World Cup in Canada

A friend from Germany asked us, “since Canada isn’t in the World Cup you don’t follow it, or do you?”.  Our respond was,  in Canada we cheer for all teams. There’s always someone on the winning side. Today, for example we saw over 10 flags on cars from different countries. Some vehicles have a flag from two different countries; my wife thinks this is because one spouse is cheering for England while the other is Portuguese, it could also be someone hedging their bets.

Spring a rebirth

The ancient religions were tied to nature. Worship of the sun, moon and earth. When man turned to the gods they wielded thunderbolts like Zeus, or fire like Vulcan. Norse gods were warriors like their followers. In India and China the gods are intertwined legends of humans as well as supreme beings. In the Shinto religion of Japan the belief is that every stone, tree, animal and person has a spirit. Nature is still at the core of the native traditions of the First Nations. The cycle of the earth, moon and sun still govern our time and seasons.

As much as we have damaged nature through our industrialization, pollution, even our agriculture, the earth continues its course in the heavens. The sun rises, the moon’s phases changes and the seasons continue their cycle. While we may damage our environment we can not altar that which is outside our control.

The transition from winter to spring always seems like a rebirth. I can imagine the ancients seeing dead trees becoming alive, the dry grasses turn to green, and fresh blooms renewing bright colours. Worshiping the return of life-giving nature. Each cycle creating a rebirth, death and rebirth of nature.

While we may worship at the altar of materialism we are still governed by nature. We can damage the earth but we can not alter its orbit.

US Recovery and Health IT

Health Reform is a hot topic these days. The partisan nature of politics in the US hides the fact that we are all human. Regardless of if you are a Republican or Democrat, a conservative or liberal the concerns about sustainable healthcare are the same.

Last week I heard Dr. Blumenthal National Coordinator for Health Information Technology speak at the College of Physicians in Philidelphia. He talked about the growing need for electronic health records. His view is that electronic records are becoming the standard of practice. What does this mean to physcian liability? At some point the “average reasonable prudent person” standard will apply to medical records, and the liability of using paper charts will increase risk to physcian practice.

This week the Ontario Hospital Association invited Newt Gingrich and Michael Moore to speak in Toronto about health care issues. Two very different political views yet one very basic theme emerged. Invididuals are looking to the healthcare system to provide excellent care. Newt’s view is that the need for personal health records, better options and personal control with patient empowerment will do this. Michael Moore expects that without change the Medicare system in the US will fail, and what is needed is a universial goverment funded program. Are they both right?

The argument about health insurance avoids the overarching issue that is looming large on the horizon: the growing number of aging seniors; and the mounting costs that the healthcare system will encur. The only way to stem this flow is to switch from high-cost acute care to preventive care.

I believe that Health IT has an increasing role to play in this. Evidence based medicine means the use of information accumulated from health records can be used to improve care. Lower cost can be achieved by reducing emergency room visits and eliminating costly hospital interventions. We need drastic action to lower healthcare costs the use of electronic health records can contribute to radically improving healthcare.

H1N1 Vaccination

Since the time of Louis Pasteur there have been detractors of vaccines. Misinformation from seemingly reliable sources against vaccination has cost countless lives. Science is not often definitive and this ambiguity is used to raise doubt in some individuals predisposed to disbelieve.

Should you take the H1N1 vaccine? Many people who don’t get the annual flu shot are already saying they won’t. Otherwise normally intelligent parents who have failed to vaccinate their children will also avoid the H1N1 flu shot. We leave many such decisions to individuals, and for minors to their parents.

H1N1 Vaccine

I am not a medical professional and not qualified to make recommendations to anyone. I will follow my own conscience and listen to the counsel of who I believe to be trusted sources. Where each of us gets our information and how we use it is as unique as our own own decision making capabilities. What I know of H1N1 and the flu shot is limited, having seen people who have it or suspect the have it makes me concerned.

