understand this and have been there myself until my ‘higher self’ shook the judgments out of me.

I worked in PM&R for ten years and would have no problem creating a treatment plan that would occupy three hours per day of my brother’s time using the neuro-rehab team. But… here I sit in the great State of North Carolina with three medical schools within 25 miles of my home and I am powerless over people’s judgmental bigotry obscuring their human empathy. Our healthcare system is sick on many levels. Yes we need policy, procedure, payment mechanisms and total inclusion but a thoughtful look at our internal judgments and motivation wouldn’t hurt either.

I like the idea on penalizing people for poor compliance. I also like the idea of rewarding people who exercise good self-management. I have had diabetes type 1 for 45 years, hepatitis c for 30 years and neuropathic pain syndrome for two years which has required I reduce my schedule to part-time. What I can tell you is that I and many others find chronic disease a lot of work and certainly wouldn’t mind a seven hour work day if we agreed to attend the corporate aerobics class for the remaining hour. This may seem as if I am whining but we see it as being given the supports necessary to take care of our human bodies; for without them we have no contribution for the society that constantly complains about the cost of our care.

Thanks for your thoughts, I believe I mirrored what your ideas are but perhaps introduced some thoughts through the consumer’s lens.


My brother-in-law explores the underworld of care transition business rules


Much fun at the check in gate!

Here’s for the Tweenies’ that have health insurance with high deductibles and co-pays making what used to be a middle class wage.So, from yesterday’s post: they sent my bro home and discontinued his home therapy since he is now ‘a fall risk’.

Not in acute care so SNF won’t take him. Acute Rehab turned him down due to inability to participate 3 hours per day. One person in household of four people has a job.  Medical expense greater than salary’s: two years out to disability…



Stay with me folks as I report the death of person from iatrogenic (system caused) de-conditioning and a family from financial pressure due to need to work less and care for the patient. My redefinition of Untangled Health is switching direction to be completely focused on consumer market. Somehow continue advocating for those falling through the business policy gaps without aggravating those who have skills to treat the people.

Real Time Hassels with Transition Management

Holy Cow!!!

June 20, 2012


I just received a phone call from my nephew who said “Uncle Jeff…I am at the ER with Dad again; he fell down again and hurt himself so we are getting more X-rays…can you help?

This is a blog so I will make this fast:

My brother-in-law is 55 years old, obese, 75+ pack year history of cigarette use, status post MI, mild obstructive lung disease with recent history of syncope (passing out) and falling to ground. In the last month he has been hospitalized three times (each time through the ER) and now is experiencing his third independent ER visit where he may in-fact be sent home.

I have been advocating for further differential work up and have explained to three physicians at two high class academic facilities that my bro is not safe at home due to fall risk and dependence with activities’ of daily-living. With each event he develops new symptoms and becomes more dependent.

As of two days ago (last ER visit) he has been incontinent of bowel and bladder and loss his anal reflex! He was to follow-up today with a neurologist.Since this referral did not happen when I was around the evaluating physician in the ER did not get the full history which included his  asymmetric swelling of the prostate gland, inability to initiate a urine stream and painful urination:  All of these being consistent for either benign or malignant prostate disease.

So far, I have been unable to get him into a medical rehab for reconditioning and further work up. Perhaps this time we will be successful or perhaps not.

What I am talking about is a problem with coordinating transitions from one medical environment to another.

With health reform Medicare will not pay hospitals if patients are readmitted within a short time of the original hospitalizations.

This is a good thing. Too late I fear for my brother-in-law.

We are in the process of fixing these systems but it will be years before we are steady-state. Of course, if Healthcare (Insurance) Reform is reversed by the Supreme Court it may never happen.


New comment added to Forbes tonight on “Direct Primary Care”


I suppose it’s worth the risk here as it appears many in the healthcare sector are insulted by logic. My colleagues and I have been saying for years that to make this high cost scenario simple for the common voter we simply need to use the “too many hands in the pie” use case. Jiffy lube works well. What would you do if you suddenly realized that the $24.95 you were paying for an oil-change was completely inconstant with your neighbors who worked at the John Deer plant down the road: Their cost; only $14.95, and your mothers cost: Well that’s a new ball game as hers is free.

So now we have Direct Primary Care. When I first started in this business we had Primary Care Gatekeepers, then we had Primary Care Case Management and now of course; the Medical Home. The best we have done is to bonus physicians on process indicators and…finally we are talking about clinical outcomes.

When I first arrived in NC in 2001 I went to work for the evolving Community Care Medicaid population and disease management folks. They “according to their data” have managed to carve significant costs out of the Medicaid budget through a model that includes a pmpm component for the PCP and additional pmpm components for what you might call Accountable Care Organizations who offer case management, poly-pharmacy review and an administrative infrastructure to make an attempt at transparency.

My learning from all of this: Transparency to one is not Transparency to another; so be sure you set your outcomes definitions before agreeing on a P4P model. Still, I like the physician-patient direct notion the best.

