Could VistA solve the eHealth problems in Ontario?

Recently I posted a piece answering the question, "Will boomers bankrupt the medical system?" In that post I fell prey to many of the same demons that haunt those in the main stream media. A reader called me on my position and brought me down with a few politely delivered, well reasoned comments. (That blog has become another example of my need, and the need of all writers, for a good editor. I thank anonymous for his/her comments. Anonymous took on the role of editor.)

My position was that seniors will not bankrupt the system. It will be expensive new technologies and drugs teamed with higher wages for health professionals (physicians in particular) that will drive increasing costs.

Anonymous argued, and quite accurately, "Guess who is using the majority of new expensive drugs... yes you guessed it, seniors." And, seniors are living longer thanks to their expensive medical care. Anonymous told me that health care costs in the last year of life are huge. More seniors means more costs, "simple math really," wrote anonymous.

Now, stepping sideways out of this brouhaha of my own making, I'd like to take a quick look at our eHeath debacle here in Ontario, Canada — possibly an example of the thinking that is running up costs independent of the boomer driven health demands.  

Screen grab of of one take on a VistA electronic health record.

While touring the American Northwest, I met a retired software developer who told me about VistA (Veterans Health Information Systems and Technology Architecture) used by the VA in the States.

He called VistA an excellent electronic health record system, and because it was paid for by the American taxpayer, VistA is written in open source code. This means that VistA offers the tantalizing promise of being adaptable to use not only throughout the States but the throughout the world and for very little cost.

When I got home, I googled VistA and confirmed that the chap was right. Although not everyone agrees VistA is the answer to all electronic healthcare record problems, it is being discussed worldwide as one possible solution.

Today, The New York Times ran an article A Digital Shift on Health Data Swells Profits in an Industry. I commented on the article asking, "Whatever happened to the idea of using VistA?" I got a number of replies plus 22 readers giving me the thumbs-up.

Here are the first comments:

The VA program is the best, most intuitive, easiest EMR to use, however, it was supposedly built on an ancient platform and so difficult to adopt. I have used Cerner (crap), Eclipsys (more crap), and the GE one (too awful to remember) and now a college program Pyramed 5. They all have issues. I miss the VA software and want to return to work there -- that's how good it is!
  — bucketomeat - Castleton-on-Hudson, NY

This was my first thought too. I've used the version of this system (CPRS) in research I've done in the VHA, and it is really well designed and already paid for to boot. . . .
  — Alice Olson - Bronxville, NY

What ever happened to the idea of using VistA?

In the US we believe that the government should do NOTHING that, left to the private sector, might turn a profit and a huge salary for some corporation and its CEO.
   — john strass - Delray Beach, FL\

This would be an excellent solution. I'm surprised that a consortium of hospitals has not gone on board with this. . . ?
  — athens area - pennslyvania

Let's give some of the other comments a quick look:

• The scandal is the VA apparently has a very good EMR (hopefully someone from the VA can chime in with their experience) that was available as open source free software. [This got 109 recommendations.]
• A doctor, Jan B. Newman, wrote the VA system is time tested, physician friendly and free . . . [compared to the other systems that] are set up to maximize profits for the IT companies, cost the physicians huge amounts to install, cost the hospitals huge amounts . . . [This got 53 recommendations.]
• The ironic thing is that the government has already paid to create the VA EMR system, allowing all VA providers 24/7 access to patient records as patients travel around the US. . . . [34 recommendations.]
• The government has a great EMR (the VA system). All commercial ones should be forced to be able to export data in a way that is 100% compatible with that. As such, they would then be 100% compatible with each other. [33 recommendations.]

There were more comments but you get the idea. The retired software fellow I met in the American Northwest has a lot of company when it comes to seeing VistA as a relatively inexpensive and very efficient answer to the electronic healthcare boondoggle.

Are there any hospitals, other than VA facilities, using VistA? I learned from an article in Forbes the answer is "yes". It seems the CEO of Oroville Hospital in California needed to digitalize the hospital's patient records. He turned to VistA, which Forbes calls "one of the oldest and most reliable electronic health records, in use at 163 VA hospitals as well as hospitals around the world."

Canadian Press (CP) reported in January that PC Leader Tim Hudak claimed eHealth spent $2 billion “with nothing to show for it." Hudak is championing open source software as the answer to Ontario's EHR mess. The news service quotes Hudak as saying Ontario must stop "reinventing the wheel." Has Hudak heard of VistA?

