Navigating Healthcare – Patient Safety and Personal Healthcare Management

Making it Easier to do the Right Thing

Behavioral Health for Positive Impact

Behavior

This week I am talking to Matt Wallaert (@mattwallaert), Chief Behavioral Officer at Clover Health. I have listened to Matt on a few occasions, most recently at the FitBit Captivate event in Chicago so I was excited to get to talk to him one on one.

Matt plays an unusual and atypical role in Clover Health – he is their Chief Behavioral Officer, a title and role that is not commonly found. He is a Social Psychologist who focuses on Judgement and Decision Making and is most well known for applying behavioral science to practical problems.

We explore behavioral health influences and how we can create interventions that will have a positive impact. How do we create incremental steps and test these and then roll out of programs to have a positive impact on health? He wanted to have an impact and wanted to make things better for people and over the course of his career has managed to do so in many places but is now focused on healthcare and specifically personal health. There’s a recurring theme in many of my INcremental interviews and I heard it again from Matt:

Assume you are going to fail

As Matt puts it – “don’t set up a durable process – for example, if you are doing a mailing do that yourself vs getting your marketing department to create the mailing”. Then head out to the next step – a Test. It is not hard to find behavioral changes that work – but that’s not the only requirement as the change has to work well enough and are scalable enough that you really want to roll them out widely.

Incremental Step to Behavioral Health

It’s not just finding good behavioral changes but rather things that are worthwhile and scalable

“If behavior is your outcome and science is your method – then you are a behavioral scientist”

As Matt says we have to make it easier to do the right thing and not blame individual choices and health behaviors when we make poor health, decisions. Listen in to find out why there are significant cultural differences in flu vaccination take up rates and what incremental steps can be taken to improve on that and hear why it is important not to blame people for poor health behaviors. Learn how they are behaving like Netflix or Pandora that can can match you to the right videos or music we should be able to match you to the right doctor

 


Listen live at 4:00 AM, 12:00 Noon or 8:00 PM ET, Monday through Friday for the next two weeks at HealthcareNOW Radio. After that, you can listen on demand (See podcast information below.) Join the conversation on Twitter at #TheIncrementalist.


Listen along on HealthcareNowRadio or on SoundCloud

Making it Easier to do the Right Thing was originally published on Dr Nick – The Incrementalist

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Future Failure Guaranteed in Healthcare

 Medical School Candidate Selection

MedEd Books Education books
Are we are selecting the wrong candidates for medical school and not teaching them the skills they really need to be good doctors?

I’m a doctor first – anytime anyone asks me what I do the first words out of my mouth are “I’m a Doctor”, followed by a follow-up explanation of my role today outside of day to day clinical medicine and the laying on of hands-on patients.

Many years ago I decided to give up my daily medical practice and it was a difficult decision. While I loved taking care of patients, I’d been beaten up in a system that pushed me to my limits and I did not like what I felt and saw in myself as I existed in a sleep-deprived haze courtesy of a 152-hour working week aka a 1 in 2.

I believed that the healthcare system was creating barriers for doing what patients really needed. And too much of my time was taken up with things that didn’t really matter. By moving into the world of technology and focusing on medical technology development, I hoped to create new tools that would improve our ability to help patients in the ways that they wanted to be helped.

My emotions about this move were conflicted, and I sought out a colleague who had been a mentor to me and shared my decision and mixed emotions about that decision. His response bewildered me.

“That’s terrible,” he said. “You never should have been allowed into medical school.”

From his point of view, the fact that a doctor was leaving the profession was not a sign that anything about the healthcare system needed to change. It just meant that the selection process for medical students was wrong and I was a flawed candidate that never should have been allowed to study medicine.

That unwillingness to examine the status quo is not uncommon in the world of medicine, especially when it comes to medical education. The current curriculum has changed very little over the past century. While science has been updated, the basic structure of medical education hasn’t changed. The daily practice of medicine, however, has changed. And it has changed a lot. Medical education isn’t preparing new doctors for the challenges they will face, and many of the skills they will need are never addressed during the four years of medical school.

But there is an even bigger problem with the medical education system: acceptance into medical school isn’t based on characteristics that are important in medical practice. We have become very focused on academic perfection and MCAT scores, with little consideration for the personality traits that lead to highly effective and compassionate physicians. We get lucky with many people, who have the academic performance and the needed personality traits, but we also train people who are not inherently suited to the practice of medicine or who have what compassion they had entering the system crushed out of them with debilitating academic testing with multiple choice questions systems. And we exacerbate the problem with a system that encourages isolation with a monstrous amount of academic study and rote learning. To excel or even survive the rigors of the system you diminish social interactions and limit them to others who are stuck in the same academic sinkhole.

