Here are a few I came across last week.
Note: Each link is followed by a title and few paragraphs. For the full article click on the link above title of the article. Note also that full access to some links may require site registration or subscription payment.
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Top patient safety pain points and where to focus improvement efforts
Begin by eliminating the false sense of safety that manual reporting produces and, from there, target these key areas.
July 20, 2018 08:37 AM
Many healthcare organizations are working to improve patient safety but serious challenges remain.
Medical errors are among the leading causes of death in the U.S. and non-lethal harm occurs even more frequently – at a rate 10 to 20 times higher than deaths, according to The Journal of Patient Safety.
A big part of the problem is the fact that determining exactly where to focus patient improvement efforts is a difficult, if not a daunting decision for most organizations.
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Human factors need to play bigger role in EHR design and implementation, AMA says
The American Medical Association and MedStar Health examined how physicians used Cerner and Epic electronic health records, and found a lot variability that could impact safety.
By Mike Miliard
July 19, 2018 12:43 PM
In an effort to assess how electronic health records are actually used by physicians, researchers from American Medical Association and MedStar Health took a look at clinical workflows at four health systems – two that use Cerner and two that use Epic.
Their findings, published this month in the Journal of the American Medical Informatics Association, point to wide variation in how EHRs are put to work and suggest that vendors could do well by implementing performance standards to optimize usability and improve patient safety.
Researchers from MedStar's National Center for Human Factors and the AMA examined how a dozen or so emergency medicine docs at each location completed six specific scenarios – two each for diagnostic imaging, laboratory and medication – in their Cerner and Epic systems. They tracked them by collecting keystroke, mouse click and video data.
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VA extends cancer initiative with IBM to leverage Watson
Published July 20 2018, 7:26am EDT
The Department of Veterans Affairs and IBM have extended their public-private partnership for another year.
The agreement will enable VA oncologists to continue using IBM’s Watson for Genomics for the identification of cancer-causing mutations and treatment options.
During the past two years, the VA’s precision oncology program—which primarily supports stage 4 cancer patients who have exhausted other treatment options—has leveraged the Watson for Genomics artificial intelligence technology under the National Cancer Moonshot Initiative to provide care for more than 2,700 veterans. The extension of the partnership will run through at least June 2019.
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HIT Think Why a holistic view of patient data is crucial in pop health
By Jerry Schulz
Published July 20 2018, 4:58pm EDT
Population health management is a core competency of an accountable care organization or a clinically integrated network that aims to succeed under value-based reimbursement. To manage population health effectively, an ACO or a CIN must have a holistic view of patient data.
Data from a single EHR does not offer this comprehensive view. The ACO or CIN must build an infrastructure that can automate the collection and normalization of clinical data from multiple EHRs and other sources, as well as claims data from payers. This infrastructure includes an electronic data warehouse (EDW) where data can be analyzed, and a health information exchange (HIE) that can be used to share key data and insights among members of the network.
This information must be injected directly into clinicians’ EHR workflows. Physicians will not leave their EHRs and go to a website to obtain outside information on their patients.
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AI software helps rule out Alzheimer’s disease from scans
Published July 20 2018, 4:24pm EDT
Using software that measures the size and volume of brain structures from magnetic resonance imaging scans can help determine whether a patient has cognitive impairment.
The new research, from the University of California, could have implications for enhancing clinician capabilities for diagnosing Alzheimer’s disease, a progressive neurodegenerative disorder that is the most common cause of memory loss in older people. While there are drugs that can delay its progression, there is no effective treatment or cure for it.
There are other causes of cognitive impairment, some of which are treatable, such as hypertension and alcohol use. However, as much as 20 percent of Alzheimer’s disease is misdiagnosed, causing incorrect or delayed treatment for many people.
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EHRs can improve patient safety - if they're optimized well
To achieve gains in quality, hospitals need to strategically pace the rollout of new features and functionality.
July 19, 2018 09:31 AM
Contrary to current levels of frustration among clinicians and other users, EHRs hold the power to positively impact patient care. But that takes a more thoughtful and phased approach than simply implementing a new electronic health record platform or upgrading to the latest version.
Instead, hospitals should proceed at a realistic and reasonable pace when rolling out baseline functions, turning on features that have matured since the initial installation, and gradually optimizing the overall functionality and user experience if they hope to achieve gains in quality and performance.
