CommonWell vs. Carequality

There are two national, multi-stakeholder collaborations towards interoperability of health information: CommonWell and Carequality. This article does a great job of providing the background and context as well as some of the details about how these two initiatives are different:

“CommonWell’s focus is narrower – it was created to focus solely on the data transmission needs of different EHR vendors. Carequality, in contrast, is working to set up one EHR framework that providers can access nationally.

In an interview with Kenneth Kleinberg, a managing director at Advisory Board Company, Kleinberg used the analogy of telephone standards to describe CommonWell’s mission: [“Vendors] need to have a certain kind of connector, accept a certain voltage, and modulate the message in a standard fashion…CommonWell seeks to become a directory service for patient identity and consent…a directory of which providers a given patient has seen.”

Carequality isn’t taking the same approach. Healthecare, from which Carequality sprung, sought to build an EHR framework, or repository, from where providers can pull patient health records, so that if a man from El Paso, Texas breaks his leg in Eugene, Oregon, all the interested parties can access the man’s health records.

Carequality is brand new and their mission is less defined. But they say they intend to build consensus on “how to accelerate seamless health information exchange” that will transmit information based on a common framework the same way that “banks came together to connect ATM networks.” To do so, the alliance has recruited more than just vendors – it extends its reach to providers, insurers, and pharmacy chains, among others.”

Where I am still a little bit confused after reading through those explanations a few times is how those mission statements will actually interact with each other when they inevitably butt heads in the real world. Time will tell if/how these efforts will succeed. At the highest level, they will serve as a test of whether industry can progress on its own or if it needs government regulation in order to focus.

One area that is right on the horizon (if not here already) is the role of data standards in consumer health information management. As the article explains, there are currently not any standards provided in the Meaningful Use program that outline how patient information generated at home can be incorporated into the clinical environment. There is a lot going on with multiple consumer-facing initiatives (Apple, Samsung, Google), so any work that builds the data inroads from the home to the clinic will be worth watching closely.





Smartwatches for Cardiac Monitoring

Could this be low hanging fruit for smart watches looking to get some early wins to gain clinical traction and credibility?

A new study suggests that extended monitoring in stroke patients can catch atrial fibrillation (irregular heartbeat), which can be a cause of recurrent strokes in some patients. More detail here, including anecdotal support from a patient:

Among the patients monitored for 30 days was William Russell, 71, a retired businessman from Collingwood, Ontario. Mr. Russell suffered a major stroke two years ago during a ski trip with his family in Calgary.

“There was no prior warning — it just hit,” he said. “My left side became completely paralyzed and my speech was slurred. Fortunately my daughter noticed it immediately and called 911.”

At the hospital, doctors gave Mr. Russell a powerful clot-busting drug that reversed his stroke. But their next challenge was to find what had caused it. They took scans of his heart and his brain and did an electrocardiogram to measure the electrical activity of his heart, but the cause remained unknown.

Mr. Russell was enrolled in the study, and after a month of wearing the electrode belt day and night, his doctor was able to make a proper diagnosis.

“His heart monitoring revealed that he was having silent episodes of atrial fibrillation,” Dr. Gladstone said. “As a result, we’ve been able to treat him with anticoagulant medication.”

Mr. Russell said that he was doing well on his new medication and had returned to hiking, cycling and playing golf. Wearing the monitor for 30 days was “a bit of a pain,” he said. “But it was worth it. Well worth it.”

Replacing such monitors with a smartwatch is not something we are ready for as a health care system just yet, but rather it’s an example of how this technology might be able to provide value right out of the gate. Most of these devices, notably Apple’s and Samsung’s, are working towards measurement/ proxy of heart beat by pulsing light into the wrist. A pretty nifty video of how this works is available here (Also, I love this dude’s accent):



The biggest question/red flag that comes to mind for me is of course, FDA regulation. If all of a sudden a consumer device is being used to capture preventable second strokes (or any one of a litany of other cardiovascular events), then we are really risking life and death based on their functionality. Based on my experience using mHealth for monitoring (2 broken Nike Fuelbands, 1 dysfunctional MapMyFitness app) I’m skeptical. Though the FDA has said they won’t regulate mHealth apps around such use cases, I wonder if hardware might raise a different issue. So while cardiovascular disease may be the number one killer in America, and we purportedly have technology that could help mitigate its impacts in high-risk populations, 2+2 does not equal 4 here just yet.

There is plenty of prior discussion and debate about this topic of course, captured nicely here. As you may note, that paper was published in 2010, or four years ago. That may serve as a representative indication of how long it will take before consumer technology really delivers value to our healthcare system.



A physical test for mental health?

This is a big deal.