We are failing to train medical students in the skills and thinking habits that make good doctors.

Recruit for compassion and intelligence, not academic perfection

The first step in getting this right is recruiting students who have more than academic skills. Perfection in academic performance is often accompanied by self-involvement verging on narcissism. To attain perfect grades in college, you have to have enormous discipline as well as intellectual ability. You also have to sacrifice time spent in other endeavors – experiences that might broaden your worldview and increase your sense of compassion. This intense focus on your own goals can create a sense that you are more important than others.

MedEd MedicalStudentID

I watch this first hand with my daughter, who makes me proud on a daily basis with her dedication and focus towards her goal – which she has had since the tender age of 5 – of getting into medical school and qualifying as a doctor. But every step towards medical school moves her inexorably away from the compassion and caring she has demonstrated on her journey thus far. Like her peers, she fears that if she doesn’t keep an intense focus on academics she will fail in her study of medicine. I know I want her as my physician but wonder if the obstacle course she must complete will change her beyond recognition.

Medical Education

 

Teach medical students skills, not just facts

Medical education is like drinking from a scientific fire hose. Few students retain more than about 50% of that data, and we neglect other skills that are more important. Doctors can instantly look up any medical fact they need so this attempted brain download of scientific detail isn’t necessary.

What isn’t taught is how to think about health, illness, and people. Medical students should be learning root-cause analysis and the ability to connect disparate pieces of data and understand the meaning. They need to learn data search skills, listening skills, problem-solving and how to be a continuous learner. They need to flex their compassion and objectivity muscles and learn the patience that will help them understand people who are different from themselves. And they need to learn leadership and how to work with others as in a team and as a team leader. These are the skills that are hard to acquire but are crucial to accurate diagnoses, more effective treatment decisions and effective management of chronic diseases.

The change is beginning

Medical schools are starting to respond to the need. In 2013, the American Medical Association gave $11 million in grants to medical schools that are developing flexible, competency-based pathways. They are making changes that will narrow the gap between how physicians are trained and how medicine is practiced. As of 2015, grants have been given to 32 medical schools, each with an innovative approach intended to prepare students for the real world of medical care. None of these programs are focused on the science of medicine, but rather the thinking, leadership and management skills needed to effectively use the science of medicine.

This is a great start, but there are 141 accredited medical schools in the U.S., and nearly 2,500 worldwide, many still using a curriculum developed more than a century ago. I hope the leaders of these schools are paying close attention to the innovations being tested under the AMA program. We all need them to do a better job of recruiting and training medical students who have the right stuff for the medical environment of this century, not the last.

Some Early Progress

The Dell UT Medical School which was funded in part with support from the Michael and Susan Dell Foundation and by a vote from local residents to increase their personal taxes to fund the development and ongoing management of this facility. They are trying a new funding model that gets rid of the conflict of interest that hamstrings many medical schools that are dependent on fee-for-service hospitals for revenue. The financial model will emphasize outcomes and cost-effective care overpayment for individual procedures and the medical school is taking a different approach to education while still encumbered by the need to meet the regulatory requirements to satisfy the medical education definitions and allow their students to compete on the current playing field for medical education the United States Medical Licensing System (USMLE) testing system

What do we need in Healthcare

More accurate diagnosis early in the disease process (12 million people annually are misdiagnosed, and about a quarter of those errors are life-threatening)

MedEd Costs

86% of healthcare spending in the U.S. was used to treat patients with one or more chronic conditions, and most of that goes for treating complications due to poor management.

Clinicians are under increasing stress and committing suicide at extraordinary rates (A systematic literature review of physician suicide shows that the suicide rate among physicians is 28 to 40 per 100,000, more than double that in the general population)

Incremental Steps to Improving Medical Education

  1. Let’s start by acknowledging the current system and trajectory is not matched to the requirements of our future doctors
  2. Find one element of the curriculum suited to a different method of teaching and change the approach. Match this with an approach to changing the testing methodology to match this more closely
  3. Enlist support to bring about change with the examining board, the clinical teachers and mentors and recently graduated doctors who can all provide relevant insights on the deficiencies of training in preparing for a medical career and what can and needs to be changed

 

Do you think I’m wrong – is our system well suited to the current requirements and just in need of some minor tuning? If I am right – what changes can we work on immediately to change the course and direction for the students now to bring about lasting improvements?