What has been reported is the older people born before 1950 are more likely to have antibodies that will help protect them from H1N1. The consensus of health professionals is that this virus is more likely to infect young adults. Women and more specifically pregnant women are most at risk of infection. The reported mortality rate of H1N1 varies from 1% to 4%; and while it is still young people who are at risk, children with preexisting conditions; diabetes and neurological conditions have higher mortality. Again consider that this high risk is both in the catching the virus and in mortality; once a person has the virus, as with any flu, how you deal with it and how your body reacts will determine the outcome.

My personal fear of H1N1 is how closely it seems to resemble the Spanish flu pandemic of 1918. This flu killed millions over several years. This virus mutated and became less viral over the years; it is likely one of the reasons why people born before 1950 have antibodies that may help fend off the current mutation; H1N1 previously called swine flu.

This week Ontario begins Flu shots for citizens. The US has been vaccinating people for several weeks now and has already seen shortages. I expect governments will do all they can to get vaccines for everyone who wants one. Individuals will have to make up their own minds on if they will get this years flu shot. I will.

Would you wear a bullet-proof vest as a policemen entering potential dangerous situation? Would you wear a gas mask as a firemen entering a smoking building? Wear gloves, put a hard hat on when entering a construction site? The flu shot, in my opinion is the same. If you are offered protect why would your refuse it? Of course the choice is your own.

Farming in the city

Recently there was an article about industrial and residential properties in Detroit being used for farms. This is an excellent idea and one that will help us all. As manufacturing shrinks the factory land used for constructing cars can be used to feed people.

Southern Ontario and Michigan are renowned as car country. Detroit, aka Motown, home of GM and Ford, automotive capital of North America and its little brother, Windsor home to Oldsmobile and Chrysler are also found in some of the most productive soil in Canada. The temperate weather in this area makes it suitable for fruit trees, vegetables and grains.

Detroit Farming

Early spring, late summer and the warming affects of the Great Lakes makes this area excellent for farming.

As a child growing up in Windsor, Ontario I watched as the orchard at the end of our street was bought, ploughed over and turned into a Ford factory. Down the road the corn, wheat and a tomato farms became parking lots and industrial sites. The land was converted to manufacturing. Now its returning to is orginal purpose.

I remember being taught that this land could sustain four cash crops in one year. Winter wheat could be planted in the fall, in spring the seeds would germinate early allowing for a quick harvest in April or May. Beans and corn could be planted along side tomatoes and harvested by August, before the end of summer crops of cabbage and root vegetables could grow right into October. Factories had replaced all this, now we can regain this farm land for what it was created for.

Farming in Detroit

Happy New Year

Maya

It is September, the true start of the new year. If you are or have been a student you know what I mean. For those of us born in this month it truly is the beginning of a new year.

We rotate around the sun. One full year’s journey. Our system of counting age. Calendars are very much human inventions. There are not natures mechansim for tracking time.

Consider how each culture from Chinese, Arabic, Hebrew, Aztec, Mayan, Roman and Egyptian have created their own unique calendar. Is there a universal method of tracking time? I don’t believe we have found it. I believe there are still mysteries of time that we have not discovered.

We still measure time like ancients; using a fixed point in time; the birth of a king, the start of dynasty or position of stars. We count days using sunrises and sunsets. Yes, we have developed time-zones and standard time but this is arbitrary as well.

We can measure the approximate age of fossils using carbon dating. Radition half-life can be used to measure time, but only in human terms. What is cosmic time?

Our universe is ever expanding, from the start to the end all the matter in the universe existed and will contiue to exist. This implies that what makes us also will exist beyond our time on this planet. Therefore we have always been part of the universe. Which makes us all ageless.

So have a great journey one more time around the sun!

What do you believe in?

When we become conscious of something, we bring about the critical collapse of the wave function, so that the perplexing mixed states of life and death disappear – Eugene Wigner (1902-95)

Man has learned to create life in a test tube and by cloning. Talking to GOD the scientists said “we don’t need you anymore”. God impressed by the progress of man suggested that the scientist create a man the way He had done at the beginning of the universe. The scientist said “sure” and reaches for some dirt. “No, no,no” said God, “get your own dirt”. -Anon

Quantum physics evolved during the 20th century to explain the universe and the atom. What is difficult to explain in classical physics is explained by quantum mechanics. The Law of Conservation states that energy can be neither created nor destroyed. In every equation we are left with the core question how did we get here?

