Just the other day the children and I had just finished reading / studying the book “The Native American Experience” by Jay Wertz. We read this book as part of home school American history studies.

    Now I grew up when westerns were still very popular, John Wayne was always helping the U.S. Calvary fight the wild Indians and it was common to play cowboys and Indians with everyone wanting to be the cowboys because they were the “good guys”! This very well documented book looks at the colonization to modern day (or occupation) of the Americas from the standpoint of the Native Americans. A viewpoint that I must admit I never looked at before and I know was never taught when I was in school. To make a long story short many of the American Natives welcomed and helped the colonialist ((aka: 1^st Thanksgiving. . .) but slowly the tide turned. The natives for the most part were an integral part of the whole territory, not really staking out parcels to call their personal property. It seemed they exhibited a greater appreciation for the earth and were deeply spiritual, although they believed in the Great Spirit versus God or Christ.

    This lifestyle of being closer to the earth with freedom to roam caused problems for the more possessive colonials that wanted to own land, build permanent towns, roads. . . Now, how can you get land from people that don’t “actually“ own it? – typically you trade something for it, or make a promise / treaty for it (then break it when “more” was wanted) or fight / kill and take it. After all, these natives are so ignorant, then don’t know how to use the land, create governing bodies and they don’t even believe in God.  

    As the natives lost more and more, there was seen the need to assimilate these people into the civilized ways of life, teach them to read, write English, learn to farm / ranch / build and to accept God / Jesus as their religious leader.

    Over time, most assimilated and adapted completely, some adapted while still holding on to some of their traditions and beliefs, some assimilated so successfully to the point of learning way s to help their people economically prosper via casinos . . . which some traditional tribal councils still do not fully approve of. These natives have adapted and now have truly become one of “us” but after all this history / retrospective what have we learned. Were the colonialist “right” or should the assimilation and adaptation gone in the opposite direction? The direction that the naturalists, tree huggers, green movement . . . are trying to lead people back to. . . as children of the earth? We know and have to admit that the “civilized people of the world” have radically changed the earth more than any other creatures ever in existence and maybe not, in all cases, for the better.

    Next, as I reflected on this overall history lessons learned, I looked at the way our bodies work coping with life, viruses and diseases. The mind / body / spirit typically start out as one in-balance entity then over time one part or more create self-centered drifts. The spirit seeks enjoyment, power, money and therefore the mind craves sweets / questionable foods as a reward or as a way to cope with the stress associated to spirit’s quest and the body assimilates / adapts accordingly. When a virus or disease enters the body there is an initial resistance but slowly the aggressor (“colonial” aggressor in the case of cancer) selfishly imparts itself on the natives to accept, assimilate and adapt till the natives are defeated (dead!) or the aggressor is reluctantly over-taken.

    I know many may not see this analogy correct, useful or even interesting and that’s the way life is – full of diverse opinions and influences, from the smallest organisms to the largest civilizations / continents. I guess my biggest point is maybe, just maybe, sometimes the paths that are taken in life are not the fairest, wisest or most beneficial in the long run and maybe there is a way we can and should learn from history / life and not just learn about it. Just learning about history – well - there’s no future in it!

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Assimilation and Adaptation - http://goo.gl/8jK5k

While on a nice extended family vacation that ended just a couple days ago, my thoughts wandered to what would be a good topic for the next blog. It is amazing the answer our creator provides! Not only offering a topic but providing the content that is just too good (and truthful) not to pass along. There was even the request to pass this obituary on!

Found this while waiting for our lunch order at a restaurant one day and looking at the "Mountain Lakefront & Rural Property Guide (Charleston, TN)" to pass some time. Here is the reprint, in it's entirety: 

Author Lori Bergman

First published in the Indianapolis Star 3-15-98"

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OBITUARY - COMMON SENSE has passed away! - http://goo.gl/Sm0zW

        In this blog I am going to definitively answer the philosophical question of is there an after-life or life after death!  - Just kidding!