 

Future Failure Guaranteed in Healthcare was originally published on Dr Nick – The Incrementalist

Improving Healthcare’s Security Posture

Blackhat

Healthcare’s Security Posture

As part of my interview series from BlackHat I spoke with Mike Weber VP Coalfire Labs – they are a large Cybersecurity Systems provider focused on securing transactions in the cloud working with all if not most of the cloud providers. Coalfire just released their Penetration Risk Report that included a special section on Healthcare. Not surprisingly the news wasn’t good showing that healthcare had the worst “External Posture” with the least security for anything that can be seen by an attacker – external facing systems such as routers, firewalls etc.

Healthcare

The biggest issue was with legacy systems and many instances upgrades installed but the legacy and unsecured systems remain in use.

Healthcare

Listen in to the interview and hear Mike’s thoughts on Incremental Steps to combat the Security challenges faced in healthcare. As he and others have pointed out Medical records are high risk because they have such a long shelf life offering a rich vein to exploit for anyone able to steal these records.

 

Incremental Steps for Improving Healthcare’s Security Posture

 

  • Upgrade Old Systems and Importantly plan retirement for old systems as part of the upgrade
  • Consolidated Your audit program to Decrease Audit Fatigue
  • Prioritize Your “Crown Jewel’s” of the data and Systems you are protecting

Here’s the short list:

  1. Personal data is the top target (highest value) – medical identity information has a smaller market
  2. Platform Access – and the ability to install ransomware
  3. Encrypt everything

Encrypt

Improving Healthcare’s Security Posture was originally published on Dr Nick – The Incrementalist

Incremental Steps to Health

Incremental Steps to Health

The Incrementalist Graphic Khan Siddiqui

This week I am talking to Dr Khan Siddiqui (@DrKhan ) radiologist, programmer, serial entrepreneur, and Founder, CTO, and CMO of HIGI – the company that is taking the concepts of consumer engagement and tracking to the next level and creating actionable insights that patients and their care team can use

Much of Khan’s journeys mirrors my journey into the space of Digital Health – starting as a programmer in school where he was building applications on a PDB-11 using punch cards and continuing on through his early work on the Electronic Health Record mining data and applying machine learning and deep learning as far back as 2005 to healthcare data.

Microsoft Kinect

Listen to his story of a turnabout of shared innovation at Microsoft where the work the healthcare team had done on image analytics was applied to the Kinect bar and gaming solving one of the challenging problems of “missing body parts”

He was involved in the early work of Microsoft Health Vault and like others believed in the mission of sharing clinical data with patients and getting them engaged was a key requirement to solving health challenges – many of which are tied up with personal behavior. Frustrated by the lack of uptake compared to the Xbox gaming system he took this experience with him to found Higi and replicate the gaming user engagement and bring this to healthcare

Listen in to gain a different perspective to Xbox gaming and how healthcare has contributed and learned from this world.


Listen live at 4:00 AM, 12:00 Noon or 8:00 PM ET, Monday through Friday for the next two weeks at HealthcareNOW Radio. After that, you can listen on demand (See podcast information below.) Join the conversation on Twitter at #TheIncrementalist.


Listen along on HealthcareNowRadio or on SoundCloud

Incremental Steps to Health was originally published on Dr Nick – The Incrementalist

Unbreakable Encryption

Encryption Algorithms Under Siege

NewImage

Over the course of history, the development and subsequent breaking of encryption standards have been a constant cycle. As new keys were developed so they were broken and the speed of with which new keys were broken has increased. Modern day encryption “Data Encryption Standard” or DES was launched int he 70’s with a 56-bit key (64 bits but with 8 parity bits). This encryption was cracked in 1999 and with the likelihood, looming NIST launched a new search for encryption standards giving rise to Advanced Encryption Standard (AES) (aka Rijndael) with 256-bit keys and is under attack both cryptographically and by brute force of faster computers including as and when they arrive. As a result, NIST is seeking new proposals for cryptographic standards to replace AES when it is broken – but with the advent of Quantum computing this will be broken too

Unbreakable Encryption

NewImage

I spoke with John Prisco, President & CEO for QuantumXchange who in his words are pioneering unbreakable encryption. I know what you’re thinking – the idea of something being unbreakable/unhackable seems impossible and I was dubious as well.