I fired off an e-mail to eHealth Ontario asking, "Why has eHealth Ontario not considered VistA or (WorldVistA) EHR software with its open source code and solid history going back decades in the U.S.? Thank you."

So far I've heard nothing back.

Chris Hadfield: photographer not amateur shutterbug

I know reporters do not mean to be insulting when they refer to photographs taken from space as "snapshots" or to the astronaut taking the images as an "amateur shutterbug." But, they are mildly insulting, insulting to the profession — the profession of journalism.

I can understand wordsmiths not wanting to repeat the same word over and over. But ink slingers let their fears get the better of them when these scribes cannot use the right word even on the first occurrence in a story. Typing the word photographer seems impossible for these keyboard jockeys.

Astronauts like Chris Hadfield are brilliant, talented individuals — experts in an amazingly wide range of fields. Take photography, astronauts are trained photographers. NASA ensures they are not only competent in the craft but in the art. There are two words scribblers should not use to describe expert shooters like Chris Hadfield, they are "amateur shutterbug."

Maybe, just maybe, if newshounds were kept on shorter leashes by newsroom editors they would not wander so far afield sniffing out stinky synonyms.

Check out the following from Chris Hadfield's space station portfolio. Snapshots or carefully composed art?

Taffy-twisted African rock reminds Hadfield of a dolphin, and Alfred Hitchcock.

Delicate cappuccino frosting decorations are, in fact, endless hummocks of Saharan sand.

Arid fingers of sand-blasted rock are barely holding on against the hot Saharan wind.

Weightless liquids behave oddly: air bubble and pepper oil jockey for position in ball of water.

Invisible cursor in Google search field using FireFox

This morning the cursor and selection box disappeared while I was doing Google searches. My web browser is FireFox.

I wish I could detail exactly all that this bug entailed but I fixed the problem and until it returns I'm unable to say more.

How did I bring the cursor back to visibility? I went to View, left clicked the mouse to bring up a short menu and finally clicked on Full Screen F11. All returned to normal. Simply hitting F11 might be a short cut.

[Simply tapping F11 at the top of the keyboard is an immediate solution. The cursor disappeared again and I got a chance to test the short cut. One tap of the F11 key, the full screen appears and the cursor is immediately visible.]

I understand that pointing at the Firefox icon, found in the top left corner of the monitor, clicking the mouse to activate the drop down menu and then selecting Maximize will also make both the cursor and the selection box visible again in the Google search field.

Hope this helps all who encounter this odd problem.

Pradaxa (dabigatran) degrades on removal from original packaging; do not place in a pill organizer.

Formerly Pradax in Canada, the name is now Pradaxa in both Canada and the U.S.

Note: The following is an UPDATE to a blog originally posted in early 2013. The views are of a patient taking Pradaxa and are NOT the views of a medical expert.
________________________________________________________________________

If you take Pradaxa (dabigatran) rather than coumadin, you must be aware of the following taken from the Pharmacist's Letter of October 2016:

Pradaxa must be protected from moisture.
All capsules must be used within four months of opening the original container.
Pradaxa must be dispensed in the original container. The bottle has a desiccant in lid.

Now, you know the core concerns. Please, read on.
_________________________________________________________________________

I started taking Pradaxa, originally called Pradax in Canada and Pradaxa in the States, more than four years ago. So, I am not addressing a new problem. And yet, this serious problem is still with us. Contrary to an FDA warning, some pharmacists are continuing to dispense Pradaxa capsules repackaged in standard pharmacy vials.

Why is this a problem? According to Boehringer Ingelheim, Canada, "Pradaxa is very sensitive to moisture in the air." For this reason, the drugmaker recommends keeping Pradaxa in its original foil blister pack or in its original special bottle with a drying agent in the lid. The company warns, "Do not put the capsules in pill boxes or pill organizers . . . " The FDA also adds a warning about storing the drug in areas which are subject to temperature extemes, either hot or cold.

Pradaxa is an anticoagulant replacement for Coumadin (warfarin). Both drugs are taken by those in danger of suffering a stroke. Compared to aspiring, Pradaxa poses less danger of causing serious intracranial bleeding. After an MRI, I was diagnosed with micro-bleeding in the brain. I also suffer from TIAs or small strokes. Small strokes can lead to large strokes if an anticoagulant is not taken regularly. I take Pradaxa twice a day.