Consider the evolution of EHRs: Between 2008 (when the tech was relatively new) and 2013 the electronic records software went from being linked to an 11 percent higher 30-day mortality rate to being associated with a .09 percent lower rate against the same metric.
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ECRI to host unplugged AHRQ clinical guidelines
After HHS shut down the AHRQ site with two decades of medical information, ECRI announced it will make the evidence-based materials available.
July 18, 2018 02:26 PM
ECRI Institute announced that it will host the medical guidelines that Health and Human Services shut down on July 17.
HHS closing the Agency for Healthcare Research and Quality site meant losing a centralized source of trustworthy, evidence-based information on clinical practice guidelines spanning 20 years of accumulated medical knowledge.
Now, the nonprofit ECRI will provide a centralized repository of current, vetted evidence-based clinical practice guideline summaries and other information, said Karen Schoelles, MD, director of the ECRI Institute-Penn Medicine Evidence-based Practice Center and director of Health Technology Assessment Consulting Services.
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Transferred patients fare better when hospitals communicate more, study finds
As hospital staffs work to improve the process of transferring patients between facilities, more communication between hospitals could improve patient care and reduce mortality, a study published in the Journal of General Internal Medicine found.
The study, conducted by researchers at the University of Minnesota Medical School in Minneapolis, found a significant amount of lost information, or changes in diagnosis, from the sending hospital to the receiving hospital.
To examine the importance of efficient communication between hospitals, the study focused on patients transferring from one hospital to another using data from more than 80,000 patients ages 18 or older in five states over a three-year period.
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Only 23% of healthcare providers measure their consumer relationship, study shows
Healthcare consumers are increasingly demanding efficient and smooth electronic experiences as they take a greater financial role in their care. However, healthcare providers, payers and pharmaceutical companies lack significant progress toward becoming more consumer-centric, according to new research by global brand and marketing consultancy Prophet.
To develop the research, Prophet conducted qualitative interviews with 50 executives at hospital systems, payers, pharmaceutical companies and digital health companies across the U.S., Europe and Asia to identify shifts organizations must focus on to move toward consumer centricity.
The five shifts identified were: "Moving from tactical fixes to a holistic experience strategy"; "moving from fragmented care to connected ecosystems; "moving from population-centric to person-centered"; "moving from incremental improvements to extensive innovation"; and "moving from insights as a department to a culture of consumer obsession."
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Analysis: Healthcare Ransomware Attacks Decline in First Half of 2018
July 18, 2018
by Heather Landi
In the first half of 2018, ransomware events in major healthcare data breaches diminished substantially compared to the same time period last year, as cyber attackers move on to more profitable activities, such as cryptojacking, according to a new report form cybersecurity firm Rockville, Md.-based Cryptonite.
In its healthcare cyber research report, Cryptonite researchers also credit this decline in ransomware events to healthcare organizations’ deploying best practice technologies to better protect and defend their networks.
The report is based on an analysis and review of data on cyberattacks impacting healthcare institutions across the United States between January 1, 2018 and June 30, 2018. The firm’s analysis and review of government data, internet sources and the direct experience of its security operations center (SOC) provide the baseline data for the analysis.
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Don Rucker: Evaluation and Management codes not working in EHR era
Published July 19 2018, 7:21am EDT
Reducing the burden of Evaluation and Management codes on clinicians is long overdue, according to National Coordinator for Health IT Don Rucker, MD, who fully supports a proposed rule by the Centers for Medicare and Medicaid Services to streamline documentation requirements for providers.
“In an era of electronic medical records, we’ve heard from everybody this is just not working,” Rucker said on Wednesday during a webcast hosted by CMS to discuss the proposed rule for the Calendar Year 2019 Medicare Physician Fee Schedule.
Rucker made the case that E&M codes have led to “a lot of note bloat” in EHRs—driven by electronic templates designed to capture information—and that the documentation required for Medicare payment is a time-consuming process for clinicians that distracts them from patient care. He also noted that the coding “generates safety issues for patients because the real clinical data is often hidden in all of the billing boilerplate.”
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EHR performance standards needed to ensure usability, safety
Published July 19 2018, 7:27am EDT
The design, development and implementation of electronic health records must be improved to ensure the usability of EHRs for clinicians and safety for patients.
