Saturday, October 05, 2019

short refresher on common skin conditions

 Pretty good presentation useful for Primary care and community health certificate holders.

https://www.peacehealth.org/sites/default/files/Documents/PC%202015%20Foo.pdf


“If you send me a piece of skin, I’ll tell you it’s skin”

 “If you send me a piece of a rash, I’ll tell you it’s a rash”

 “If you tell me what you’re looking for, I’ll tell you what if it fits”

 “If you don’t know what the rash is (when you can seen all of a person’s skin), please don’t expect me to give you an answer from a tiny piece of skin”

 Do not depend on a skin biopsy to provide a diagnosis for your patient’s rash

 A skin biopsy should be performed only if one can correlate the pathologic findings with clinical findings to reach a diagnosis


revolutionary new approach to identify potentially fatal complications in of diabetic patients

With a revolutionary new approach that analyzed just a few drops of blood, scientists from Northwestern Medicine, the University of Chicago and Wuhan University in China detected earlier and more accurately if diabetic patients had developed life-threatening vascular complications such as heart disease, atherosclerosis and kidney failure. 
It is the latest discovery in a new blood-testing technology that Northwestern scientists used most recently to detect liver cancer in patients and is now being tested in other major cancers.  
“We’re very excited to apply our earlier findings in cancer patients to diabetic patients,” said co-corresponding author Wei Zhang, associate professor of cancer epidemiology and prevention at Northwestern University Feinberg School of Medicine. “This discovery is going to revolutionize how quickly and non-invasively we can identify potentially fatal complications in the hundreds of millions of diabetic patients worldwide.”
2/3About two-thirds of the 424 million diabetic patients worldwide die from vascular complications.
The prototype of this novel technology was developed by Dr. Chuan He, the John T. Wilson Distinguished Service Professor at the University of Chicago. Zhang and He worked together to create the blood test. 
About two-thirds of the 424 million diabetic patients worldwide die from vascular (i.e. blood vessel) complications. Detecting these complications early could spur treatments to control the development of severe disease or death.
Current methods of diagnosing vascular complications in diabetic patients – analyzing a patient’s body mass index (BMI), the length of time they’ve had diabetes or a blood test analyzing how much waste product is present – are prone to error and don’t identify complications early enough to intervene with treatment.
This blood test is different. 

How it works

With just three to five milliliters of blood, the non-invasive, clinically convenient test analyzes a patient’s DNA by using highly sensitive blood biomarkers.
If the diabetic patient has developed a vascular complication, the damaged blood vessels release new DNA into the bloodstream, which appears in the blood test and signals the problem to doctors.  
The findings were published Oct. 1 in Clinical Chemistry, the leading international journal of clinical laboratory science. 

5-Hydroxymethylcytosines in Circulating Cell-Free DNA Reveal Vascular Complications of Type 2 Diabetes

Ying YangChang ZengXingyu LuYanqun SongJi NieRuoxi RanZhou ZhangChuan HeWei ZhangSong-Mei Liu
The study examined 62 diabetic patients (12 patients without vascular complications, 34 patients with a singular vascular complication and 16 with multiple vascular complications). This highly sensitive blood test was able to identify if a patient had vascular complications much more accurately than current diagnostic methods.

Abstract

Background: Long-term complications of type 2 diabetes (T2D), such as macrovascular and microvascular events, are the major causes for T2D-related disability and mortality. A clinically convenient, noninvasive approach for monitoring the development of these complications would improve the overall life quality of patients with T2D and help reduce healthcare burden through preventive interventions.
Methods: A selective chemical labeling strategy for 5-hydroxymethylcytosines (5hmC-Seal) was used to profile genome-wide 5hmCs, an emerging class of epigenetic markers implicated in complex diseases including diabetes, in circulating cell-free DNA (cfDNA) from a collection of Chinese patients (n = 62). Differentially modified 5hmC markers between patients with T2D with and without macrovascular/microvascular complications were analyzed under a case–control design.
Results: Statistically significant changes in 5hmC markers were associated with T2D-related macrovascular/microvascular complications, involving genes and pathways relevant to vascular biology and diabetes, including insulin resistance and inflammation. A 16-gene 5hmC marker panel accurately distinguished patients with vascular complications from those without [testing set: area under the curve (AUC) = 0.85; 95% CI, 0.73–0.96], outperforming conventional clinical variables such as urinary albumin. In addition, a separate 13-gene 5hmC marker panel could distinguish patients with single complications from those with multiple complications (testing set: AUC = 0.84; 95% CI, 0.68–0.99), showing superiority over conventional clinical variables.
Conclusions: The 5hmC markers in cfDNA reflected the epigenetic changes in patients with T2D who developed macrovascular/microvascular complications. The 5hmC-Seal assay has the potential to be a clinically convenient, noninvasive approach that can be applied in the clinic to monitor the presence and severity of diabetic vascular complications.
  • Received for publication April 8, 2019.
  • Accepted for publication August 6, 2019.