        As an emotional tough 2011 for me, my family and close personal friends comes to a close I hope to make this 3^rd blog pertaining to my observations of health ó death my last, at least for a while.

        In the 1^st blog ( Funeral Arrangements – A Health Changing Experience!  -  http://goo.gl/WJHx8 ) it reveals a lot of hidden details and costs that surround a loved one dying, the arrangements, under much sorrow / stress, that need to be followed up on and some suggestions on what can be done while alive to help make that time of passing less painful for the one’s left behind.

        The 2^nd blog (A Fine Line Between Quality of Life (Lifestyle Standard) and Quality of Health?! -  http://goo.gl/vKTRX ) concerns loving family / caregiver decisions / persuasions to keep their loved one healthy and happy as possible, ultimately who makes the final decisions and, in reality, where should this health concern / training actually start.

        NOW, on to "is there life after death" but NOT as it concerns the person who has passed away but as to those close loved ones that are left still here, alive above ground, on earth. It has been interesting to see the full gamut that this life after death takes, ranging from “very quickly moving on / starting new and fresh” to “feeling guilty – responsible for what happened” to “kinda sitting around waiting for their time to go” and all points in-between.

        It all starts after the funeral reception is over and everyone has to return to their regular routines, of course these are changed for those that are very immediate family to the deceased. When everyone goes home and it’s the one, two or few that are left! Toughest will usually be on the “one home alone”. Initially they can stay active taking care of the gifts, distributing / watering the flowers and arrangements, paying the related expenses, writing the thank you notes, going through / dealing with the personal affects. . . There will be personal times of memories and sadness / tears and this is a normal part of life but the holidays / regular family get-togethers can be pretty rough as well.

        It’s how one proceeds from here, the choice they make that determines if there will be life after death. I have seen in one instance the “thank you” cards for attending and/or “giving in memory” were sent out the day after the funeral and the personal effects sold / donated within the month (not cruel but these things needed to be done and this person is just not a procrastinator). Then adjusting to, in this case, single life again. Started fixing some things around the house, chores like grocery shopping, watching TV, all which were normal activities before as well. Suggestions for activities outside the norm were made, like joining senior groups or volunteering but that has not been accepted yet.

        In another case, one of my cousins died last year from cancer and her husband sent us a picture collage Christmas card that tells of his upcoming retirement in April, shows pictures of his pilot training / flying, his “new” co-pilot and describes his plans to go spelunking (I have to look up what that is) in Carlsbad Caverns, hiking to the bottom of the Grand Canyon. . .! In an odd way is hard to see someone move on after a loss of “my blood” family member but actually I am very happy for him. It’s life / it’s learning to live again / it’s life after death.

        All life after death experiences are different as the individuals involved are and that not bad nor good, it’s again the way life is so richly meant to be – the good with the bad - sad versus the happy. . . The greatest concern I really have is seeing some grieving individuals slip into a state of depression and, if there is to be a lesson in this blog, it’s praying / reminding the caring friends / loving family members to be there to support / believe in this person / these people through this very important time of transition.

        There can be life after death and sometimes being there, even if it’s inconvenient sometimes, can make all the difference in both or all your lives.

        I wish everyone the happiest holiday possible and prosperous happy new year. 

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Is there Life After Death? - http://goo.gl/owfIi

                This past year my family and I have been having a rougher one than the last few. Mother-in-law passed away, another close friend of my wife’s, her husband had also passed, my wife’s cousin’s spouse’s mother passed, my lifelong friend had a heart attack / quadruple bypass and the rest of life’s unending other problems kept just getting in the way.

                A whole lot about life, and death, was learned during this time and probably the one lesson that was and still is the most challenging is “how far/hard does a loving caregiver / family member / friend  “push” or try to encourage the one with health concerns to improve their health habits?”

