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Blockchain as Our Future

In case you still have not understood how much of a game changing technology blockchains can be, this article from the World Government Summit gives a pretty good picture.

why is this article cool?

It's super cool, because humanity now has a way to solve the big messy global transition from paper to electronics in an interoperable, functional and scalable way! And this article will give you example of exactly how this can become true and how game changing it will be from a technical, medical and governmental perspective.

resources

I've personally struggled with this concept for a long time. When i thought about it, the options i would come up seemed to be only 3:

  1. Vendors: those who develop the systems that providers use to collect and store clinical data retrieved from patients.
  2. Providers: the doctors who provide medical care also by collecting and storing patient's data in systems developed by the vendors.
  3. Patients.
At the end, i came to the realization that, even though each one of these parties can have influence on the data itself, none of them are the actual owners of the data: clinical data is a human heritage and should be accessible to everyone.

And here's why none of the above options really convinced me.

Vendors

I have heard some stories where a product vendor holds the doctor hostage of clinical data: the doctor might not pay for the vendor's services any longer and the vendor, instead of simply interrupting its actual services, it also decides not to allow access to the clinical data to the doctor any more. My initial reaction to that has always been "hey, that's not ethical: the vendor's don't own that data, it's the practice's (or doctor's) data!". Yes, i feel strongly against this behavior.

Providers

Maybe doctors own the data they collect. After all, they have put in the investment of purchasing the hardware and finding the patients and actually collecting the data. But even this never felt quite complete, because what happens when the provider retires and doesn't really do anything with the data they collected? Should all that data get lost with him or her? Decades of hard work gone to waste? That doesn't seem quite right either.

Patients

So if the patient owns the data, then they would have to be the ones ultimately responsible for it's integrity and safety. Certainly they could allow others to take care of it for them, however it could be hard to make sure that the entire medical record remains "in one piece". What if the patient accidentally or purposely deletes parts of the medical record?

So after a lot of struggle with this, i decided to tackle the problem starting from first principles. And i came up with this list:

  • Everyone wants to suffer less.
  • Illness, pain and death are most commonly associated with suffering.
  • Humanity is striving to reduce its diseases, physical pains and to elongate its lifetime.
  • Medicine has provided ways to fight diseases, reduce pains and increase life expectancy.
  • Improvements in the medical field require lots of scientific research.
  • Scientific research requires lots of clinical data.

If the above points hold true, then it follows that there is a direct correlation between human suffering and clinical data. Which means that

Lots of Clinical Data Help Humanity Suffer Less

So at this point it became pretty apparent to me that clinical data is a human's heritage and should be therefore available to anyone for research or patient's care purposes, provided the datum consumer is not ill-intended. 

Certainly patient and provider should have a say as to who should have access to which part's of the data, and if the data should be able to identify the patient or not. In some cases, it is best if the patient is not aware of some opinions, thoughts or discoveries of the medical provider yet. Similarly, a patient might not want to fully trust a specific medical provider or for some other reason want to just give access to a partial subset of his or her clinical data to a provider. However these configurable permissions should not stop the data from being anonymously, globally and forever available. Besides, isn't this what humanity has always wanted? The ability to just walk into any medical provider's office without anything more than an ID, and allow them to access our medical records in order to provide medical care for us? 

What remains now is figuring out a technology that can allow for all this to work. Up until 2008, the software we at our disposal was not able to provide a functional, reliable, secure, scalable solution to the problem. However, the invention of the Bitcoin has introduced the new concept of the blockchain, a technology which theoretically has all the physical capabilities to make the above concept become real. Now, just the fact that the technology is there, doesn't mean the problem has been solved: after all, we also currently have the technology to colonize Mars. That doesn't mean we can colonize Mars without putting in some serious work. And serious work is required in the medical field as well, before we can manage to make this technology become widespread.

 

ADEA Washington Update

ONC Issues Request for Information Related to Interoperability

HHS, Medicare and Medicaid Services, CHIP, EHR | Permanent link   All Posts

 

 The Office of the National Coordinator for Health Information Technology (ONC) has published a Request for Information (RFI) aimed at establishing the correct metrics to use when trying to assess whether the goal of widespread interoperability of electronic health care records has been met.

why is this cool?

It's exciting, because this means the government is serious about actual real interoperability: they want to define a way to measure how well medical software can communicate with each other.

more details

Under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), Congress declared it a national objective to achieve interoperability by Dec. 31, 2018. The bill also says that by July 1, the Secretary of Health and Human Resources must set up metrics to make sure this is achieved.

The RFI, released on April 8, is designed to seek opinions from various stakeholders on three subjects: the major components of interoperability that need to be considered; possible metrics that could be used; and other sources of data that will work to craft a metric that will measure interoperability in the broadest sense.