Friday, October 04, 2019

Tips on practice management 10-4-2019 Just text “DRRAM” to 555888!

Of the patients who had missed an appointment in the last year, most (52.4%) reported that they simply forgot to attend or cancel. 28.6% cited that they wrote down the wrong time or date, and 23.8% said they had to miss the appointment due to other issues such as traffic or work.

I tend to forget the appointments  and  have  showed up  on wrong date and time for my eye appointments  which improved greatly since the  ophthalmologist's office started text reminders

The data is clear: text messages are the preferred way to inform patients about upcoming appointments.


By now it’s clear that patients prefer text messages, but what is it about SMS that makes it so useful for reducing no-shows? Unlike emails, phone calls and postcards people always read their texts. There’s no app to install and texts work on every cellphone. Consider the following:
Texts are read instantly.
Emails may sit in inboxes for hours or days before they get opened. 90% of texts are read within 3 minutes of receipt!
Texts are friendly and unobtrusive.
Patients can check their texts even if they’re not available to answer a phone call. And they can easily refer back to the text later if they forget their appointment time.

Texts are  almost never ignored.
Less than 1% of all text messages go unread. There’s no spam box for them to go to, and the notifications can’t be turned off.
  • Keep your messages succinct and easy to read
  • Include the date, time and location of the appointment
  • Ask patients to reply Y or N to confirm
  • Remind patients to bring the necessary paperwork
  • Send messages between noon and 5 pm
  • sample text 
  • You have an appointment with Dr.Rama on Thur 10/17/2019. Reply Y to confirm or N to cancel. Call our office at 888-927-1826 if you have any questions or need to reschedule. Don’t forget to bring your insurance card.

Is Text Messaging HIPAA Compliant?

Text messages are not HIPAA compliant because they are stored indefinitely on the cellphone companies’ servers. Additionally, cellphones can be lost or stolen which could expose personal health info. As you can see in the example above, the specialty of the provider is not revealed. Neither is the reason for the appointment, the treatment the patient is coming in for, or the medication they are  taking. No information of this nature should be revealed unless a member of your staff is certain they’re speaking directly to the patient.

Alert patients of new test results
Reach out to individual patients with important information. Include secure links to test results as soon as they’re ready.
 Normally clinics do not bother to call patients for normal results  . Patients think 
" No news is Good news "  but no news is no news  the ball might have  been dropped.
but in fact calling the patient  with the good news that their  tests are normal is  a brownie point in your favor

Transactional TextsPromotional Texts
Appointment remindersReminders to schedule next appointment
Checkup remindersAdvertising new services
Health tips
Patient satisfaction surveys

Promotional messages, on the other hand, are any other texts that aren’t directly involving an existing transaction.
If your patients have the ability to schedule appointments online, this is the perfect opportunity to enroll them in your text reminder service.

We now offer convenient text message reminders!
Sign up for appointment reminders, monthly health tips, and more!
Just text “DRRAM” to 555888!
courtesy 

Open EMR More developers 3543 than users 1926 ?

Check these;
SMS enabled in Demographics/Choices.
Global settings for proper SMS acct data and Time of Appt. vs how far in
advance to send SMS.
SMS provider acct settings.
Check your cron log & Apache error log

Open EMR

More developers than users?