But here’s what’s interesting – the foundation of the technology is the Heisenberg (no not that Heisenberg) uncertainty principle

 

You have to go deep into theoretical quantum physics to understand the background to this and while no expert I’m fascinated by the quantum world. This explanation in the Encyclopedia Brittanica is helpful comparing the concept to measuring the pressure of air in your tires TL;dr you can’t because as soon as you attach the pressure gauge you change the pressure. Essentially you can never know with perfect accuracy both of the position and velocity of a particle. It is impossible to determine accurately both the position and the direction and speed of a particle at the same instant.  You could learn more from the always brilliant Richard Feynman video Lecture: Probability and Uncertainty in Quantum Mechanics

Cryptography

Single Photon Based Encryption Keys

That uncertainty is a physical property, not a mathematical derivation (the foundation of encryption). QuantumXchange uses the quantum properties of single photons (light) to exchange data between two locations, with keys derived from the exchanged quantum information. The keys are Tamper Evident: Any attempt to intercept (look at or break) the key will change the state thanks to Heisenberg Uncertainty Principle causing a change in quantum state thereby corrupting the key – in which case those keys are rejected and a new pair created.

All this takes place on “Dark Fiber” from Boston to Washington DC and offering this up to customers in the healthcare and financial services markets and have examples already in play of oil rigs using their Quantum Keys to secure the huge numbers of IoT devices that are used in critical infrastructure and control for oil drilling and production

This concept is especially important for Healthcare data which has the longest shelf life of any data in the industry so protecting it over extended periods of time is essential if we are to maintain patients privacy and confidentiality

Here’s the Interview:

 

Unbreakable Encryption was originally published on Dr Nick – The Incrementalist

Artificial Intelligence in Medicine

Artificial Intelligence in Medicine – Better More Rewarding Medicine

The Incrementalist Graphic Anthony Chang

Incrementalist Chang

It was great to catch up with colleague and friend Dr. Anthony Chang (@AIMed_MD) Pediatric Cardiologist, Founder of Artificial Intelligence in Medicine (AIMed) and Director of Medical Intelligence and Innovation Institute (MI3) .

How did a pediatric cardiologist find his way into the field of Artificial Intelligence, Machine and Deep Learning?

Those of you that saw the original Watson Jeopardy Challenge

Anthony like me had the same reaction to this incredible achievement by the IBM Watson team that beat out the top 2 Jeopardy champions with an Artificial Intelligence Computer system that consumed the contents of the internet library and tested out the correct answers more frequently than the two human champions.

With a background teaching statistics augmented with an MS in Biomedical Data Science/Artificial Intelligence, he has blazed a path to attract colleagues and data geeks from around the world to participate in the future of healthcare augmented by data

For those of you challenged understanding the terminology of the space this Venn diagram is helpful in putting the various disciplines in perspective

AI Deep Learning and Big Data Venn Diagram

Along the way, he like many of my other guests has discovered the value of the adjacent possible – in his case adjacent to data scientist and technologists with clinicians deeply invested in day to day clinical care – both learning from each other

We cover everything from machine learning and data science through the requirements for clinicians (or not) to gain qualifications in data science. Hear his eloquently answers the age-old question of

Will I still have a job once AI has replaced me

TL;dryes and it will be more rewarding

Join me as you hear how and why you should change the way you think of medicine and data. The good news is – you can participate in the next AI Med event which mixes specialist, clinicians, data geeks and patients from around the world in a unique experience that offers a great learning and mind opening experience.


Listen live at 4:00 AM, 12:00 Noon or 8:00 PM ET, Monday through Friday for the next two weeks at HealthcareNOW Radio. After that, you can listen on demand (See podcast information below.) Join the conversation on Twitter at #TheIncrementalist.


Listen along on HealthcareNowRadio or on SoundCloud

Artificial Intelligence in Medicine was originally published on Dr Nick – The Incrementalist

Are Your Pagers Leaking PHI Data

Hospital Paging Systems Security

Blackhat
Mark Nunnikhoven Trend Micro

I spoke with Mark Nunnikhoven, VP of Cloud Research at Trend Micro talking about their recently published paper: Leaking Beeps: Unencrypted Pager Messages in the Healthcare Industry which were designed and built in an era when it took a lot of resources and technology to access the system but now all it takes a couple hundred dollars and a pc add-in and you are in.

“When pagers first came out the effort to interact with the system was high”

TL;dr Pagers in the Clinical setting are unencrypted and represent a security risk for breach of Personal Health Information

Mark’s Incremental step – don’t include PHI in any pager traffic, then get rid of pagers and replace with mobile devices that have end to end encryption

In their study they found that the transmissions are not encrypted and contain multiple elements of PHI – they saw lots of examples – (you can download the report here) but the summary of the exposure of PHI information in the unencrypted messages being sent analyzed by TrendMicro offers a peek into the potential breaches taking place on a daily basis

Mark also mentioned another report on Securing Connected Hospitals that looked at connected devices highlighting the huge increase in attacks on healthcare information systems in particular with Ransomware

 

 

Incremental Steps for Securing Your Pager System

  1. Don’t Include Personal Health Information in Pages but rather ask for a Call Back
  2. Replace the Old Style Pagers with New Technology and Devices, and
  3. When Building Devices you must build security into the product

 

Are Your Pagers Leaking PHI Data was originally published on Dr Nick – The Incrementalist

Mindfulness and Meditation

Stress
Mindfulness and Meditation

This week we are focusing on mindfulness and meditation and why it is important for your health. People that include mindfulness and meditation in their daily routing find they are better able to deal with pain, have improved immunity, sleep better, lower their blood pressure and have less inflammation.