Now, here are some considerations which arise from my 30 years in population medicine and 45 years as a diabetic with complications.

Figure out the illness burden component if it is a bone of contention that will be used in the future by practitioners that don’t like statistics.

Create an all-inclusive global capitation rate that includes fee for service, pay for process (EBG) and pay for clinical outcomes which include improved quality adjusted life years. Also consider how to test for and measure non-compliance (see my blog on medication adherence today at www.untangledhealth.com).

For God’s sake get some buy-in from your specialty brothers and sisters and the facilities where you park your patients for procedures and care from time to time.

Let’s use me as a model: 55 year old male executive with diabetes X 45 years, non-smoker, non-drinker but other comorbidities including hepatitis C, arthritis, neuropathy and retinopathy. Kidneys are good but I am on an ACE.

So number of drugs =six; an insulin pump with continuous glucose monitoring due to lack of awareness of hypoglycemia. My co-pays and deductibles alone are $5000 per year and the insurance plan cost in the NC High Risk Pool is around $7000 per year at last glance.

I have lots of ideas about keeping me compliant (again check out the blog above). Step on up my doctor friends it is time you take your power back and re-assign wasted dollars to true health-care not new positions created to help patients “navigate” their way through this haunted house. Cripes, you can have an MA do that in your office if you provide some special training and get rid of all of the insurance business rules. GO FOR IT.

Congress Passes Socialized Medicine and Mandates Health Insurance – In 1798 | The Health Care Blog



God Help Us

Congress Passes Socialized Medicine and Mandates Health Insurance – In 1798 | The Health Care Blog.

Please take a peek at my response.

Here is the historical reference in my blog response to the responses to the author in THCB.

EMTALA requires hospital Emergency Rooms must triage, evaluate and treat uninsured patients that  show up in the ER. This means many folks get primary care services in the Emergency Room and if you look at hospital fiscal charge off expenses many are in this category due to non-payment.

DSH payments are Federally backed State payments currently received by hospitals that care for uninsured at a disproportionately high ratio to insured patients when compared to normal facilities.

Under PPACA mandatory enrollment will reduce DSH payments if not cut them completely.


The British Primary Care System and Its Lessons for America | The Health Care Blog

The British Primary Care System and Its Lessons for America | The Health Care Blog.


Great post today on UK system. Makes a nice follow up to my complaints yesterday.

This is my reply to MD as Hell who was noting many issues with attorneys.

YAHOO!!! Yes, a confirmation of what my dear friends from UK have told me for years: And of course if we look at Barbara Starfield’s work for the Maryland Commission on PCMH measures she concluded a need for universal enrollment, a single payer AND these clinical functions. The results, better health outcomes. More visits to GP, fewer to specialty, less cost, increased quality adjusted life years.


Her comments in 2008

At the clinical level

–the critical structural features are Accessibility, mechanisms of Continuity/Information Systems, and Range of Services available in primary care.

–the critical process features are Problem Recognition on the part of practitioners (both for initial problems and for reassessment) and Utilization of primary care services, both over time and for new problems as they arise.


Together, these features achieve the evidence-based FUNCTIONS of primary care: First contact, Person-Focused (not disease focused) care over time, Comprehensiveness, and Coordination.


MD as Hell, my good friend Steve is a board certified ER doc who busts his butt for fairly reasonable life. One Friday evening a well-known malpractice attorney was in a car accident and presented in Steve’s ER with enough trauma to require lots of volume replacement, head tongs etc. Steve told me the next day that it took everything he had to not bend down and tell the attorney that he would save his life if is surrendered 33% of his future income. We both had a good laugh at that. Of course Steve didn’t say that, the guy lived and this was 30 years ago.


So what do we do: Well here is what I am observing:

Physicians 50 and over are retiring all around me.

Physicians 35-50 are wishing they would get paid the amount that they projected for their sub-specialties’ procedure of choice: Stent, joint replacement, IOL etc. The physicians that are 35 to 50 (far too few) that are engaged in PCMH work are pleased with the new outcomes based incentive systems, those who are not are living in wealthy areas as concierge docs. The kids that I have worked with the last two years in FQHC’s actually enjoy what they do and are learning to lead teams.


Me, I am a program manager IT guy who started as a CV technologist so I never got used to huge incomes and have always enjoyed each craft I learned.


As a diabetic for the last 45 years I can honestly say that my feet were infrequently checked until the last few years when EBG training occurred in the primary care setting. Since I have a good buddy who is an ophthalmologist (see my blog on Dr. Jeffrey Taylor at www.untangledhealth.com) I have been closely observed and received the   best laser, scleral buckles and IOLs at an affordable price since he wrote of extensively high co-pays.


I figure I have 15 years left and do not want to throw in the towel but teach folks about the history of medicine, insurance and technology in our nation of addicts so they can make more informed decisions at the voting booth. Another guy, John Harrison on this blog is doing the same thing.


So I am asking you physicians to stay with us, be angry, sacrifice something important as we all need to do for re-engineering and build a new system for the future.