The RFI also asks what it calls “overarching” questions that include such things as whether ONC should use just one data source for consistency or different data sources, what the most important measurements are and how it should define “widespread” in terms of the “widespread interoperability” it is trying to measure.

Interested parties may submit comments until 5 p.m. on Friday, June 3.

 

It's official: the AAO is now sponsoring the PANIO effort

 

Well, this is not really news: the AAO has been investing on projects like PANIO for quite a while. However, what just happened is that the American Association of Orthodontists is now hosting this server (and therefore the PANIO efforts), and is therefore paying for it's electricity and bandwidth. This is huge. Thanks.

The history

At the beginning, some years ago, i was hosting this wiki in a server which was already running all the time at my parents office. However, their Internet Service Provider was doing funny things, and i soon realized that while i had no problems at all accessing it, some users would not be able to access it at all (it was wierd).

So then i decided to host on Google Compute Engine. Except those server aren't free. So i was shelling out roughly $40/month to have a system which wasn't even powerful enough, and needed to reboot every night, and would still crash every few weeks or so.

After a few years of having to spend money for something that wasn't even that great, i expressed my frustration, and the American Association of Orthodontics came to rescue: The AAO has provided a virtual server with 4 times as much memory and 10 times as much disk space at no cost for us.

I completed the move over the weekend.

The IHE has had a profile for being able to test interoperability of healthcare provider directories. Just recently, IHE USA has started their own version, which should be compatible with the international IHE version, in addition to providing extra details to accommodate for US needs.

A Healthcare Provider Directory (HPD) is just what it sounds: it's a public directory of private health providers or of institution health providers. Or, as defined on the IHE document itself, HPD directory structure is a listing of the following two categories of healthcare providers that are classified by provider type, specialties, credentials, demographics and service locations.

  • Individual Provider – A person who provides healthcare services, such as a physician, nurse, or pharmacist.
  • Organizational Provider – Organization that provides or supports healthcare services, such as hospital, Healthcare Information Exchange (HIE), Managed Care, Integrated Delivery Network (IDN), and Association.

The goal is to have a standard for this directory, such that every group, individual, organization or institution who is maintaining one, could have the ability to share it, and make a more comprehensive and up to date version available. 

why is this cool?

Honestly, i'm not 100% sure. Here's my thinking: Healthcare often needs to find locate a group of providers for care for referring patients to other specialists, or finding other doctors quickly in an emergency situation. Having a list (or many lists) of healthcare providers which can all be queried with the same language has a huge advantage.

For example, with a standardized protocol for the healthcare provider directory, there could be organizations which maintain a central directory by providing a simple user interface to download or update the directory, allowing other institutions to make use of the latest and most up to date version available.

What i'm not clear about, is who would be maintaining these directories, and what would their incentive be to adhere to this standard.

See Also

Dr. John Grubb steps down

Dr. John Grubb has been of great help and an invaluable resource. He has most recently followed up to make work item ACT-6 A Digital Standard for Sharing Orthodontic Viewsets progress steadily. We really hope he will still find time to volunteer work with us. His feedback is greatly appreciated and he will always be welcome to join us, physically or remotely.

Thanks John!

Email from John Grubb

It is time for me to step down as a representative of the American Association of Orthodontists and the American Board of Orthodontics to the Standards Committee on Dental Informatics (SCDI). The journey has been enjoyable working with so many talented and committed professionals; and, I will miss greatly the camaraderie.

I wish you and all of the people involved in the SCDI process the very best for the future success of this very important process!

Very respectfully,

John

John E. Grubb, DDS/MSD

 

 

Nuove regole prevedono che

  • ci sia un ulteriore consenso al trattamento dei dati che tratti specificamente il gestionale elettronico; 
  • il paziente abbia la possibilità di non accettare che i propri dati vengano inseriti in un gestionale
  • lo studio informi al "Garante" 1

    entro 48h in caso il vostro sistema sia stato hackato e ci fosse il rischio, quindi, che i dati sensibili siano stati (volutamente o non) rilasciati a persone non autorizzate a leggerli.

Vedi Anche

The open book Issues in Contemporary Orthodontics gets published today and with it, chapter 9, which covers 3D surface scanning for intra and extra oral images (3D impressions and 3D photographs) as well as 3D printing technology and how it could affect the orthodontic practice.

The chapter is called 3D Scanning, Imaging, and Printing in Orthodontics, has been written by Emilia Taneva, Budi Kusnoto and Carla A. Evans and is available directly from the publisher's website, or downloaded here.

Overview

When orthodontic practices go paperless, the question of resolution arises: what is the best resolution to scan documents? Rumors say that 300 DPI is the level that is suggested on-line for preservation of materials which will be destroyed but need to be maintained from a legal perspective. However, this resolution produces large amounts of data and can eat up drive space quickly.