The potential of this research is the ability to bring “hard” physical measurement to the “soft” world of mental health, which is traditionally assessed via questionnaires or surveys that are at best subjective and proximal to the truth.

It seems to be the latest in this trend of other “instant” testing efforts, such as this one, or this one. But this has far more upside, as mental health issues such as depression are basically invisible today. Measurement and quantification means more accurate diagnostics, more accurate assessment of treatment effectiveness, and a new set of research opportunities for treatment.

It could certainly help with stigma too, though other “hard” diseases such as HIV or cancer still carry plenty of that.



Kobe, on Desire

“Sometimes you want something so much that it slips away from you because you’re holding on too tight. You have to be patient. Even though you want it, you have to understand the best way of going about getting there. You have to stay focused on that. You can’t allow frustration or urgency to kind of choke the process.” – Kobe Bryant

The Illusion of Mental Illness and Creativity

From “There Was No Couch: On Mental Illness and Creativity” by Jalees Rehman.

Before I started my psychiatry rotation in San Diego, I had been convinced that mental illness fostered creativity. I had never really studied the question in much detail, but there were constant references in popular culture, movies, books and TV shows to the creative minds of patients with mental illness. The supposed link between mental illness and creativity was so engrained in my mind that the word “psychotic” automatically evoked images of van Gogh’s paintings and other geniuses whose creative minds were fueled by the bizarreness of their thoughts. Once I began seeing psychiatric patients who truly suffered from severe disabling mental illnesses, it became very difficult for me to maintain this romanticized view of mental illness. People who truly suffered from severe depression had difficulties even getting out of bed, getting dressed and meeting their basic needs. It was difficult to envision someone suffering from such a disabling condition to be able to write large volumes of poetry or to analyze the data from ground-breaking experiments. The brilliant book “Creativity and Madness: New Findings and Old Stereotypes” by Albert Rothenberg helped me understand that the supposed link between creativity and mental illness was primarily based on myths, anecdotes and a selection bias in which the creative accomplishments of patients with mental illness were glorified and attributed to the illness itself. Geniuses who suffered from schizophrenia or depression were not creative because of their mental illness but in spite of their mental illness.


The whole essay is fascinating and well written, covering hypermedicalization, media bias, sham science, and more.

End of Life Care

The Compassionate Physician
By Ambrose Bierce
A KIND-HEARTED Physician sitting at the bedside of a patient afflicted with an incurable and painful disease, heard a noise behind him, and turning saw a cat laughing at the feeble efforts of a wounded mouse to drag itself out of the room.”You cruel beast!” cried he. “Why don’t you kill it at once, like a lady?”

Rising, he kicked the cat out of the door, and picking up the mouse compassionately put it out of its misery by pulling off its head. Recalled to the bedside by the moans of his patient, the Kind- hearted Physician administered a stimulant, a tonic, and a nutrient, and went away.

Celebrating World Markets

…may be shortsighted. Homi K. Bhaba poignantly explains further:

“There is a kind of global cosmopolitanism, widely influential now, that configures the planet as a concentric world of national societies extending to global villages. It is a cosmopolitanism of relative prosperity and privilege founded on ideas of progress that are complicit with neo-liberal forms of governance, and free-market forces of competition. Such a concept of global development has faith in the virtually boundless powers of technological innovation and global communications. It has certainly made useful interventions into stagnant, state-controlled economies and polities and has kick-started many societies which were mired in bureaucratic corruption, inefficiency and nepotism. Global cosmopolitans of this ilk frequently inhabit ‘imagined communities’ that consist of silicon valleys and software campuses; although, increasingly, they have to face up to the carceral world of call-centres, and the sweat-shops of outsourcing. A global cosmopolitanism of this sort readily celebrates a world of plural cultures and peoples located at the periphery, so long as they produce healthy profit margins within metropolitan societies. States that participate in such multicultural multinationalism affirm their commitment to ‘diversity’, at home and abroad, so long as the demography of diversity consists largely of educated economic migrants – computer engineers, medical technicians, and entrepreneurs, rather than refugees, political exiles, or the poor. In celebrating a ‘world culture’ or ‘world markets’ this mode of cosmopolitanism moves swiftly and selectively from one island of prosperity to yet another terrain of technological productivity, paying conspicuously less attention to the persistent inequality and immiseration produced by such unequal and uneven development.”

(from Preface to the Routledge Classics Edition of ‘Location of Culture’)

I was most recently reminded of the one-sidedness of such glorification of ‘world markets’ in reading this article about Bangalore. Think about the last article you read about India. I bet it was either about a lot of people who died in some natural disaster, or about  the market potential of the region (or the failure of that potential to actualize).


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