Forums

Help

Tips on practice management

If you’re considering new practice software or trying to tweak yours for the best client reminder system you can, keep these 10 tips in mind:
1. Schedule every client’s next visit before the current one is over
If clients leave without scheduling a next visit—even if that scheduled visit is only temporary until they can confirm their schedule—they’re less likely to return when they should, if at all. People get busy, other things in life take priority, and before they know it pet owners are months behind on their pet’s wellness visits. The practice then loses out on an opportunity to not only keep the patient current, but also postpones an opportunity for profit. Some practices provide appointment details on the back of a business card or fill out a postcard that gets sent a couple weeks before the appointment. The key is capturing appointment details in your software so that all of the other methods of communication can take place.
2. Tally as many “touches” on your client as possible without being annoying
Your practice touches a client each and every time you or a team member communicates face to face, calls, snail-mails, emails, texts, Facebook-messages, or tweets at them. And the more you and your practice stay top-of-mind for clients, the better the likelihood they’ll remember their appointments and show up when they’re supposed to. In addition, they’ll know your practice is there for them in case they have questions or problems leading up to their scheduled appointment.
Of course, it’s up to you to figure out how many touches is just right for your clients. The last thing a practice wants is to annoy their clients by contacting them too many times. The right number of touches depends on your clients’ preferences and varies from practice to practice. Start with one or two and see how that goes. Then expand to three, four, or more, and see what the client response is. Closely monitor your client visits from clients receiving reminders. Some practices may find that one is enough, whereas others may find that they need more than that. If general feedback becomes negative, then it may be time to scale back by a touch or two.
 Methods of touching
Magazine  
E-mail 
Newsletter 
Phone call 
Twitter 
Postcard 
Facebook 
Letter 
Text message 
Other 

“The most common way of reminding clients of appointments is, of course, a reminder postcard,” Dempsey says. “Many practices also call, text, and/or email clients a day or two before a scheduled appointment. Diversifying your communications with a client ups the chance that the client will comply with the scheduled appointment.”

4. Automate your reminders …
Your practice is busy, and it’s not always easy to find time to send reminders. Automated communications allow you to set your coming-due and past-due communications (emails, postcards, thank-yous, birthdays, etc.) at one time and feel confident that the work is being done for you. A well-run practice should send reminders for appointments,immunizations,preventive measures, refills, birthdays,, grand openings, open houses, and, of course, “we’ve missed you” notes to those clients who’ve seemed to disappear.
5. … But stay in control of your client communications
Easy-to-use automated communication software solutions are great, but make sure you’re still in control of your message, Holihan says. Know whom you’re communicating with and be aware of your service reminders. One best practice is to review your communications list weekly and make appropriate changes in your practice management system.
6. Communicate your unique brand
Make sure that you partner with a software service that conveys a professional look and feel for your practice—including your name and your practice’s logo. That branding should be on all reminders—both electronic and paper—to create brand recognition among your clients. Bring that branding over to your Facebook and Twitter reminders to create even more awareness.

7. Speak directly to your clients and their pets
Use a service that includes the names of your clients and pets in all aspects of communication. Dempsey says most software packages do this for you. It helps keep your relationship with clients personal and allows you to send your reminders directly to Sparky.
8. Make sure you respond
If you receive client correspondence, make sure messages go to an email account that is checked often, Holihan says. Some practice management software download emails directly into the system. If you don’t respond to your clients, they’ll assume you don’t value them or their pets. If correspondence lands in the management software, you can always go back and check on client concerns when sending out reminders. If some clients are concerned about fleas, when flea season rolls around, send them postcards reminding them to visit.
9. Personalize to cut through the clutter
Dogs should get dog cards, cat should get cat cards. Connect with your clients by creating a multi-channel communication plan with coordinated postcard, email, and social media templates. Communications materials that reflect the seasons and holidays is one great way to stand out.
10.Always send a personalized thank-you after a visit
Email makes this easy, and it helps you tout the value of your services. “I would always include details for their next appointment,” Dempsey says. “For example, ‘Thanks for coming! We look forward to seeing you again on December 3rd!’” These 10 suggestions might take a bit more time and effort, but they can create better compliance on appointments 


has a lot of have tos

TASK #1

Spend 5,000 years going back and forth with clients to schedule appointments, reschedule, and then reschedule again.

TASK #54

Wish on the closest shooting star your client actually pays their invoice on time (and their credit card clears) after their session…unlike the last guy.

TASK #485

Nervously stumble through that first client call since you meant to send them an intake form–but then the phone rang, the dog barked, the emails poured in, and it didn’t get done.