Without my anti-clotting medication I have a six percent chance of suffering a serious stroke in any given year. That's six strokes in a hundred at risk patients. One of the six will die and the other five will suffer strokes causing differing degrees of debilitation. Strokes are the fourth leading cause of death in the U.S.

If you take Pradaxa, check your prescription bottle. My last one was a palm-and-turn plastic bottle with a lid riddled with holes. Pradaxa is only good for four months after its original bottle with the special desiccant-containing lid has been opened.

How long my three month supply of Pradaxa, dispensed in a bottle with holes in the lid, retained its potency is anyone's guess. There is no question the last capsules would be markedly degraded. That much is certain.

Atrial fibrillation (AF) affects a great many people and according to the Mayo Clinic is increasingly common in seniors. AF is a type of irregular, often rapid, heartbeat that can lead to the formation of blood clots in the heart. These clots can migrate to the brain where they cause a cerebral infarction, a cerebrovascular incident — a stroke in simple terms.

My heart is in constant atrial flutter, similar to, but not quite the same as, atrial fibrillation. My daily low-dose Aspirin is not strong enough to protect me from the increased threat of stroke. My doctors discussed my situation and settled on Pradaxa 110mg as the best option. Pradaxa also comes in two other strengths: 75mg and 150 mg.

Black marker dates Pradaxa still in foil.

Transferring Pradaxa to a pill organizer is a common mistake. Lots of people do it. There is an "Important" instruction on the side of the box but it is at the bottom of a list and in the same type style as the other notes. For a truly important instruction, it does not jump off the package as one might expect it would.

I confess, when I first started taking Pradaxa I missed the warning. I'm an old geezer. My making a mistake is not surprising. It is to be expected. But clearly my pharmacist has also missed the warning. How common is the mistake? Like so many today, pharmacists are overworked. The staffing at my drugstore has been cut and this, I believe, can lead to errors.

I have now had Pradaxa dispensed in both the original bottle and the blister packs. I prefer the blister pack. I'm old. My memory is not good. Unable to continue using a weekly organizer for my Pradaxa, I take a Sharpie permanent marker and write the day and time of day, AM or PM, that each pill must be taken on the blister pack itself.

I believe this is very important. Pradaxa has an extremely short half-life. The concentration in your body drops drastically in just 24 hours. For this reason taking a dose quite late, or completely forgetting a capsule, increases the risk of stroke.

I find it strange that if grapefruit should not be consumed while taking a drug my pharmacist has a sticker for this. The sticker is slapped on the pill bottle at the time the prescription is filled. Pradaxa needs a similar day-glow sticker to warn folk not to expose the capsules to air, to keep the medication in its original container until it is taken.

If a druggist dispenses Pradaxa in anything other than the original packaging, one pharmacist told me the capsules should be immediately returned to the drugstore to be safely discarded. The pharmacist should replace those capsules with new as it is difficult to know how much humidity such capsules have encountered. Were they kept in a bathroom with a steamy shower, or stored in a kitchen near pots of boiling water? The druggist told me not to take a chance. Return the capsules.

One last thing about Pradaxa. There is now a reversal agent available. In an emergency situation where there is a need to reverse Pradaxa’s blood-thinning effect, Praxbind (idarucizumab) is now available. I personally know how important this can be. I had to have emergency bowel surgery a little more than 12 hours after taking my last dose of Pradaxa.

For more info on Pradaxa, check out the Pradaxa website or follow this link to a story in The Globe and Mail: Questions raised about new class of blood thinners.

Read the Globe story and you will realize that Pradaxa has had mixed reviews, especially in the media. A word to the wise, don't rely too heavily on media reports when it comes to medicine. Yes, Pradaxa is a dangerous new drug, but then weakening the blood's ability to clot is clearly a dangerous practice. Warfarin, formerly the drug of choice, is also a dangerous drug.

As I said earlier, I was once on warfarin. I had to have my blood regularly tested to be certain I was getting the maximum benefit from the drug. Warfarin, in some people, can be notoriously difficult to regulate.

It must be noted that the maker of Pradaxa has claimed no regular blood testing was required with the new anticoagulant. MedPage Today and others are reporting that monitoring drug plasma levels could improve the safety of Pradaxa. I have had my blood tested twice and so far Pradaxa is working as promised.