That’s the conclusion of a new EHR usability and safety analysis funded by the American Medical Association and led by researchers at MedStar Health’s National Center for Human Factors in Healthcare.
“While there are many benefits to using EHRs, there are also usability and safety challenges that can lead to patient harm,” said Raj Ratwani, lead author of the study and director of the MedStar Human Factors Center.
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HIT Think Fostering a culture that supports evidence-based practice
By Staci Porter
Published July 19 2018, 5:45pm EDT
Evidence-based medicine is generally regarded as the “gold standard” of clinical practice. As I travel across the country helping hospitals add evidence-based content to their EHRs, I often encounter organizations that are not culturally prepared to embrace practices based on the best and most current clinical evidence.
Hospitals seeking to fully embrace evidence-based medicine may want to first assess their organization’s culture. The successful adoption of evidence-based practices requires a culture that supports clinical decision making based on an examination of the latest research, rather than an over-reliance on intuition, outdated regimens or a “that’s-the-way-we’ve-always-done-it” approach.
Between my current role as a clinical informaticist and my years as an RN in community hospitals, I have identified several key organizational practices that provide excellent insight into a hospital’s culture and serve as good predictors of a hospital’s readiness to embrace evidence-based medicine. If your organization seeks to foster a culture that is supportive of evidence-based medicine, these best practices are a great place to start.
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Track patients with barcodes in tech revolution, urges Matt Hancock
Chris Smyth, Health Editor
Patients should be tracked with barcodes and hospitals must get rid of paper prescriptions, the new health secretary will urge as he tells the NHS: “Tech transformation is coming.”
Matt Hancock will use his first speech since taking over last week to extol the “vast” opportunities for technology in the NHS, as well as attempting to repair relationships with NHS staff that were often frayed under his predecessor, Jeremy Hunt.
He will tell an audience at West Suffolk Hospital today that “it is heartbreaking to see how undervalued you often feel”, and reassure them: “I value you. I admire you. I will fight for you and I will champion you.”
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IDC and Gartner on blockchain: What CIOs should be doing now
Hospitals ignoring blockchain risk being left behind, IT firms say, and they share advice about getting work underway.
July 18, 2018 08:56 AM
Blockchain. Health IT professionals know about the distributed ledger technology so full of promise for boosting EHRs, enabling interoperability, data cybersecurity and streamlining the supply chain.
Those are just three of the oft-cited use cases. Myriad others have already emerged, and more are surfacing while technologists and IT executives sort the hype from reality.
The overarching question, in the meantime is: What will it take for blockchain to gain a wider foothold in healthcare?
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https://mhealthintelligence.com/news/many-mhealth-apps-for-mental-health-arent-offering-sound-advice
Many mHealth Apps for Mental Health Aren’t Offering Sound Advice
Researchers at the University of Sydney have found that many popular mHealth apps designed to help people with mental health concerns aren't giving the right device on how and when to seek treatment.
July 17, 2018 - New research suggests that mHealth apps designed to address mental health issues may be doing more harm than good.
In a study of some 60 popular consumer-facing mobile health apps available in the US, Canada, UK and Australia, Researchers at the University of Sydney in Australia say they oversimplify what could be a serious condition, suggesting that everyone has mental health concerns and that many of those issues could be self-managed.
"Implying mental health problems are present in everyone promotes the medicalization of normal states," Dr. Lisa Parker, a Postdoctoral Research Associate with the University of Sydney's Charles Perkins Centre and School of Pharmacy and lead author of the study, said in a press release accompanying the study, which was published in the Annals of Family Medicine.
Parker said the apps that her team studied “tended to encourage frequent use and promoted personal responsibility for improvement.” But by taking a general approach to a complex field, she said, many of them could prompt people to seek help that they don’t really need – or, in the other extreme, convince people who need medical help that they can go it alone.
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Epic, Cerner make up 50% of hospital EHR market share, ONC data shows
July 17, 2018
More than nine in 10 hospitals use an EHR vendor that offers technology certified under the ONC's latest product criteria, according to ONC data last updated in June.
The ONC maintains an online dashboard of data estimating the market share of various certified EHR vendors, based on the percent of hospitals and clinicians that use the developers' technology. The dashboard is based on the most recent data from hospitals and clinicians participating in the Medicare EHR Incentive Program.
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Why cybersecurity incidents are up 32% from last year
A new report from Positive Technologies details the top threats facing businesses in a variety of sectors.