AFTER


Well, that’s the want toway of working.

TASK #👍

Book more clients, get paid on time, and automate & organize with the right tools on your utility belt.

Wednesday, October 02, 2019

Now if I want to step out for 20 minutes I need to send in a requisition 14 days in advance

Central scheduling office saves money and time while scheduling fair work shifts


Now if I want to step out  for 20 minutes I need to send in a requisition 14 days in advance !


Meeting staffing demands and ensuring a hospital has the right personnel at the right time can be a difficult task. However, Bryan Medical Center in Lincoln, Nebraska developed a unique way to meet the challenge. The central staffing office uses Cerner Clairvia℠ Staff Manager and Demand Manager in a central scheduling office to save time and address scheduling issues.
Cerner Clairvia allows Bryan employees to project staffing resources, as well as create and manage schedules for the medical, surgical, intensive care unit (ICU), neonatal intensive care unit, labor, delivery, emergency and nursing departments.
“Staffing is such an important part of the day-to-day function of the units, and to have the support of the central staffing office is beneficial. The staffing office knows the resources available throughout the organization.” 
– Angela McCown, BSN, RN, orthopedic/trauma and medical surgery oncology nurse manager, Bryan Medical Center

How Dictators Come To Power In A Democracy

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How Dictators Come To Power In A Democracy

English: Portrait of Adolf Hitler.
Adolf Hitler. (Photo credit: Wikipedia)
Dictatorships are often unexpected.  They have arisen among prosperous, educated and cultured people who seemed safe from a dictatorship – in Europe, Asia and South America.
Consider Germany, one of the most paradoxical and dramatic cases.
During the late 19th century, it was widely considered to have the best educational system in the world.  If any educational system could inoculate people from barbarism, surely Germany would have led the way.  It had early childhood education -- kindergarten.  Secondary schools emphasized cultural training.  Germans developed modern research universities.  Germans were especially distinguished for their achievements in science – just think of Karl Benz who invented the gasoline-powered automobile, Rudolf Diesel who invented the compression-ignition engine, Heinrich Hertz who proved the existence of electromagnetic waves, Wilhelm Conrad Rőntgen who invented x-rays, Friedrich August Kekulé who developed the theory of chemical structure, Paul Ehrlich who produced the first medicinal treatment for syphilis and, of course, theoretical physicist Albert Einstein.  It’s no wonder so many American scholars went to German universities for their degrees during the 19th century.
After World War I, German university enrollment soared.  By 1931, it reached 120,000 versus a maximum of  73,000 before the war.  Government provided full scholarships for poor students with ability.  As one chronicler reported, a scholarship student “pays no fees at the university, his textbooks are free, and on most purchases which he makes, for clothing, medical treatment, transportation and tickets to theaters and concerts, he receives substantial reductions in price, and a student may get wholesome food sufficient to keep body and soul together.”