I have been asked several times in the last few months if I believe in God? It’s a simple question with a complex answer. It is important to separate this question from “what religion are you?”

Man has always needed God to explain the universe. Ancient man attributed lighting to God. Zeus threw bolts of lighting, in India and Asia the Gods where the creators and the destroyers. We have had multiple Gods, even in monotheistic religions there are aspect of plurality. Does man always need a God to explain the universe?

“God created man in His own image”, this is a typical Judeo-Christian belief. It is our shallow thinking to believe that this means physical attributes. I tend to believe man created God in their own image. We envision a grey bearded old man sitting on a cloud. Perhaps “His own image” is our consciousness.

Our essence is star dust, we are particles of the universe gathered and configured to be living creatures. Yet, every explanation and theory about life and the creation of the universe ends up at the same point. Nothing.

How is it possible?

Transparency is Critical

I am of the opinion that transparency reduces errors as well as corruption. My belief is that you should behave as if the world is watching you. And in this day and age this would seem to be the case.

Everywhere you turn there are cameras, all forms of media channels, and lurkers. Do you remember Rodney King? Do you think the policemen would have acted the way they did if they knew a camera was recording their actions?

Access to information laws make it possible for reports to get detailed information from meeting schedules, bills and invoices along with any public document. There is just no hiding the facts, and if someone tries this it is more damning than the actual evidence.

Politics and healthcare have been linked for many reasons this past year. Primarily it is because of the escalating costs associated with government run programs, our aging population and our rising chronic diseases. Some believe that government should not run our healthcare system. I believe if we trust the government to collect our taxes, pay for education, build our roads, and manage the military than why is healthcare any different?

We need to be transparent on the cost of healthcare and the delivery of it needs to be focused on the people involved. You don’t want a doctor or nurse to pause for a second, when delivering care to check if you can afford it. If a patient needs help then provide the care needed. No insurance company, private or public should get in the way of patient care. No secret decisions or exclusions; transparent public scrutiny is the best way to achieve better care.

I recall reading about a hospital that not only allowed but encouraged patients to review doctors’ notes and entries in their paper charts. What the administrators noticed is that very quickly the doctors’ handwriting improved. The reason is obvious, patients would ask questions of notes they couldn’t understand or read, this increased the time doctors’ spent to explain what they wrote. Clearer written notes also became more explicit and coherent. Imagine.

Now if this was electronic, the patient could also review, annotate and correct errors. The system could provide full audit trail and timestamps. No more questionable practises, short hand notes or incorrect doctors’ orders. And also better drug management would be possible.

Shining a light on health practices, giving access to those that need it while securing privacy of personal details, I believe will lead to better health outcomes. The same is true of financial investments and government.

Would Bernie Madock have been as successful with his ponzi schema if everyone knew how their money was being invested? Would Watergate have happened? It’s all well and good for newspapers and investigators to find and report on these events, yet it would be to everyone’s best interest to prevent them from happening, and the means to achieve this is greater transparency.

Security by Design for eHealth

How secure is your home, your car, your office? Do you use double bolt lock or have bars on your windows? How about internal alarms?

For the most part your answer to these questions depends on where you live and the value of your possessions. At the very least you have locks on your door, but you may leave the door unlocked from time to time. This is risky yet unlikely to result in major loss. If you do it too often and become lax in your home security then you give a thief opportunity that puts your possessions at risk.

Bank Vault

The level of security and privacy is dependent on the risk tolerance related to the value of what you are protecting and personal risk avoidance. When in comes to our personal health information the value of which is questionable, security can vary. Critical details about us and identifying information that can be used to obtain fraudulent documents or prescription must be treated with great care with the highest level of security. Our less personal details are not likely to be used to gain access to our money or take possession of our personal goods; these pieces of data are less important. While you may need the security of a “fort knox” to secure critical data, a simple key and lock is all that is need for other less critical details.