By Laurel Deppen | July 17, 2018, 7:00 AM PST
On Tuesday, Positive Technologies released a report revealing an increase in the number of cyber incidents occurring between Q1 2017 and Q1 2018. According to the report, analysts identified a 32% jump in unique cyber incidents.
While a general growth of cybersecurity issues could be considered typical, the report found that several other cybersecurity related concerns have also increased over the year as well.
Hackers, according to the report, have an increased interest in personal data such as account credentials. Data theft also makes up for a large share of the total cybersecurity threatscape— 13% more than the 2017 average.
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https://www.healthdatamanagement.com/news/health-catalyst-offers-predictive-suite-for-patient-safety
Health Catalyst offers predictive suite for patient safety
By Fred Bazzoli
Published July 18 2018, 7:40am EDT
Seeking to improve patient safety in hospitals, Health Catalyst has released a module that uses predictive and text analytics to monitor and predict potential threats to patients.
Called the Patient Safety Monitor Suite: Surveillance Module, it’s intended to be combined with concurrent clinical review of data. The new offering is built on the company’s Data Operating System, which is its platform for delivering analytics to healthcare organizations.
In addition, the company announced that it has applied for certification as a patient safety organization with the federal Agency for Healthcare Research and Quality. As a PSO, Health Catalyst says it can collect patient safety events from its customers and then analyze them to gain new insights. As a PSO, member customers could contribute patient safety event information without fear of litigation.
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HIT Think How cloud computing is changing the role of the CIO
By Eric Helmer
Published July 18 2018, 5:34pm EDT
The transformational potential of cloud computing is widely celebrated, but what’s less appreciated is how dramatically it changes the job of chief information officer.
The transformational potential of digital business is now more widely recognized in the era of the cloud, and CIOs who demonstrate an ability to harness that potential are winning more recognition and respect as part of the senior leadership team.
However, the CIO also has less of a monopoly on IT innovation—leaders in other business or functional areas of healthcare organizations have been emboldened to make independent technology selection decisions if IT is slow to act. CIOs must make peace with shared decision making while still asserting the need to integrate and secure data.
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LabCorp goes down after network breach, putting millions of patient records at risk
Hackers breached one of the largest clinical laboratories over the weekend, forcing a shutdown of the network to contain the cyberattack.
July 17, 2018 11:52 AM
North Carolina-based LabCorp Diagnostics, one of the largest clinical laboratories in the U.S., was forced to shut down its network on Sunday after officials detected suspicious activity, according to a recent U.S. Securities and Exchange Commission filing.
Over the weekend of July 14, hackers got into LabCorp’s network. Officials immediately took certain systems offline as part of its breach response policy to contain the hack. As a result, test processing and customer access to test results was temporarily impacted.
According to its site, LabCorp services more than 115 million patient encounters annually, which potentially put all of those patient records at risk if they were located on the impacted network. LabCorp did not respond to a request for comment.
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https://www.healthcareitnews.com/news/opioid-epidemic-unc-health-care-integrate-epic-ehr-states-pdmp
Opioid epidemic: UNC Health Care to integrate Epic EHR with state's PDMP
UNC Health says the move will help tackle the opioid problem and save clinicians time.
July 16, 2018 02:44 PM
The University of North Carolina Health Care at Chapel Hill announced plans to integrate its Epic EHR with the state’s controlled substance reporting system.
UNC, in so doing, joins the growing ranks for providers aligning with Prescription Drug Monitoring Program efforts to fight back against the opioid epidemic. Indiana, for instance, said in 2017 it would integrate electronic health records software with its Inspect platform to better track prescribing of controlled substances statewide.
In January 2018, Nebraska became the first state to require all drugs to be reported to its PDMP and, in that same month, Ochsner Health System, in New Orleans, integrated opioid monitoring within its Epic EHR.
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eCare Plan Set to Improve Doctor/Pharmacist Relationship
Plan will allow pharmacist documentation to be available via EHRs, easing transfer of information
Plan will allow pharmacist documentation to be available via EHRs, easing transfer of information
MONDAY, July 16, 2018 (HealthDay News) -- The Pharmacist eCare Plan is designed to improve communication between pharmacists and physicians by allowing documentation to be available via electronic health records (EHRs), according to an article published online in Drug Topics.