What are the Incremental steps to get you into a regular habit of mindfulness and meditation – the first step is to find what works for you. What’s the best time and where is the best place that works for you? Once you have decided where and when, like most other incremental steps it requires you to take that first step. It can be hard and one of the important things is to understand that you don’t have to do it for very long – even a few seconds can be helpful and then work up to longer times.

There are a range of apps you can download to help you start including some great free apps and I talk about some of those choices and options
Here are 5 free apps you can download that can help you get started

Can I ask a favor – if you like the video, please subscribe to my channel, and if you don’t leave me your feedback/thoughts on how I can improve things

Mindfulness and Meditation was originally published on Dr Nick – The Incrementalist

Getting into the Exercise Habit

Exercise Routine

In this weeks video I discuss getting into the habit of exercise

Getting into a regular routine for exercise is the first step to making this part of everyday activity. How do you do that – the first step like most other incremental steps is to start. It can be hard and one of the important things is not to seek to do too much initially. If you can only get 5 minutes of exercise, get that. Once that’s a regular event and you are finding that easier, extend the time and distance to 10 minutes, 15 minutes and keep adding.

As for locations outside is always a good place to start but if that’s not ideal you can always try and find a gym, buy some cardio equipment maybe a second hand one or find a nearby mall to start your exercise program.
It can be hard to start but the most important thing is to start – if you can find a friend and start together, company always helps and if someone is expecting you it helps to keep you showing up every day.
Here are some simple suggestions for starting an exercise program

 

 

 

 

Getting into the Exercise Habit was originally published on Dr Nick – The Incrementalist

Exploiting Implanted Medical Devices

Hollywood Future Predictions

Spoiler Alert – for anyone who has not watched the Showtime series “Homeland” or not got past Season 2

 

Hacking Medical Devices – Homeland Broken Heart; Picture from Seriesandtv.com

In the Episode titled “Broken Heart” (December 2, 2012) we watch a hacker gain remote unauthorized access to the Vice Presidents Pacemaker and induces a tachycardia (increase in the heart rate) causing him to succumb to a heart attack. Abu Nazir kills the vice president by accessing his pacemaker remotely:

 

 

While the whole operation seemed almost too simple, it was not an implausible tactic. We saw this in October when Darren Pauli wrote about a researcher in Australia who

“reverse-engineered a pacemaker transmitter to make it possible to deliver deadly electric shocks to pacemakers within 30 feet and rewrite their firmware.”

The risk was real enough that Dick Cheney revealed his fear of this hack to have the wireless function turned off in 2007 and it was covered in this piece in the NY Times A Heart Device Is Found Vulnerable to Hacker Attacks but was discounted based on the high cots and need for sophisticated equipment.

Billy Rios – Security Researcher

Enter a security manager and researcher – Billy Rios who, thanks to an unplanned extended visit to a hospital surrounded by a slew of unsecured access points in his hotel room and devices connecting via WiFi connected to him went on an 18-month journey to study the risks.

 

This presentation is the culmination of an 18-month independent case study in implanted medical devices. The presenters will provide detailed technical findings on remote exploitation of a pacemaker systems, pacemaker infrastructure, and a neurostimulator system. Exploitation of these vulnerabilities allow for the disruption of therapy as well as the ability to execute shocks to a patient.

He presented his findings at BlackHat 2018: Understanding and Exploiting Implanted Medical Devices

Here’s the video of the hack demonstrated at the event:


I was fortunate to speak to him to discuss the journey, his findings and thoughts on incremental steps to mitigate this

As Billy points out – it is essential for the clinical team to focus on these risks, understand the concerns raised by the security researchers and others and provide the essential clinical perspective missing from healthcare security discussions

Here is the live stream of their presentation and demo:

https://www.facebook.com/plugins/video.php?href=https%3A%2F%2Fwww.facebook.com%2FDrNickvT%2Fvideos%2F1860967050661827%2F&show_text=0&width=267

Exploiting Implanted Medical Devices was originally published on Dr Nick – The Incrementalist