YOUR SPOUSE HAS CARDIAC ARREST - WHAT THEN?

At a meeting a few days ago, I brought along  the January 27, 2011 New England Journal of Medicine article by Gust H. Bardy, M.D. "A Critic's Assessment of Our Approach to Cardiac Arrest." Since NEJM is copyright protected, I gave the original article serially to several health care professionals.

Bardy observed that success with home automated external defibrillators wasn't as good as the experience when they are used in public places and posits that the sudden collapse of a spouse may be associated with a delay in the ability of the survivor to call for help, which accounts for the disparity.

On reading the article, one of the doctors asked "why doesn't the home AED automatically call 911 and provide an alert and address when it is removed from its holder?"

If there is an AED expert among my readers, please answer the doctor's question (I will publish the answers) so that we may improve the likelihood of recovery from home cardiac arrest. Are there cost, technical, bureaucratic  or other barriers to this solution?

Another Privacy Rights Violation Results In a Large Financial Settlement

Once again, the Office of Civil Rights has gone after health care privacy violations, though this time, a well known institution, Mass General and its physicians were the target. Here is the entire notice provided to me by OCR.

Massachusetts General Hospital settles potential HIPAA violations

February 24, 2011

The General Hospital Corporation and Massachusetts General Physicians Organization, Inc. (Mass General) has agreed to pay the U.S. government $1,000,000 to settle potential violations of the HIPAA Privacy Rule.

Mass General, one of the nation’s oldest and largest hospitals, signed a Resolution Agreement with HHS that requires it to develop and implement a comprehensive set of policies and procedures to safeguard the privacy of its patients. The settlement follows an extensive investigation by OCR.

“We hope the health care industry will take a close look at this agreement and recognize that OCR is serious about HIPAA enforcement.  It is a covered entity’s responsibility to protect its patients’ health information,” said OCR Director Georgina Verdugo.

The incident giving rise to the agreement involved the loss of protected health information (PHI) of 192 patients of Mass General’s Infectious Disease Associates outpatient practice, including patients with HIV/AIDS. OCR opened its investigation of Mass General after a complaint was filed by a patient whose PHI was lost on March 9, 2009. OCR’s investigation indicated that Mass General failed to implement reasonable, appropriate safeguards to protect the privacy of PHI when removed from Mass General’s premises and impermissibly disclosed PHI potentially violating provisions of the HIPAA Privacy Rule. 

This impermissible disclosure involved the loss of documents consisting of a patient schedule containing names and medical record numbers for a group of 192 patients, and billing encounter forms containing the name, date of birth, medical record number, health insurer and policy number, diagnosis and name of providers for 66 of those patients.  These documents were lost on March 9, 2009, when a Mass General employee, while commuting to work, left the documents on the subway train. The documents were never recovered.

“To avoid enforcement penalties, covered entities must ensure they are always in compliance with the HIPAA Privacy and Security Rules,” said Verdugo. “A robust compliance program includes employee training, vigilant implementation of policies and procedures, regular internal audits, and a prompt action plan to respond to incidents.”

If you believe that a person or organization covered by the Privacy and Security Rules has violated your health information privacy rights or otherwise violated the Privacy or Security Rules, you may file a complaint with OCR at http://www.hhs.gov/ocr/privacy/hipaa/complaints/index.html.

Read the HHS Press Release    Read the Resolution Agreement and CAP 

Additional information about OCR’s enforcement activities can be found at www.hhs.gov/ocr.

What Is The Cost of Violating Patient Right To Records Rule ?

I have received this notice, posted by the federal Office of Civil Rights, and reproduced it in its entirety. See link:

Click for the Washington Post article on this situation.

HHS Imposes a $4.3 Million Civil Money Penalty for Violations of the HIPAA Privacy Rule

February 22, 2011

OCR has issued a Notice of Final Determination finding that Cignet Health of Prince George’s County, Md., (Cignet) violated the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).  HHS has imposed a civil money penalty (CMP) of $4.3 million for the violations, representing the first CMP issued by the Department for a covered entity’s violations of the HIPAA Privacy Rule.  The CMP is based on the violation categories and increased penalty amounts authorized by Section 13410(d) of the Health Information Technology for Economic and Clinical Health (HITECH) Act.

“Ensuring that Americans’ health information privacy is protected is vital to our health care system and a priority of this Administration. The U.S. Department of Health and Human Services is serious about enforcing individual rights guaranteed by the HIPAA Privacy Rule,” said HHS Secretary Kathleen Sebelius.