Today In: Opinion
While there was some German anti-Semitic agitation during the late 19th century, Germany didn’t seem the most likely place for it to flourish.  Russia, after all, had pogroms – anti-Jewish rioting and persecution – for decades.  Russia’s Bolshevik regime dedicated itself to hatred – Karl Marx’s hatred for the “bourgeoisie” whom he blamed for society’s ills.  Lenin and his successor Stalin pushed that philosophy farther, exterminating the so-called “rich” who came to include peasants with one cow.
Why, then, did the highly educated Germans embrace a lunatic like Adolf Hitler?  The short answer is that bad policies caused economic, military and political crises – chow time for tyrants.  German circumstances changed for the worse, and when people become angry enough or desperate enough, sometimes they’ll support crazies who would never attract a crowd in normal circumstances.
Like the other belligerents, Germans had entered World War I with the expectation that they would win and recoup their war costs by making the losers pay.  The German government led their people to believe they were winning , so everybody was shocked when the truth came out.  Then U.S. President Woodrow Wilson gave a speech outlining his high-minded “14 Points,” leading the Germans to expect a peace negotiation.  But the British and the French – America’s principal allies -- were determined to avenge their losses, and vindictive terms were forced on the Germans.  They felt betrayed and humiliated.  Germany’s principal military commanders realized that whoever signed the armistice would be hated, so they resigned and let a civilian official sign it (he was subsequently assassinated).  As a result, the Weimar republic, Germany’s fragile democracy, was immediately discredited.
Hitler was among those agitating against the Weimar government.  He joined the German Workers’ Party that, in February 1920, became the National Socialist German Workers’ Party (NSDAP) – later shortened to Nazi.  It offered a witches’ brew of nationalism, socialism, anti-Semitism and anti-capitalism.  The German historian Oswald Spengler influenced early Nazis with his idea of “Prussian socialism.”
Hitler’s main talent seemed to be as a speech maker, so he began giving speeches that appealed to Germans embittered and disillusioned by the outcome of the war.  He denounced Jews, capitalists and other alleged villains, vowing to rebuild German greatness.
Historian Ian Kershaw observed that “Without a lost war, revolution, and a pervasive sense of national humiliation, Hitler would have remained a nobody.”
Then came the inflation crisis.  Victorious Allies demanded that Germany pay steep reparations, apparently without giving much thought about how the Germans would get the money for that. Trade restrictions made it harder for German companies to earn money through exports.  European tariffs generally tripled and were as much as 800% higher than prewar levels.
The German government defaulted on its reparations agreement.  Determined to extract reparations from the Germans, in January 1923 the French sent troops into the Ruhr where much of German industry was located.  The German government responded by subsidizing those who pursued passive resistance against the French.  Consequently, German budget deficits soared.
By itself, reparations would have been daunting, but Germany also had a financially stressed-out welfare state.  Almost 90 percent of German government spending went for a big bureaucracy, social programs, money-losing nationalized businesses and other subsidies -- a portfolio of obligations uncomfortably familiar to us.  The German government subsidized municipalities, much as U.S. states are begging the federal government for bailouts now.  Germany had a troubled government-run pension system like our Social Security.  The German government provided health insurance for millions of people.  There were German government programs for 1.5 million disabled veterans.  The government lavished subsidies on the arts.  There were government-run theaters and opera houses.  Government-owned railroads lost money.  The German government even operated factories producing margarine and sausages, which lost money.
The German central bank began printing stupendous quantities of paper money to pay for all this.  At the peak of the inflation in late 1923, only 1.3 percent of German government spending was covered by tax revenue.  The result was that in less than five years prices soared 100 billion-fold.
Inflation harmed everybody to one degree or another.  Many bank deposits were devalued to nothing.  Historian Gerald D. Feldman reported that gangs of unemployed coal miners plundered the countryside, because farmers refused to trade their produce for worthless paper money.  The government enacted rent controls that limited the ability of landlords to recover their costs and discouraged developers from building more apartments.  So cities borrowed from foreign lenders to build housing that lost money.  Libraries and museums couldn’t maintain their collections because of inflation.  Much scientific research became financially impossible, too.
Historian Konrad Heiden reported, “On Friday afternoons in 1923, long lines of manual and white-collar workers waited outside the pay-windows of German factories, department stores, banks and offices.  Each received a bag full of paper notes.  According to the figures inscribed on them, the paper notes amounted to seven hundred thousand or five hundred million, or three hundred and eighty billion, or eighteen trillion marks – the figures rose from month to month, then from week to week, finally from day to day.  People dashed to the nearest food stores where lines had already formed.  When they reached the stores, a pound of sugar, for example, might have been obtainable for two million marks; but by the time they came to the counter all they could get for two million marks was a half-pound.  Everybody scrambled for things that would keep until the next pay-day.”