Looking back, this is of course easy now – as your seeing everything 20/20, the mother-in-law had congestive heart / renal failure and was 90 years old and not too much realistically could be done to improve her condition. Yet we saw her a few months before enjoying her birthday cake, playing with her grandchildren on her lap, conversing / playing cards with everyone and then a "just short few months later", she was tired all the time, strenuous for her to just walk around the house and steadily losing weight (and truthfully, interest in life). After a short hospital stay that seemed to improve her condition a bit we tried to get her to eat more to put on some needed weight, drink more water, tried having a physical therapist come to the house to build up her strength. . . but it seemed everything we were doing made her more upset. Despite all our efforts and medical miracles, she passed away within two weeks of that last hospital stay due to a combination of complications she had – in other words, old age.

                My wife’s cousin’s spouse’s mother passed, she was 92 years old, diabetic, had numerous health issues and complained over the last several months about stomach pains. They gave her meds that were to help soothe the stomach that they thought might be a side effect of some other meds she was taking but they didn’t help. Finally, an MRI scan showed she had cancer terminally throughout, prognosis was 2 to 3 months but she lived, with hospice care also being provided, only 12 days after she was informed of her condition. She loved “Three Musketeers” candy bars, homemade cakes and pies but being diabetic she “wasn’t allowed (as long as she didn’t get herself caught that is!)” to enjoy them, even to the end - again, seeing everything 20/20 now!

                My wife’s close friend’s husband (age 87 energetic years old) was kinda not as easy of a decision to make but seeing 20/20 now it kinda looks different. He walked into the hospital for a 5-way heart bypass (didn’t even know they could even do that many bypasses!) and came out of the operation just fine, except he had a hard time breathing on his own. This condition was supposed to improve but finally after over two months of no breathing improvements but a worsening physical condition from being bed-ridden so long, the decision (his living will request) was made to “pull the plug” with his family in bedside attendance. Tough call as “we” always hold out for every possible hope for the one we love.

                My best friend (in his 60’s) made out the best of the bunch. He went in to the hospital one morning for a scheduled hernia operation, complained about chest pains and was diagnosed as having a heart attack. Long story short, a week after being admitted he had a quad heart by-pass and after a couple weeks of rehab is on his way back to recovery. Amen and praise the Lord! Now the tougher part, he is pure Polish heritage, just like me, and the traditional foods we love, well, it’s not the best for a person with heart and/or high blood pressure (that’s me) conditions. Stuffed cabbage, kielbasa w/ sauerkraut, borsch. . . is it really “living” without these delicacies? Not being able to make the deer season opener this year was enough of a heartbreaker!!! The fine line between lifestyle and health gets a little grayer, even though logic (loving caregivers / family / friends too) dictates this “reckless” way of life has to stop.

                Then the line gets blurrier still!!! What about the “healthy” smoker, knows they should quit but it’s been a standard part of their lifestyle for a major part of their life and. . .

Or the person who slowly steadily, since early childhood, increased their weight over the years to the point now that it is or could very well soon to be affect their health / mobility. . .

What about couch potatoes that just love to play (“addicted to!”) video games or sit around and watch TV?

Hmmm - lifestyle or health – who makes the choices, who ultimately chooses and sometimes it’s who ultimately “pays” (time / effort / dollars / stressful decisions) too? Lifelong learned / adopted habits are sometimes “loved” by now, integrated parts of the standard of life and are very hard to mentally and physically break!

I guess looking at / thinking about these examples and millions more, it seems the quality of lifestyle can have a major impact on our present / future health – “duh” – common sense! Caregivers / family / friends do all they can to help and support getting their loved one healthy again but where does this “concern” really have to start? Well, where does learning our lifestyle start? Doesn’t it really start at home as a child in the examples the family/caregivers set, the “health” lessons that are taught by family or through schooling, the friends that are kept, places travelled. . .? This is where they get their SOL (Standard Operating Lifestyle)!