According to the Mayo Clinic, warfarin reduces the risk of stroke by about 64 percent. Unfortunately, ". . . only 50% of patients with atrial fibrillation who would benefit from warfarin therapy receive it, and the discontinuation rates are high. At 1 year, more than 25% of patients stop warfarin . . . " For these reasons, drugs like Pradaxa are very attractive.

My doctors believed Pradaxa to be better at stroke prevention than warfarin and with a lessened chance of major bleeding. Some time ago, I had an MRI that revealed micro-bleeding in my brain. Not enough is known about micro-bleeding for my doctors to feel confident putting me on warfarin. The rate of intracranial bleeding with Pradaxa has been shown to be less than that of warfarin. To lessen my risk of suffering a major bleeding event in my brain, and after consulting with the neurology department, my doctors decided the best alternative for me was Pradaxa110 mg taken twice daily. I continue to take an aspirin daily, the 81mg kind.

There's a lot of which to be aware when taking a drug like Pradaxa. Read the warnings that come with all your meds carefully. Check out the Pradaxa info online. Click on the links that I have supplied. If your doctor advises a drug like Pradaxa don't be too quick to dismiss the suggestion. Doctors go with the best odds. I liked one comment made on another site discussing Pradaxa: "You can transfuse blood, but you can't transfuse brain".

Lastly, here are a couple of websites you might find interesting. The first is a website run by the Harvard Medical School. The article is titled: Is the alternative to warfarin safe and effective? The second is a site dedicated to AF: StopAfib.

Good luck with your meds.

And if you are interested in knowing more about my emergency operation, done before the release of the reversal agent Praxbind, here is a link: 16 hours in the ER; 16 hours well spent.

Film: Humbug.

Digital has eliminated neither art nor craft from photography.

The New York Times has published another in a seemingly unending parade of eulogies to the passing of film: Picturing the End of Analog.

I don't miss film. If I had to use just one word to describe film, I'd say expensive. It was expensive to buy, expensive to use, expensive to process and expensive to store.

And, if you will allow me the luxury of adding just one more word to my description, I'd say difficult. It could be difficult to find when needed, difficult to process and difficult to store.

Close-up, wide angle, telephoto: One digital camera.

One reads all sorts of stories about the artsy qualities of film. Some of the stories are true. But some of the art was the result, not of craft, but of ignorance.

I knew a rather famous photojournalist who was well known for his contrasty colour images. He captured the grittiness of the news, the harshness of those moments with a style unmatched by other shooters. All his pictures weren't rendered with bald, stark highlights, that would have made his approach simply a style gimmick.

Then I met the great man. Working outside the country on assignment for the local paper, I had to have some colour film processed by this famous photojournalist artist. He processed the film by hand, dunking it in stainless steel tanks immersed in a water bath to stabilize the temperature of the processing chemicals.

When the film was dry, I picked an image and stuck the negative into a portable Leaf scanner to transmit three colour separations back to the newspaper. The image I saw on the little Leaf monitor was awful; It was contrasty; The highlights were bald.

See it, shoot it. The power of small, ever-present, digital cameras.

I removed the film from the scanner and examined it under a strong light. The colour film was suffering from silver retention. There was a black and white negative hiding in the colour negative.

At that time, colour film went into a bleach bath before going into the fixing bath. The bleach bath converted metallic silver in the film back into the silver halide it had been before being dipped in the developing tank. Thanks to the bleach bath, the fix bath removed all the silver from the film. Fix only removes silver halide; It does not easily remove metallic silver.

I had learned the reason for the contrasty images this photojournalist was known for. He didn't understand the chemistry involved in processing colour negative film. Most of the time he dumped his bleach before it lost it potency. He used his chemical bath for a set length of time, regularly replacing it with fresh chemistry. But sometimes, if he processed more film than usual, his bleach grew weak and failed to convert all the metallic silver created during development back into silver halide.

At those times he produced art. Film: Humbug.

Digital encourages experimentation. No film, no expense. Just fun.

Will boomers bankrupt the medical system?

This post was knocked off far too quickly and the well-thought out comments appeared to punch holes in my position. I admit, I was far too quick out of the gate. I made the mistake that newspapers make daily. I am now in the process of taking another look at rising health care costs and the part played by the rapidly growing senior segment of the population.

In the meantime, here is an article worth a read despite being a little stale dated: What is driving health care costs? And here is anothe: The Costly Paradox of Health-Care Technology.