People employed in the private sector were enraged when unionized government employees – who carried out the government’s disastrous economic policies -- succeeded in having their salaries pre-paid, so they could convert the currency into goods before the currency depreciated further.  The publication Soziale Praxis reported: “It seems significant to us that public opinion is now gradually turning against the civil service to an extent that gives great concern.  How much hostility is daily directed against that portion of the employed German people with civil service status is shown by the press and also even by those parties which previously supported the civil service and now press for a reduction of the civil service.”
Hitler gave speeches appealing to those he called “starving billionaires” who had billions of paper marks but couldn’t afford a loaf of bread.  Altogether, during the inflation, Hitler recruited some 50,000 Nazis and became a political force to reckon with.  Economist Constantino Bresciani-Turroni called Hitler “the foster child of the inflation.”
To be sure, he attempted a coup that failed (November 8, 1923), and he was imprisoned.  But he retained his key followers and wrote his venomous memoir Mein Kampf that became the Nazi bible.
During the late 1920s, the German economy began to recover, and there was less interest in the Nazis.  In the 1928 Reichstag (legislature) elections, they won only 2.6% of the vote.
If good times had continued, Hitler might have been forgotten.  He needed another crisis for a shot at gaining political power.
The crisis came as a succession of misguided policies created obstacles to enterprise and brought on the Great Depression.  The government promoted deflation.  It fixed prices at above-market levels that discouraged consumers from buying, and it fixed wages at above-market levels that discouraged employers from hiring.  Government-sanctioned cartels restricted competition.  High taxes made it harder for people to save and invest.  High tariffs throttled trade.  When German producers were able to export goods, they had difficulty collecting payment because of exchange controls.  All these policies made it harder for the economy to grow.
Moreover, German banks were vulnerable, since they hadn’t fully recovered from the inflation that had wiped out a substantial portion of their capital and left them dependent on short-term foreign deposits that could be withdrawn.
As the number of unemployed went up, more Germans voted for the Nazis, and the number of Nazi members went up again.
Hitler maintained non-stop agitation for power.  He travelled constantly, giving speeches throughout Germany.  He wanted his opponents destroyed, so he demonized them.  He accused them of being traitors.  Two Nazi paramilitary organizations, the S.A. and S.S., launched bloody attacks on his opponents.  This attracted more thugs who liked violence and were good at it.
Every night, there were Nazi rallies and marches. Hitler’s henchmen promoted him by publishing a Nazi magazine, distributing Nazi records and promoting Nazi movies.
They became the largest political organization  in Germany, and by January 30, 1933, with the help of a little blackmail, Hitler emerged as Germany’s chancellor – the head of government.  He proceeded to consolidate unlimited power before anybody realized what was happening.
We should understand that Hitler didn’t take over a small government with an effective separation of enumerated, delegated and limited powers.  He took over a large welfare state.  It had been created by the autocratic chancellor Otto von Bismarck, it expanded rapidly during World War I and gained total control of the economy.  War-related private businesses were turned into government bureaucracies.  The government shut down private businesses that officials considered unnecessary.  There was forced labor, and nobody could change jobs without government permission.  For the first time, this “war socialism” showed the world what a socialist economy would look like, and it became a model for Lenin and other communist theoreticians.  The Allies directed the dismantling of the German war machine, but a government-run economy substantially survived.
Although Hitler echoed Soviet-style central economic planning with a Four Year Plan, his method was suffocating regulation rather than outright expropriation.  There was nominal private ownership but government control.  He dealt with unemployment by introducing forced labor for both men and women.  Government  control of the economy made it virtually impossible for anyone to seriously threaten his regime. Hitler added secret police, death camps and another war machine.
The German educational system, which had inspired so many American progressives, played a major role in all this.  During the previous century, the government grained complete control of schools and universities, and their top priority was teaching obedience.  The professorial elite promoted collectivism.  The highest calling was working for the government.  In 1919, sociologist Max Weber reported that “The honor of the civil servant is vested in his ability to execute conscientiously the order of superior authorities.”
Lessons for us today:
  • Bad economic policies and foreign policies can cause crises that have dangerous political consequences.
  • Politicians commonly demand arbitrary power to deal with a national emergency and restore order, even though underlying problems are commonly caused by bad government policies.
  • In hard times, many people are often willing to go along with and support terrible things that would be unthinkable in good times.
  • Those who dismiss the possibility of a dictatorial regime in America need to consider possible developments that could make our circumstances worse and politically more volatile than they are now – like runaway government spending, soaring taxes, more wars, inflation and economic collapse.
  • Aspiring dictators sometimes give away their intentions by their evident desire to destroy opponents.
  • There’s no reliable way to prevent bad or incompetent people from gaining power.
  • A political system with a separation of powers and checks & balances – like the U.S. Constitution – does make it more difficult for one branch of government to dominate the others.
  • Ultimately, liberty can be protected only if people care enough to fight for it, because everywhere governments push for more power, and they never give it up willingly.
Jim Powell’s next book will be "The Fight For Liberty, Crucial Lessons From Liberty’s Greatest Champions Of The Last 2,000 Years."  He’s a Senior Fellow at the Cato Institute.