Navigating Healthcare – Patient Safety and Personal Healthcare Management

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

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Unbreakable Encryption

Encryption Algorithms Under Siege

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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

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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

The Best Exotic Marigold Hotel

Posted in DigitalHealth, Healthcare Technology, Innovation, Inspiration, Technology by drnic on February 9, 2017

HIMSS is rapidly approaching and I am excited to be presenting:

The Best Exotic Marigold Hospital: Learning digital lessons from the hospitality industry to personalize the healthcare experience on Monday February 20, 2017 — 01:30 PM EST – 02:30 PM EST in the Chapin Theatre (W320) – Session ID:
43

The Friction of Travel

As part of my role I travel a lot and I have watched the travel experience change over the last several years. Remember the time when you actually visited the check-in desk before proceeding to the gate to get your boarding pass?

 

I remember that in the early days I still wanted to go to the check in desk but quickly discovered that the ability to check in at home the night before made my life easier and reduced the friction of travel. The same is happening in the hospitality industry and I am excited to be presenting with Nathalie Corredor, SVP Startegy for Hilton Worldwide

 

The Hilton group have invested a huge amount of effort in refining their Digital Experience you can do everything from make a reservation, choose her room, get your digital key access once again decreasing the friction of travel. This increases the customer satisfaction and improves the hotel staff productivity so instead of spending time checking in guests and creating key cards, the staff can spend their time making sure guests feel welcome and taking care of their individual requests and needs. By removing people from the administrative process, the hotel was able to make the guest experience more welcoming and friendly.

Healthcare environments can learn some important lessons from the hospitality industry, as well as retail and travel websites. By taking service staff out of tasks that are more efficiently done by computers, these industries are able to personalize the customer experience, improve accuracy of data entry and cut their costs.

For companies in the hospitality, retail and travel industries, efficiency, accuracy and cost control is directly related to their ability to compete successfully for customers. But just as important is the customer experience. These industries have learned that a customer irritated by the friction in the buying/checking in process is a customer who will seek out other options in the future. While some customers will put up with a poor experience to cut costs if they must, as soon as those customers find an affordable option that is less irritating, they are gone. And, importantly, companies are no longer being compared just to the competition in their own market — now their competition is any optimal experience from any industry. If our online interaction with Amazon is friction-free, then we want and expect the same experience from everyone else.

You can read more here on the Beckers Health IT and CIO Site (Beckers – The Best Exotic Marigold Hospital – Nick van Terheyden)

 

 

The Best Exotic Marigold Hotel was originally published on DrNic1

Memorable Healthcare from 2015

Posted in Innovation by drnic on December 31, 2015

The New York Times pulled together a list of memorable stories from 2015 (Medical and Health News that Stuck with us here)
– The discovery that Ebola is not cured nor over
– The ongoing war against epidemics and debilitating and now potential treatable diseases
– Anxiety and stress increasing (or is it increasingly diagnosed) and little progress in treatment
– The ongoing Drug Nuclear arms race of blockbuster (and unaffordable) prices for new drugs
– valuing time with the clinician for discussion of end of life care
– the sorry state of mental health in this country pales into insignificance with the chain therapy in Africa
– Despite real progress in treating Type 1 Diabetes unnecessary limitations are still being placed on children

Its been an interesting year and we have made much (rapid) progress. These stories are just the tip of iceberg and next year expect many more and heres hoping for some real change to a broken healthcare system

Memorable Healthcare from 2015 was originally published on Dr Nick van Terheyden, MD

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Science, Evidence and Clinical Practice

Posted in Health, Healthcare, HealthIT by drnic on September 4, 2013

A recent article on the The Difference between Science and Technology in Birth on the AMA site demonstrates the challenges we still face in getting clicnal practice influenced by science and data. Studies and data may show the path for best clinical practice but as the authors note there are multiple instances of the clinical community – in this case the OBGYN – either knowingly or unknowingly failing to follow the best practices

For deliveries in the US evidence tells us that fetal monitoring in low risk pregnancies has a deleterious effect – yet it remains standard practice in most settings to place external scalp electrodes and intrauterine pressure catheters

Although we still see external continuous fetal monitoring employed in many low-risk pregnancies, “as a routine practice [it] does not decrease neonatal morbidity or mortality compared with intermittent auscultation…. Despite an absence of clinical trial evidence, it is standard practice in most settings to place internal scalp electrodes and intrauterine pressure catheters when there is concern for fetal well-being demonstrated on external monitoring” [3].