How do you secure data in your health information? Data that is stored must be encrypted with restricted access; when viewed it must only be displayed to a verifiable user with correct permission. Even with high-level security it is impossible to prevent a wandering eye on a screen. Early in our development of health information access the question of security and privacy always came up. Usually asked by doctors and nurses who raised this objection as a means to slow adoption. My quick response to questions on the security of electronic data was to point out that; currently fax machines in the hallway had patient data displayed, that behind the nurses station a white board with patient names and other identifying data was displayed for anyone visiting their unit; and that carts of patient charts are routinely rolled around the hospital and that these paper folders routinely would be left unattended. Electronic health information systems are much more secure than paper and non-electronic means. When records are electronic it means you can get access to your data much more easily than paper folders locked in a doctors cabinet or the basement of the hospital health records department.

Ideally we would want full control and access to all our own health information and be confident that it is not being misused or shared without consent. We currently don’t have that control. We rely on our doctors, our hospitals and other government agencies to maintain and control access to our health information. In the province of Ontario and many other jurisdictions individuals have the right to access and control permission to all their health information. Of course the practicality of receiving all this information from a hospital or doctors’ office makes it difficult. How would we get the paper forms and input them ourselves into our own health application? If records were electronic patient have better opportunity to access and control premission to their own information.

We need to ensure that proper percautions are being taken to store our information. To secure our health information the personal identifying data must be encrypted and only viewable by verified access. While user name and password is relatively simple, there are better ways to ensure privacy and security. A smartcard with proper token identification would be a strong method to secure access.

The NEXUS system is used by the US, Mexico and Canada for “trusted travelers”. The system issues a card for this program that uses several layers of security. First a person registers online and their user name and password is issued; then a face-to-face interview is conducted and documents verified (passport, driver’s license etc.); photo id is made and a retina scan is taken along with other details; then a card is issued with an RFID. When entering the country, rather then wait in a lineup, the “trusted traveler” uses the NEXUS card; unsheathed from the RFID blocking cover to access a self-help KIOSK. The traveler positions themselves in front of a device that takes a retina scan, which is compared to that on file, the proximity of the card is all that is required to match the individual to the online file. No swiping or entering of card number or pin is needed. The system verifies who you are by something you are carrying (the card) and your physical attribute; your retina scan. The process is quick and easy. The difficult part was in the verification and issuing of the card.

In Ontario the government issues an OHIP (Ontario Health Insurance Plan) card that is used for payment of services. Many individuals still have the old “red and white” card that is simply an embossed plastic card with only a 10-digit number on it.

OHIP Card

Individual refuse to part with this because the newer cards contain a “version code” and has an expiry date. Neither of these has embedded security, although the newer cards have a photo and a magnetic stripe that contains some personal identifying information that can be read by swipe machines. Other provinces and territories in Canada also issue health cards to citizens, due to our universal health care and the Canada Health Act a citizen could receive care in Ontario using their Alberta health card. Except for layout and check-digit calculation most systems in hospitals and clinics don’t verify health cards. It is unlikely that a fraudulent card would be detected or rejected until well after services have been provided. In the past it was known that some individuals would use the old “red and white” to obtain services for family members that were not eligible for OHIP, this type of abuse is minimal. Replacing all cards with a common standard and using smartcard token or RFID would be beneficial for all healthcare providers and consumers.

To create a secure and private electronic health application one could use the credit card and banking industry model. A credit card is issued from a specific institution, with the first grouping of numbers uniquely identifying the bank and card issuer, then there is a unique number associated with the individual. The card also has security features like check-digit algorithm, and security code. Other features like holograms, photos and smartcard and magnetic swipe all can be implemented on cards. The ability to add RFID would further enhance such an access verification tool.