The problem appears complex -- this should come as no surprise -- and the media's immediate scapegoat, seniors, may be wrong. For an example of a well written but quite possibly wrong-headed take on seniors and their affect on the healthcare system, read this piece by Larry Cornies which ran in The London Free Press: Boomers duty-bound to reduce health-care footprint. Compare the Cornies article with this one from The Economist with a section titled: Money and mortality: the implications of aging on healthcare costs.
_____________________________________________

According to The London Free Press reporting on a talk by David Foot, the demand for health care in Ontario will ramp up sharply when baby boomers hit their senior years. Foot believes, "We have about a decade to get health care right before it hits the fan."

Many would agree with Foot that there is a growing problem, but many would argue that the health care issue is not driven by the increasing costs associated with health care for the elderly. The Globe and Mail, a competitor to The Free Press in their home market, carried a story with quite a different slant. Globe writer Andre Picard wrote:

"This alarmist view of our aging society is challenged in a thoughtful new report from the Institute for Research on Public Policy.

"Instead of falling prey to ageist fear-mongering, Neena Chappell, the Canada research chair in social gerontology and a professor in the Centre on Aging of the University of Victoria, takes a level-headed look at the data and offers up practical solutions for meeting the health needs of the baby boom generation."

The Globe piece goes on to argue a position that I have seen in print many times. I wondered why The Free Press reporter didn't question Prof. Foot on this point. The Globe accurately reported the following:

"There have been, of late, a number of studies debunking the notion that seniors are principally to blame for spiraling health costs. In fact, it is new technologies, new drugs and higher wages for health professionals (physicians in particular) that are pushing up costs."

 To read the two stories, here are the links:

• Baby boomers blamed for sluggish economic outlook in Ontario
• We need a health plan for boomers now

This is an issue that is very important to me. I am a senior and a baby boomer. I watched as my maternal grandparents aged and finally slipped away. Both lived into their 90s and neither was a big drain on the health care system. They lived in their own home until their mid 80s and then they moved in with my mother and me for their remaining years.

When my mother found herself on her own after the death of my grandparents, she moved in with my sister. After more than a decade living in Oakville, she packed her bags and moved in with me in London. When I got married my mother was part of the package. She lived with me and my new family until she died at 89.

Families taking care of loved ones in their final years are more common than you might think. The government should encourage families and support them in their efforts to take care of aging parents and grandparents.

In one area both The Globe and The Free Press reports agree: We, as a society, need a plan as we prepare for the dramatic growth in the number of seniors. What we don't need are scare stories.

London police did excellent job putting injured deer down

A deer was struck recently by a vehicle in London, Ontario. It was left severely injured. It's limbs smashed; Its antlers broken. When police arrived, the fatally injured animal was suffering in a parking lot, unable to walk.

It was a tough situation but the London police made the right call by ending the animal's misery quickly. But many didn't view it that way, and many people did view the shooting of the deer. A Londoner captured the incident on his cell phone and posted the video on YouTube. It has had more than 15,500 viewings.

Deer are common in the city and collisions with vehicles all too frequent.

The London Free Press quotes a police constable: "We have to consider the surroundings. If we used a round that penetrated through the deer, we would have to be prepared for ricochet." The officer used a 12-gauge shotgun to put the injured deer away with three shots in less than half a minute.

The truth is dying is tough. It is not often immediate. I did some research and found what hunters themselves have to say about their kills.

"I shot one whitetail doe there [behind the shoulder, in the heart/lung area] and she ran at least 60 yards before dropping. I shot a fallow doe last Sunday and the shot went through the lungs and out the other side of the deer. She hobbled down off the little hill she was standing on, then down a draw about 150 yards from me. By the time I got to her she was giving up the ghost, but she had lived for a minute or two."

Another hunter listed his kills, saying:

• '05 Shot a big bodied buck, 50cal muzzle loader, thru the heart. Ran 100 yards decent blood trail.
• '07 bigger bodied buck, 7RM ballistic tip center of the shoulder. Dropped dead, three men could not find a bullet hole. NO blood.
• '08 .50 cal thru the center of one shoulder, exit 4" behind other. minimal blood hard tracking approx 100 yards.

I don't hunt but I did once work for the Ministry of Natural Resources. I used to hear the hunters with whom I worked chatting. I learned a quick kill did not mean immediate death. The London police officer was armed with a good weapon for discharging in a built-up urban area. His weapon was less than ideal for killing a deer. He did a good job, weighing his options, and carrying out a difficult duty.