David Pope, Pharm.D., chief of innovation and cofounder of STRAND Clinical Technologies, addresses the importance of breaking down the traditional barriers to exchanging data between physicians and pharmacists. The Pharmacist eCare Plan, which is designed to improve communication between pharmacists and physicians, has recently entered the market and is receiving steady adoption.
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Government adviser leaves controversial NHS data scheme for private sector
Former journalist who led error-strewn care.data programme goes to work for Australian telecoms company
Fri 18 Sep 2015 04.52 AEST Last modified on Thu 21 Sep 2017 08.22 AEST
Tim Kelsey is leaving NHS England to work in the private sector in Australia. Photograph: handout
One of the government’s top advisers on technology, Tim Kelsey, has resigned from the NHS to take up a job with the health data division of Australia’s largest telecommunications company.
A controversial figure who led the error-strewn care.data programme, which aimed to create a single database of all English patients’ medical records, Kelsey will leave his role as NHS England’s national director for patients and information in December.
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Health Plan Victims of Healthcare Data Breaches Surge 1,000%
The total number of individuals impacted by healthcare data breaches at health plans surged by more than 1,000 percent in the first five months of 2018, according to Fortified Health Security’s 2018 Mid-Year Horizon Report.
By Fred Donovan
July 16, 2018 - The total number of individuals impacted by healthcare data breaches at health plans surged by more than 1,000 percent in the first five months of 2018, according to Fortified Health Security’s 2018 Mid-Year Horizon Report.
Health plans reported 24 breaches that affected 884,360 individuals in the first five months of this year, up from 15 breaches affecting 70,166 individuals during the same period last year.
Business associates also saw a jump in number of breaches and individuals affected. They reported 12 breaches affecting 100,602 in the first five months of 2018, up from seven breaches affecting 71,462 individuals during the same period in 2017.
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Ransomware attacks drop as organizations raise defenses
By Fred Bazzoli
Published July 17 2018, 5:26pm EDT
Ransomware attacks are significantly declining, and active defense strategies are highly effective but underused, according to a recent report by ISACA, a global association of technology professionals.
For its State of Cybersecurity 2018 report, ISACA surveyed 2,366 cyber security professionals, and found that 50 percent have seen an increase in cyberattack volumes relative to last year. In addition, 80 percent of respondents said they are likely or very likely to be attacked this year.
Despite an increase in cyberattacks generally, however, ransomware attacks are significantly declining, the survey found. Last year, 62 percent of respondents experienced a ransomware attack, compared with 45 percent this year, a drop of 17 percentage points. This is likely because organizations are significantly better prepared after last year’s WannaCry and NotPetya attacks, the study said.
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Text messaging helps VA trim missed appointments
Published July 17 2018, 4:54pm EDT
A recently launched text messaging program from the Department of Veterans Affairs is designed to reduce no-shows for medical appointments by more than 100,000 over three months.
The program is VEText, which serves as an appointment reminder system. VA started rolling out the program in March 2018 and 138 VA facilities currently use it.
The automated interactive service enables a veteran to confirm or cancel the appointment. As of July 9, more than 3 million veterans have received VEText messages and canceled 319,504 appointments.
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Bimodal IT Key to Unlocking Innovation in the Age of EMRs
By Don Woodlock | July 16, 2018
How do you ensure the reliability, scalability, performance, and dependability of your EMR/EHR and innovate at the same time?
We have reached an important plateau now with the digitization of healthcare. We have adopted electronic medical record systems in nearly all hospitals, most clinics, and doctor’s offices in most countries around the world.
There are some debates as to how much this has impacted patient care. But it has no doubt been a giant stepping stone to better information and workflows in the clinical care process. We are clearly standing on that next stone and ready to move forward.
But as EMRs become the bedrock IT system in the operation of a health system, it has introduced a problem: How do you ensure the reliability, scalability, performance, and dependability of your EMR and innovate at the same time?
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Social determinants of health gain traction as UnitedHealthcare and Intermountain build new programs
Organizations are each expanding services to address non-medical factors that can have a significant impact on individual and population health.
July 13, 2018 02:35 PM
Two high-profile healthcare organizations – Intermountain Healthcare and UnitedHealthcare – are investing millions to tackle social determinants of health.
These are the latest examples of the rise of social determinants in various realms of healthcare, notably public and population health initiatives, quality and safety efforts and, to a certain extent, value-based care.