 

They list several other standard practices including

  • routing episitomy
  • Use of Doula’s
  • Challenges with Epidurals

Reasons for these behaviors are varied but as the authors state:

Many well-intentioned obstetricians still employ technological interventions that are scientifically unsupported or that run counter to the evidence of what is safest for mother and child. They do so not because a well-informed pregnant woman has indicated that her values contradict what is scientifically supported, a situation that might justify a failure to follow the evidence. They do so out of tradition, fear, and the (false) assumption that doing something is usually better than doing nothing

Until we fix these basic issues there seems limited opportunity to implement intelligent medicine and real evidence or science based practices.

 

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http://drvoice.blogspot.com/2013/09/science-evidence-and-clinical-practice.html

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Introverts and Extroverts and How to Deal with them

Posted in Health, Healthcare, HealthIT by drnic on August 22, 2013

In a great piece on FastCompany titled: Are you an Introvert or an Extrovert? What it Means for your Career, Beth Belle Cooper explores what she considered a binary position or bucket to put people in but discovers this is really a continuum and one that we as individuals don’t sit at one spot all of the time

As she describes – it is an Ambivert Personality Scale Continuum
An important aspect to healthcare in our interaction with the ever expanding teams that contain wide variations of individuals

But in thinking about work, health acre and interactions the 12 tips for dealing with the different groups seemed like great advice all round
12 Tips for Dealign with Introvert
  • Respect their need for privacy
  • Never embarrass them in public
  • Let them observe first in new situations
  • Give them time to think don’t demand instant answers
  • Give them advanced notice of expected changes in their lives
  • Give them 15 minute warning to finish what they are doing
  • Reprimand them privately
  • Teach them new skills privately
  • Enable them to find one best friend who has similar interests and abilities
  • Don’t push them to make lots of friends
  • Respect their introversion and don’t try and make them into extroverts
10 Tips for Dealing with Extrovert
  • Respect their independance
  • Compliment them in hte company of others
  • Accept or encourage their enthusiasm
  • Allow them to explore and talk things out
  • Thoughtfully surprise them
  • Understand when they are Busy
  • Let them Dive Right in
  • Offer them Options
  • Make physical and verbal gestures of Affection
  • Let them Shine
I think what’s interesting is most of us are in both camps at different times – the two lists seem like great advice all round

https://navigatinghealthcare.files.wordpress.com/2013/08/038d6-3016031-inline-scale-750647.png?w=300

http://drvoice.blogspot.com/2013/08/introverts-and-extroverts-and-how-to.html

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Technology as an Aid vs Hinderance to Doctors

Posted in Health, Healthcare, HealthIT by drnic on August 12, 2013

A recent article in Becker Hospital Review:  Technology Should Aid Human Interaction: Q&A with Dr. Nick Terheyden, CMIO of Nuance featured some important points to make


Health IT needs to fade into the background. It needs to become part of the fabric of the office rather than the focal point, and then the interaction will change

  • Using the tools to allow the clinician to focus on the patient not the technology
  • Human beings deal in narrative and stories, patients want to tell their story and clinicians need the richness of the narrative to help guide medical decision making
  • Remove the Physical Barriers to the clinicians patient interaction
  • Healthcare is not the focus – the patient is

The key to our future and to the successful use of health IT will be turning the focus back on patient and the physician.

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http://drvoice.blogspot.com/2013/08/technology-as-aid-vs-hinderance-to.html

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Interview with HealthTech Vision

Posted in Health, Healthcare, HealthIT by drnic on August 8, 2013

I had the pleasure of speaking with Alex Welz of Health Tech Vision last week and he posted the interview here – or you can listen to it below

The importance of bringing intelligent voice interactions to Health IT especially as medical technology moves to into the Mobile world. It is an exciting time with technology offering real hope

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http://drvoice.blogspot.com/2013/08/interview-with-healthtech-vision.html

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Presenting at Health2.0

Posted in Health, Healthcare, HealthIT by drnic on July 31, 2013

See me at Health 2.0” src=Excited to be presenting at Health2.0

There have been exciting innovations in Cloud based Intelligent Speech Understanding and our new development tool set is offering a way to help healthcare providers transform patient stories into high-value clinically actionable medical information. No more burdening clinicians with data entry tasks.