In a Notice of Proposed Determination issued Oct. 20, 2010, OCR found that Cignet violated 41 patients’ rights by denying them access to their medical records when requested between September 2008 and October 2009.  These patients individually filed complaints with OCR, initiating investigations of each complaint.  The HIPAA Privacy Rule requires that a covered entity provide a patient with a copy of their medical records within 30 (and no later than 60) days of the patient’s request. The CMP for these violations is $1.3 million.   

During the investigations, Cignet refused to respond to OCR’s demands to produce the records.  Additionally, Cignet failed to cooperate with OCR’s investigations of the complaints and produce the records in response to OCR’s subpoena.  OCR filed a petition to enforce its subpoena in United States District Court and obtained a default judgment against Cignet on March 30, 2010.  On April 7, 2010, Cignet produced the medical records to OCR, but otherwise made no efforts to resolve the complaints through informal means. 

OCR also found that Cignet failed to cooperate with OCR’s investigations on a continuing daily basis from March 17, 2009, to April 7, 2010, and that the failure to cooperate was due to Cignet’s willful neglect to comply with the Privacy Rule.  Covered entities are required under law to cooperate with the Department’s investigations.  The CMP for these violations is $3 million.

“Covered entities and business associates must uphold their responsibility to provide patients with access to their medical records, and adhere closely to all of HIPAA’s requirements,” said OCR Director Georgina Verdugo.  “The U.S. Department of Health and Human Services will continue to investigate and take action against those organizations that knowingly disregard their obligations under these rules.”

A copy of the Notice of Final Determination and Notice of Proposed Determination may be found at http://www.hhs.gov/ocr/privacy/hipaa/news/cignetnews.html.

The Perfect Storm?

As a person who practiced hematology, I learned to ask a few questions early in my career and early in my physician-patient relationships: what kind of work do you do now and what kind of work have you done?  Where do you live now  and where did you live before moving to your current location?  Do you have any occasion to handle toxic materials at work or in your personal life.  Do you live down-wind from a refinery?  When you were in the armed services, did you come into contact with toxic materials, including radiation and chemical warfare or biologic materials? Tell me about your hobbies, and specifically whether you are exposed to wood dust or fine shavings?.  Tell me about your use of alcoholic beverages, drugs and other substances. Tell me about your smoking history.

While all of this may be interesting to my readers, few probably think that it is relevant to them, but environmental toxic exposures play a major role in causing disease.  You may keep your weight under control, be careful about taking saturated fats, never pick up a salt shaker and exercise regularly, but if you are exposed to toxic substances in your environment, in your food and in your home, you may develop leukemia, cancers (bladder, lung, skin, testicles and others), black lung disease, serious infections, emphysema, brain disorders, and a host of other disabling, fatal and expensive-to-treat diseases. And if we allow our children to have those exposures, they are also at risk.

All of which, at a time when the country is working desperately to control its health care costs, makes me wonder why any political party would seek to weaken our environmental laws. Does it make sense to try to roll-back health reform and simultaneously roll back the environmental protections which America - with much effort - has invoked to protect its children, men and women?  Has this become a country in which we cannot trust one another to take reasonable care of our children, workers and vulnerable citizens?  Is the tension between financial interest and the well-being of our citizens always to be resolved in favor of financial interests?

Be Generous To Your Supporters and Evil To Your Enemies

The practical rules of politics haven't changed since the days of Plato. As we watch the revolution in Egypt, we understand that those rules are as alive today as ever. The problem for our Congresspeople, with respect to health care, is to determine who are their supporters and who are their enemies.

If you want to know who financially supports your Congressperson, call that person's office and ask.  Or search online.  In either case, you will only find part of the answer since direct financial payments to Congresspersons' campaign funds, amounting to a few million dollars here or there for strategic Congress operators, is only part of the story. The other part - much more difficult to calculate -  comes from individuals and groups who provide funding which gives them extraordinary access to your elected officials. Those Congressional votes aren't bought, but access is, and with access comes only one side of the argument about health care reform.

The tougher part is figuring out  "who is your Congressperson's enemy"?  Is it the kids who, if health reform were to be repealed, would lose their health insurance, lose their access to medical care, lose their medical care and treatments and get sick enough to die or become permanently injured. Is it the people who should be paying for their own health insurance, but prefer to use resources which other people pay for in the form of taxes and exaggerated medical costs - and go through life cost-shifting?  Is it the well-paid health insurance executives? Is it the pregnant women who can't get health insurance?  Is it the laid-off workers whose employers have cut-off their access to health insurance benefits?  Is it the Medicaid patients whose states have run out of money to treat their leukemias, cancers, heart disease, diabetes?