Each card would be associated with an individual. Also with this model a card can have sub-accounts so that a parent can access records for child of other family member that has granted them access. This would be useful for better service traking. Take for example a child whose parent are divorced, each parent can have their child added to their card so that access to care is unencumbered when the child is with the other parent. This is also useful for family members such as elderly parents. The card has the ability to be a security key into an electronic health application. It isn’t the only consideration, it is a good start.

eHealth Application Design

The concept of a personal health information application is compelling. As individuals we want our health information accessible by our doctor, pharmacists and other care providers when needed. We also want security and privacy when the information is not being used.

Today your doctor maintains a file folder with your health information in it in their office. If your doctor is like 80% of doctors today they keep your records in paper form. If you go see another doctor only if information is communicated from one physician to the other. Usually by phone doctor to doctor, or nurse to nurse or even by fax.

Should you be hospitalized the facility will start another file folder for your data. Your family doctor may be notified, but unless he has privileges at the hospital they are unlikely to participate in your care there. And it is unusual that your family doctors’ files will be transferred or shared with the hospital staff.

Health Information Gap

Pharmacies will fill prescriptions received from your doctor or from any legitimate board certified doctor. Because you can take a prescription to any pharmacy it is unlikely that the pharmacy has a record of all your medication. Since you get prescriptions from your family doctor, specialist or hospital physician it is unlikely that anyone of these sources has a complete history of your prescription or medication. If you use over-the-counter, alternative remedies or vitamins it is unlikely that anyone will review these within your health information.

How can we communicate our health concerns or issues effectively and reliably even when we can speak for ourselves? Ideally we want the care provider to have all the information they need, we don’t want them to be guessing. The best way to provide your doctor with all they need is to bring it yourself and have it available for them right then and there.

There are many paper based personal health journals that you can buy. These are notebooks that are sectioned off with categories about your conditions, medication, daily diet and activities. For people with ongoing or chronic conditions like diabetes these notebooks may have specific sections for glucose levels and lab tests related to the disease.

Patient Centric

Today’s technology allows you to access your money anywhere in the world through bank machines. You can share photos of your vacation instantly with family members and friends from around the world. Web technology and the global infrastructure it is based on allow us to access information from both reliable and unreliable sources alike. We also walk around with technology on smart phones that is more sophisticated then business computers of 10-15 years ago that were tethered to our desks.

The ideal of having a secure, private health information available anywhere in the world is not just theoretically possible it is technically feasible.

Syncronized Health information

To begin we need to secure data both at rest and in motion. The latter is the simple solution; using SSL (Secure Socket Layer) and encrypted end-to-end transmission of data we can prevent interception and misappropriation of personal data. For secure data being stored we can use encryption of personal data based high-level cryptology. While it is recognized that there is no perfect solution for encrypting data there are techniques used that will make the theft and decryption of this personal data un-economical for hackers. After all how important is it to be able to determine a specific individual’s ailment? What needs to be secured is personal identifying details that could be used for identify theft.

Two security levels must be considered – the physical security and the access security. Physical security can be addressed by the location of the database. Is it the physical machines that store the data in a safe place? And if the machines are compromised physically by someone entering the datacenter and taking the machine will the information still be safe? Therefore the means to decrypt the data and the actually physical files can not be together. This way multiple sources need to be compromised to unlock the information. Think of this like a safety deposit box that needs two unrelated people to have keys to enter, if you only have one it’s still not possible to break into the safe. This is similar to the access security as well.

Permission to access that data can be secured by userID and password. But this is only a minimum. Usernames and passwords are often simple, people tend to use the same user name and password on several applications for easy of recall. Strong passwords are easy to create but few people follow the basics on how to establish password, even more critical is that many users don’t change their passwords frequently. There are techniques to force strong passwords, to expire passwords at regular intervals and to improve user access.

To return to the banking example when accessing you money online you use a physical card and secret pin. When using online banking without a card reader device, you use a login with the card number as well as potentially a security code that is printed physically on the card. Can a similar method be used for health care systems?