See me at Health 2.0” src=Florence

You can see it here integrated by by Sense.ly

We have a mobile development platform with more than 750 developers signed up already

The mobile health platform is good at delivering information but the interface can be challenging and capturing the medical decision making difficult using on screen keyboards and point and click methodology.

Mobile speech enablement offers tools that facilitate the navigation and human device interaction and includes capture and clinical understanding services that turn narrative into discreet actionable data to capture the clinical decision making

You can see a brief demo here:

Hope to see you at Health 2.0

http://1.bp.blogspot.com/tKrgEN1BE6ZNBby2HTfxtw-mFRxEkr3JiD6gPmD25fb6iRaZOQpBsJUwx-7ly0eewlm7LslH7zq3vpipEfrrFYpTYvn7_HR2oxlcHM_QpdVR7q0c9Q

http://drvoice.blogspot.com/2013/07/presenting-at-health20.html

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Running out of Time

Posted in Health, Healthcare, HealthIT by drnic on July 29, 2013
All truly great thoughts are conceived by walking
Friedrich Nietzsche
Don’t walk behind me; I may not lead. Don’t walk in front of me; I may not follow. Just walk beside me and be my friend
Albert Camus

I met Regina Holliday a while back at one of the many conferences that she attends:

At this conference she was there to present and was also creating a painting. Her reputation had preceded her and I was excited to meet her in person and hear her story first hand. I had seen some jackets at conferences and had discovered the story behind the Walking Gallery. An idea that came from a tragic story in a healthcare system that is broken

Back in 2011 a video was made featuring many from the gallery filmed at the Kaiser Permanente Total Health Center:


The Walking Gallery from Eidolon Films on Vimeo.

You can see her presentation on Slideshare here:

But there is nothing that could match the power of hearing this in person.

Regina offered to paint my story and it was months before I could pull together some photographs and sit down to articulate my personal journey in healthcare but that all came together a few weeks ago, almost in time for another walking gallery gathering – with so much going on Regina knew what she was going to paint but had not (as the picture shows)

 managed to download it quite yet

My journey to medical school and joining an honorable and privileged profession started when I was still at school and I remember the seminal moment that made me realize this was the pathway I wanted to take:


I was visiting my older brother in London we exited from Victoria rail station just as somebody had been run over by a bus. I watched as my brother pushed his way to the front of the crowd and he stooped own while very one watched – he was a doctor and knew what to do. As I stood on the sidelines watching I realized that I want to be doing rather than watching

I was a very young medical student and while I enjoyed medical school there was no doubting the fact that I was dealing with something that was really quite unique and challenging emotionally. Life and death was part of normal clinical activities and shortly after my 22 birthday I graduated

(I have been heard to joke that the TV Series Doogie Howser was modeled on me as that was some years later – he was also the original blogger).

My Story

Running Out of Time

Practicing medicine in the United Kingdom in the national health service which while delivering great care placed an enormous burden on the people delivering that care. The environment was challenging, especially for a young junior doctor and I found myself questioning what I’d let myself in for. My first clinical job I worked 132 hours per week, I had Tuesday and Thursday evening off. At the time, that was the norm and all of my colleagues had the same work schedule as I did and I noticed that my senior colleagues not only had that working schedule but also took on more clinical responsibility. My weekends were hellacious, waking up on Friday morning and not finishing until Monday evening. I shared the work with a colleague and friend by the name of Niamh Anson. We would share the on-call work and split the activities, with one of his covering wards and the other covering the emergency department admissions.

The constant and chronic sleep deprivation took its toll and I repeatedly questioned the job I was doing and indeed whether I was even safe. The nurses proved to be our saving grace and several occasions when we made mistakes through simple tiredness they caught these mistakes and quietly corrected or prevented our errors. I don’t remember a single time of being on call when I wasn’t up most of the night and typically at leas every hour. Rarely did this not require a visit to either the ward or the emergency department. Many the time, I would walk from my living quarters to the emergency department angry at the system that would place such a burden on anyone and wondering if there was something wrong with me.