Logic dictates what lifestyle changes we should be making for ourselves – yea yea, I need to lose some more weight, exercise more (actually have to start again – uggh), and watch out for that Polish food – uggggggh – and I know it is not easy to do. I have to thank the Lord I never started to smoke! What has made/is making these changes significantly easier for me is realizing I am establishing the SOL for my children, family, friends and improving my own health in the process – a double bonus!!!

There will be other stressful / confusing “life” decisions I know I will have to make for / with others, that’s just a part of life itself. But I know I will have a comforting feeling deep inside myself that concerning myself, I helped create, from the start, a healthier SOL, not so much for myself but for the one’s I love. BTW, I have my “Living will” and “final arrangements” documented too.

This past Halloween the family went to the TurtleBee Farm Harvest Party rather than the traditional trick or treating the neighborhood. We ate relatively healthy food that we all brought to share (chili cook –off too – high in fiber!), chatted and sang songs around the campfire, went on hay rides, played games including soccer (Kids got plenty of exercise as did I but I was a little sore the next day  =];-/ ), learned about bee keeping and topped it off with a home-made pie tasting contest! OK, the pie contest maybe wasn’t the healthiest part but it was done in moderation and I believe it was a better compromise – lifestyle versus health - than eating those bags full of candy!

How about you? Ready to get on board a healthier SOL train?

BTW, Just recently my wife and I saw the movie: “Courageous” and if you haven’t seen it yet, we highly recommend it. Fathers (police officers mostly) taking, no, committing to responsibility, real responsibility to properly raising their sons / children. Plenty of great lessons on how much impact you / a parent can have on a child’s life! Bring Kleenex!

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http://goo.gl/vKTRX - A Fine Line Between Quality of Life (Lifestyle Standard) and Quality of Health?!

    Long long ago a local town or tribe, the local doctor or Shaman . . . knew who their patients / people were and they were the only source for medical attention – really no need to keep medical records because it was stored in their memory!

    Later, with more people needing to be cared for, it lead to less personalization and “paper” needed to be kept on each patient just to “keep the record straight”.

    Today it’s more and more people being cared for by fewer doctors but in some cases, attended to by multiple referred-to specialists that may be working out of multiple hospitals and paper records just can’t seem to keep up with the need for collaborative medical information.

    Technology now allows us the opportunity to digitally record ALL this medical information / opinions and store it either on-line or a backed-up practice office server or a memory stick / device or all / any combination or bits and pieces in multiple locations as with different doctors, specialists, hospitals. . . that are using different EMRs.

    Now let’s complicate this situation even further! With these records now being in digital format it makes telemedicine consulting feasible with expert specialists virtually anywhere around the world. This global medical consulting “out-reach” can then actually fuel medical tourism which can potentially spread a patient’s medical treatment/records out even further!

    As a side note, I am not even going to touch on the data security controversy that surrounds all this medical data that is potentially out there and how it could be used or misused! That could be a whole other blog or even series of books!

    OK, so now we have all this medical data out there but how do we address all these multiple portals / storage devices / locations (maybe paper still). . .in a way there is an easy quick process to find the “pertinent” medical information for a situation or emergency at hand?

    When I was employed for a large automotive OEM, a project I was the lead on was how to manage most of the corporation's digital assets, from pictures/images to video presos to documents / PowerPoint decks. . ., so that they could be mined for the pertinent information and re-used / re-purposed by properly authorized individuals. 

    This project took many years to just get off the ground, there was a need for a centralized "metadata - pointers" database but beside the shear logistics, all groups did not want to give up control / info even if that was to their benefit. Note here, the corporation finally settled on three Digital Asset Management (DAM) products to use with "discussions" about settling on to one, that was before I retired a couple years back. The company has since been purchased by another company and I have lost track of the project's progress or lack of. 

    I unfortunately see EMRs / patient portals. . . following a similar path and the in-fighting, sorry, I meant - "political/economic resistance" may actually prevent it from happening in my lifetime BUT I hope and pray I am wrong. 