Intermountain is investing $12 million over three years in programs to coordinate community care services that address the social determinants of health in two Utah cities, Ogden and St. George. UnitedHealthcare is awarding $1.95 million in grants to local organizations that are expanding services to address some of Wisconsin’s key social determinants of health, such as food security.
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Next-gen clinical decision support tools: Analytics and health data in the EHR workflow
CDS vendors are working to incorporate AI and machine learning into their products to boost diagnostics, imaging, pathology and radiology.
By Bill Siwicki
July 16, 2018 10:08 AM
Clinical decision support technology is becoming more popular among healthcare provider organizations to blend large volumes of information and ensure that the key details do not escape the attention of the care team. The fast rise of artificial intelligence and machine learning in clinical decision support tools has generated excitement over the potential for providers to revolutionize diagnostics, including in the areas of pathology, radiology and imaging.
Clinical decision support technology experts offer a variety of opinions on where the tools are headed and how healthcare provider organizations should prepare for tomorrow’s tools —and the next generation of technologies will be tasked with providing greater guidance and sound advice in new ways.
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Should researchers studying EHRs contact patients if they find a problem? Patients weigh in
July 13, 2018 |
Researchers are increasingly mining data found in EHRs for various studies, bringing to light an unexpected ethical dilemma: What if the research team finds an untreated health concern while reviewing an individual patient record?
"The use of EHRs for research has the potential to improve the diagnosis and treatment of disease," a team of researchers from Nashville, Tenn.-based Vanderbilt University and Durham, N.C.-based Duke University wrote in a recent study published in the Journal of the American Medical Informatics Association. "Researchers will almost certainly discover discrepancies in EHRs that call for resolution."
For the study, the team sought to explore patients' attitudes toward being contacted by a researcher who had access to their medical record. The study authors conducted 15 focus groups across urban and rural communities in the southeastern U.S., during which a moderator presented three vignettes related to whether a researcher might have a reason to contact a patient.
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Using encryption to help fight data breaches
- By Nick Jovanovic
- Jul 13, 2018
The question seems simple, “What will it take to stop the breaches?”
Cybersecurity continues to be a priority in all branches of government as well as for businesses, to academic institutions and everyone in between. Despite this attention and an increase in resources, the number of data breaches continues to escalate, with federal agency data under siege. Seventy-one percent of government respondents to a recent survey report their organization was breached sometime in the past. Our Federal Edition of the 2018 Thales Data Threat Report reports that of those organizations, 57 percent have been breached in the last year – a number that is three times the rate just two years ago. More alarmingly, perhaps, is that 67 percent of all enterprises have been breached with many of those having been breached more than once.
These statistics indicate that data breaches remain pervasive within the federal government, and that the current methods to secure agency data are not working as effectively as they could.
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Health IT Roundup—Healthcare breach costs outpace all other industries; Digital health funding hits $4.9B globally
by Evan Sweeney
Jul 16, 2018 3:11pm
Healthcare breaches come with a hefty price tag
Healthcare organizations that suffer a data breach pay more than $400 for each lost or stolen record, according to a survey.
That’s nearly twice as much as the next-highest industry, finance, and almost four times as much as the retail industry.
The global survey conducted by IBM Security and the Ponemon Institute included in-depth interviews with nearly 500 companies across a range of sectors that experienced a breach. According to the results, healthcare companies pay $408 per lost or stolen record compared to $206 per record in the financial industry and $174 per record among pharmaceutical manufacturers.
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Data augmentation enables AI to find breast cancer early
Published July 16 2018, 4:43pm EDT
Increasing the amount of breast imaging data available to train deep learning algorithms may lead to earlier identifications of “architectural distortions,” which are tissue anomalies that are often the earliest manifestation of breast cancer.
Breast cancer is the deadliest cancer affecting women worldwide. Early treatment is an important way to combat the disease, and the most used exam to do so is digital mammography, where the radiologist looks for masses, microcalcifications and architectural distortions, identifiable as an asymmetric area of the breast tissue caused by subtle contracting.
Almost 40 million mammograms are performed annually in the United States alone. However, reading all of these images can be expensive and time consuming. In addition, they are also subject to human error. For instance, architectural distortions can be benign, such as the site of a prior biopsy, but also can be the earliest indication of breast cancer, appearing as much as two years before any other anomaly.
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Enjoy!
David.