On one particular day my two team members were not at the hospital. Niamh was on holiday, one which had been booked many weeks ago but as is normally the case medical staffing had failed as usual to find replacement. By two in the afternoon, the emergency department had 17 patients waiting to be seen by me, there was a patient in intensive care on a ventilator that was having problems, and the cardiac care unit had a patient that was having a lignocaine reaction. I reached breaking point and called medical staffing, and told them I was quitting. Their reaction, humorous in hindsight but at the time not, was to tell me that my contract did not allow for me to quit. Fortunately the ward sister from the cardiac care unit intervened and quietly called my two attending’s. The next thing I knew I received a call from one of them asking me to meet him in the emergency department. I thought my career was over and proceeded down to meet him expecting to be blasted and read the riot act. I was pleasantly surprised to find my two consultants there stuck into seeing patients and helping me out. One of them admitted all of the patients in the ED department while the other dealt with the patient on the intensive care unit in the coronary care unit.

Between us we were able to triage and treat all the patients by the end of the afternoon. Even now as I think back to that story I still find myself quite emotional about the experience and support from two outstanding individuals. They rounded it out by insisting that we went to the local pub for a drink and listened to me and provided counsel and support.

Sadly they were not typical of the senior staff in the health system and most took the view that they had suffered this level of overwork and therefore everybody else should experience the same. This was a recurring theme throughout my time as a clinician and I found most disturbing and many times very depressing.

If I am walking with two other men, each of them will serve as my teacher. I will pick out the good points of the one and imitate them, and the bad points of the other and correct them in myself.
Confucius

I remember vividly one instance where the attending surgeon I was working for heard that I was taking a sabbatical and thinking about leaving medicine. He started by saying that I was terrible shame, and I thought he was about to offer some guidance/support and thoughts about where the system is wrong and how I might cope with it. Sadly he proved to be similar to many of his colleagues and peers and felt that the system was wrong in allowing me into medical school. The system should of been better at weeding me out since there was clearly something wrong with me not with the system. He like many of his peers believed the baptism by fire, sleep deprivation and the general demeaning of junior doctors was an essential part of training and character building. As he put it, he had experienced this in his junior doctor days and he’d survived and done fine. What he failed to appreciate was that at the time he was practicing as a junior doctor, emergency call was typically a Porter coming to his door knocking on his door to tell him that somebody was “going off” and leaving a cup of tea for him. He would dress himself, drink his tea and proceed to the ward, where the patient had either died or survived, but there was very little that he could do to influence the outcome. My experience consisted of being surgically attached to an emergency page that would bark out at me at all hours, telling me to go to a ward or location in the hospital for an emergency resuscitation the could take anywhere from five – 60 minutes.

There is no easy walk to freedom anywhere, and many of us will have to pass through the valley of the shadow of death again and again before we reach the mountaintop of our desires
Nelson Mandela

My friend and colleague Niamh Anson

had many of the same experiences and like several of my colleagues elected to move away from the system leaving the NHS for Australia, perhaps hoping that this system would be more bearable. Sadly some years later she committed suicide as too many of my colleagues and friends do.

So my Walking Gallery Jacket:

As Regina described the picture:

The sky represents the never ending shifts as does the hour glass. The medical students and doctors are all standing beside me, also exhausted. My friend and colleague Niamh Anson jumping off the hour glass due to stress….

In what can only be described as a “stroke of luck” the painting of my jacket was caught on Fox 5 News doing a piece on the Walking Gallery (right around 00:24 -> 00:50 and around 01:28):

DC News Weather Sports FOX 5 DC WTTG
Or if the vide does not appear you can click this link

My jacket coming at number 227 – I hope we get all of these together one day.

If you don’t like the road you’re walking, start paving another one.
Dolly Parton

Like everyone else – I too have an oath to wear my jacket and use it as a tool to spread the word and effect change:

No one saves us but ourselves. No one can and no one may. We ourselves must walk the path
Buddha

https://navigatinghealthcare.files.wordpress.com/2013/07/62f90-nickwithregina.jpg

http://drvoice.blogspot.com/2013/07/running-out-of-time.html

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