The docs, the nurses, the hospitals, the technicians, the pharmaceutical companies, the manufacturers of large magnets and ionizing radiation collectors have all had a pretty good run. But it is over; we can walk away, stick around and complain with no suggestions or create something that works for everyone.



Jeff Harris

Untangled Health




Donald Berwick | The Health Care Blog

We are dropped from the universe into loving hands (unfortunately not for all though)






Donald Berwick | The Health Care Blog.

I am losing hope. Dr. Donald Berwick has been an individual that I have followed since 1996 when I lived in Boston. He is foremost a dedicated servant to efforts involving improving the quality of healthcare in our country. I am not using the term quality as a market strategy here but from the perspective of a person with diabetes who would trust this man with his life. Dr. Berwick IS Dr. Safety. He is the founder of the Institute for Healthcare Improvement where many of us policy and quality wonks spend our time learning new strategies to decrease medical error rates and prevent morbidity and mortality in hospitals. Dr. Berwick launched the save 100,000 lives campaign that focused on the National Institute of Medicine report from 2000 titled Crossing the Quality Chasm. In it they cited hospital acquired preventable infection, and many other issues as being unacceptable. We learned to quickly diffuse treatment guidelines for the prevention of ventilator acquired pneumonia and empowered fast response teams all over the country in demonstration hospitals. The fast response protocol allows any observant (family member, housekeeping staff etc. to hit a panic button if they sense a patient is in danger). Trust me folks, thousands of people have died who could have been saved if the patient’s family or nursing assistant who know the patient better than the attending physicians and charge nurses were allowed to activate a multidisciplinary rapid clinical evaluation.  I have experienced this as a clinician and personally when my niece Marianna passed away from  an asthma exacerbation that was observed hours earlier and reported by a respiratory therapist whose request to call for an emergency evaluation was disregarded by the local hospital’s charge nurse. She was 32 years old and NO ONE should die from asthma these days.

So Dr. Berwick was appointed to direct the Centers for Medicare and Medicaid Services in 2009 due to his international respect and knowledge of our healthcare system. According to NPR he was asked to step down this week as congress would not re-confirm his appointment. Why? Because he had made a positive comment about the UK National Health Service.

Once again we have a completely biased and uninformed group of bureaucrats drawing conclusions that we are commie, pinko socialists using antiquated references and experiences from the cold war: branding individuals with outdated labels, selling their fear to the ignorant voter who by no means is stupid but simply uninformed as to the corruption and shell games that drive health care practice in our country.

I am having flashbacks from Archie Bunker in the All in the Family series from the 1970s.

Meanwhile, we have republicans and democrats (all of whom you and I elected) being exposed for their million dollar hypocritical business deals and appear to not care as we re-elect, re-elect and re-elect. So we are headed to slaughter.

I am not giving up: I have been screaming for consumer rights as a patient, provider and program manager for thirty years. I have evidence of direct commentary from State officials demanding a termination of my contract with one of my customers three years after I left the State’s employ. The information presented was false, I confronted the issue with proof which discredited the spurious information by my personal patents and documentation; received a tearful apology and had no recourse since the NC law has a one year statute of limitations on defamation of character. By the way, my client whose board member instructed her to beware of me immediately informed me of the conversation and kept me on to perform my strategic contract which they were quite pleased with.

The issues that we have here refer back to the discussion on finding the gold that we all have to offer as opposed to presumptive guilt of our industrial colleagues. I am disgusted at our species and sometimes wonder if we shouldn’t hit the reset button.

So, we have fired one of the most dedicated professionals in our clinical world who has given thousands of free lifetime hours during his most productive time in life as a simple act of service.  He was the wrong brand… for those who continue to believe that 2011 is no different from 1776 and use such arguments to convince you my friends that they actually know what they are doing.

I am begging you to take your country back in a peaceful manner by understanding where the shadow people are, following the dollar and asking yourself if it is working for you. I ask that you not blame a single party, institution or person but own the responsibility yourself and find strength in your numbers.

As history usually points out I imagine that nothing will change, the occupy wall street and tea party movements will become nothing more than marketing tools for democrats and republicans next year and all will be diluted when we experience some form of economic recovery and we continue to not engage the homeless “eye to eye”.

Are you familiar with the behavior of Tasmanian Devils AND have you seen the movie 13.

With love and respect to my readers:

Jeffrey Harris   Communitarian Republicrat with fiscal conservative beliefs.

So you all know: every one of my wealthy and successful friends who agree with my opinions keep telling me to shut up as they are frightened for my career. You see I presently have no job and they want me to keep a low profile. My defect of character here is that I can’t as to do so would be to abandon my hope for eliminating disparities in health outcomes.

Dr. Berwick, I apologize for every vote I cast save for the President in 2008. I have hope and will continue to follow you in your efforts to teach us all that we actually have a heart. Perhaps quick 2D echos on every citizen to help them identify with that piece of themselves that miraculously works itself to death to maintain each persons life.