X-Ray

The recommended resolution for 2D Cephalogram X-Rays is 12bit grayscale (ca 4k shades of grey) and 300DPI scanning resolution. This is based on published studies, that state that below this resolution, the identification of landmarks becomes less reliable. However, this is crucial only for x-ray which need to be measured, i.e. cephs and, in some rare cases, postero-anteriors. For all other x-rays, the minimum resolution to get the job done can be much less because the job gets usually done by simply looking at the radiograph, without taking any measurements.
In any case, i would avoid BMP: they can get extremely large and slow to manipulate. DICOM would be the way to go. But if that's not an option, a high-quality JPG works great too: It can provide some compression, while keeping the images usable.

Paper

While 150 DPI is enough for practical usefulness (in other words, for being able to read and understand all information which was present on the paper version of the scanned document) of maybe (i'm guessing based on my personal experience) 90% of printed material, 300 DPI will make a difference if one wants to OCR the scanned documents, or for those 10% of documents which have a very fine print. I have no idea about the legal perspective.
However, one would expect a modern database system not to have any issues with 300DPI scanned PDF files. I would personally therefore keep scanning at 300DPI, and upgrade storage solution/practice management server to a 1 or 2TB drive. A 2TB should allow an average of 180MB/patient, for 10k patients. That's about 20 9MB images (very high 300DPI xray or other). And in a few years, when they start getting close to the 10k patients, the practice probably upgrade storage to 10TB or so.

See Also

 

On August 15th the AAO Bulletin published an article discussing the importance of establishing what medically necessary orthodontic care actually means. This has become crucial, ever since the Affordable Care Act (ACA) introduced benefits for orthodontics as part of the embedded pediatric (dental) medical policies... only available to those patients whose cases are considered to be "medically necessary".

See article below.

DICOMweb Hands-on Workshop

DICOM will hold the DICOMwebTM Hands-on Workshop, scheduled September 10-11, 2015, in Philadelphia PA. This could be a very cool workshop.

See Also

We are moving forward on our effort to provide a document that can explain developers/vendors how to exchange a set of images in a specific layout using DICOM (i.e. Structured Displays). So say provider provider A wants an opinion from provider B: A will send clinical data (with a set of images) and will expect B to be able to see the images in the exact same layout that A sees them, as this will simplify the collaboration. Thanks to DICOM Structured Displays, this will be possible even:

  • by sending all images with relevant information, such that the receiving system will know what they are and where to store them.
  • without creating a static composite PDF or JPEG file, with all the images inside.

So the ABO (American Board of Orthodontists) already defined a standard layout for their board exams. But that was just one layout. We are defining 3 layouts (which will serve as examples for the documentation), and are asking the ABO if we can call them ABO-01, ABO-02 and ABO-03.

 The ABO (American Board of Orthodontists) already defined a standard layout for their board exams. But that was just one layout. We are defining 3 layouts (which will serve as examples for the documentation), and are asking the ABO if we can call them ABO-01, ABO-02 and ABO-03.

ONC Privacy & Security Guide

The Office of the National Coordinator for Health Information Technology has released in April version 2 of the Guide to Privacy and Security of Electronic Health Information. Here's an excerpt from their website:

Need help implementing the Health Insurance Portability and Accountability Act (HIPAA) Privacy, Security, and Breach Notification Rules in your health care practice? Check out the Guide to Privacy and Security of Electronic Health Information [PDF - 1.27 MB].

The Office of the National Coordinator for Health Information Technology (ONC), in coordination with the U.S. Department of Health and Human Services (HHS) Office for Civil Rights (OCR), created the Guide to help you integrate privacy and security into your practice. The Guide covers a variety of topics highlighted below. Download a pdf of the full Guide [PDF - 1.27 MB] to learn more.

References

 

 

Information blocking occurs when persons or entities knowingly and unreasonably interfere with the exchange or use of electronic health information. This report focuses on potential information blocking by health care providers and health IT developers, including vendors of EHR technology. 

Here's the April 2015 report from the Office of the National Coordinator for Health Information Technology (ONC) to the US Congress explaining the obstacles to implementing interoperability and informatics standards.  The federal government has spent $28 billion on health IT and Congress wants to know the details of information blockage.

This report (see link below) from ONC to Congress was discussed at the April 21 meeting of the Illinois Health Information Exchange Advisory Committee.  The gist of the discussion was that the pilot studies on EHR interoperability have been excellent, but further progress will be difficult due to the reluctance of vendors and stodgy institutions to adopt existing informatics standards, especially HL7 standards. The Chair likened the situation to selling cars, saying that the states will have to mandate features that software must have in a manner similar to emission standards for cars. Our dental software vendors are lagging also.

http://www.healthit.gov/sites/default/files/reports/info_blocking_040915.pdf