So who are the politicians' supporters who play the music that certain segments of Congress dance to, and who are the politicians' enemies who "deserve" to be dealt evil?  Who shall live and prosper and who shall be denied health insurance and die?  Who deserves just treatment and who does not? What are the ethical rules governing political votes on health care reform?

When Johnny Comes Marching Home Again - Then What? The intersection of Science and Public Policy

President Obama's promise to draw down forces in Iraq is in the process of being fulfilled. But only some of America's soldiers, marines, sailors and air force men and women make it home. Others are reassigned, this time to Afghanistan, about which a more opaque vision of troop withdrawal is dangled before us. Our all-volunteer forces continue their exposure to extraordinary stressors which severely try even the most even-tempered, fit and well-balanced men and women.

And then we see stories about, and pictures of, troops on duty, surrounded by their enemies who are sworn to (and do) kill and maim them, suddenly brought to the United States again. And other stories, about their family problems, suicides, drug use, problems with the law, post traumatic stress disorder and our government's promise - once again - to take care of our wounded warriors "better this time" without convincing evidence that the promise will be kept. In the 20th and 21st centuries we have seen budgetary constraints, long-term disability costs, the military need to return its troops to duty rather than acknowledge their need for withdrawal from combat, and an unwillingness to face the truth about the effects of wartime stresses on the men and women who serve America determine our policy about caring for returning military.

As described in my last blog, there is a new scientific tool which might help our government distinguish the men and women who are most at risk of damage from the stress of wartime service, and who are damaged by their experiences. My question is: will our military carefully study and then appropriately utilize existing and developing telomere research as one (of several) screening tools before and after sending people into combat to determine who is at risk and who has been injured by service?

There is a very real risk: that sending people to war in Iraq, Afghanistan and other far-flung posts, will invariably lead to serious stress-related damage to their chromosomes and be associated with destruction of their families, suicides, drug use, problems with the law and post traumatic stress disorder. Who would be willing to volunteer for military duty then? What family would approve of that service? What citizenry would then vote in favor of a war in far-off places?

Does It All Come Down To This? You Are Stuck With Your Genes, But Can Do Something About Telomere Length

Last night's "Gerald and Sally DeNardo Lectureship" at Santa Clara University featured the University of California at San Francisco's Elizabeth Blackburn, Ph.D., 2009 Nobel Prize winner in the Physiology of Medicine. Speaking about telomeres, of which you, the reader have billions (2 per chromosome, 23 pairs of chromosomes per cell and more than 100,000,000,000 cells in your body), Professor Blackburn likened the full-length telomere to the intact tip of a ribbon shoelace, a structure which prevents unraveling and destruction.

Blackburn's research has disclosed that certain unicellular organisms, when undisturbed, have  built-in systems for preserving the length of each telomere through multiple cell divisions but that laboratory interference with that length-preservation results in shortened cell life (loss of immortality).  Going further, she and other scientists have discovered cellular mechanisms for preserving the length of the telomeres and scientific means for interfering with those cellular mechanisms.

People are not unicellular organisms living in Walden Pond, but Blackburn's discoveries have also demonstrated that peoples' lifetime events which result in shortened telomeres lead to the ability to predict life-shortening diseases including cardiovascular disease and diabetes. The events are not genetic, as much as environmental and the good news is that some of them are under society's and our individual control. The bad news is that our population has not had convincing serious long-term commitment to doing things which stabilize or lengthen telomeres, improve our resistance to diseases, lengthen lives and reduce the cost of health care.

Blackburn cited adverse childhood events, chronic stress (including adult post traumatic stress disorder, pessimism and, in men,  hostility) as factors which she can associate with telomere-shortening and a corresponding poor survival prognosis. Stabilization and perhaps lengthening of telomeres is associated with increasing education, exercise and stress reduction.

So turn off the television, get off your rear end, take a pleasant walk, find sensible methods to relieve your stresses and stabilize (and lengthen?) your telomeres.  It is likely that these simple acts will help you to live better and longer! You can also stop blaming your parents for the "bad" genes they gave you since most of your health problems may stem from your own habits and environment.