    My mother-in-law had a Primary Care Physician (PCP), several specialists and three hospitals (one hospital is still with paper records without an EMR in the works to any of the workers knowledge) and, currently, just record gathering was a nightmare! 

    In a perfect world, all a patient’s medical records, or at least the metadata pointers, would be in one database location and this information could be searchable to drill down to only the important pertinent data relating to the situation at hand (provided that accessing person had permission to access all those records too – HIPPA issues here for sure).

    In a semi-perfect world there would at least be a single sign-on portal that would link all a patient’s portals / stored records in one website so a properly authorized person could access those records and be able to search out meaningful / pertinent medical information for the situation at hand.

    Fortunately, or unfortunately, for today we can create our own Personal Health Records (PHRs) that we can place the digital and/or scanned information into, either online or on a personal storage device (or both). It can contain the information that could save your life in an emergency but the main drawback is, IT CAN BE A LOT OF WORK to assemble!!! Then how does one prioritize and organize the data so the most important / pertinent data shows up easily / quickly “first” and all the rest of the “supporting data” is still in there but doesn’t clutter up that important “first” stuff?

    So let me pose these questions to all of you that have read down to this point thus far:

1. What do you feel would be “all” the important data / information, medical or otherwise, that one should have on a PHR card or online PHR database?
2. Where do you feel, and are comfortable with, that this data should stored? Memory card / stick? CDs? On-line PHR service or portal? Papers in a folder / binder? Any or all of the combinations above?
3. What do you believe should be the “first read – most important” information that should be on a PHR card or online database?
4. Should some of the files be password protected while others should not (What if you are unable to relay or put-in a P/W during an emergency)? If yes to P/W some, what files should be protected and which should not?
5. What ideas/thoughts do you have for your medical records access policy? IE: any doctor / nurse / medical professional. . . can access all of them? Only my PCP and maybe specialists that I have a HIPPA agreement on file with (but what if you were traveling?)? Or???
6. How old should the records go back to or should all / some of the records go “all the way back” and what should the criteria/reasons be for that record retention policy?
7. What file formats do you feel these files should be stored as?
8. What’s your thoughts on those proprietary x-rays, CT scans, MRIs. . . files/viewers that come loaded on the CDs you can received as part of your “requested” medical records?
9. Should all these files be searchable? If yes, through what means / product(s)?
10. Any other thoughts or ideas you have that would make a PHR (YOUR PHR) more useful in case of an emergency or even for a “new patient” doctor visit?
    
    

    Please contact me (PEndrasik@GreenSmartLLC.com) sharing your answers, thoughts, opinions, further questions and ideas concerning this blog and it’s open questions. Thank you in advance for your participation.

    In the meantime, I/we at Green Smart Consulting LLC will work with folks to help pull their PHRs together in some logical sequence of importance because "when seconds count – important information cannot afford to be found minutes away". 

From Not Having the Information THEN Too Much Information? - http://goo.gl/VOKT9

It was a tough “weekend plus” to say the least!!!

Katie – She was my wife’s (and her brother’s) 90 year old wonderful mom, my father-in-law’s beloved wife of 64+ years, my sweet mother-in-law, brother's wife too, “loved tooo much” grandmother of our two 7 year old children/ wife’s brother’s two girls, beloved relative and dear friend of so many many more, passed away from old age in her home on Friday August 26^th, 2011 with family at her bedside.

She is at peace with the Lord but that’s when the hell-on-earth started for the loved one’s left behind!

After the initial shock ended, reality set in and next steps needed to be taken, it was who do you call now or what do you do? It started with a call to the funeral home who informed us they needed a number from the medical examiner before they could come to pick her up – call the police - 911.

Police were called but paramedics, lights flashing and all (uncalled for we felt), were required to arrive first to connect the EKG. . . to confirm death. They were met after a few minutes by police and the officer received the paramedic’s report, but still had to check the body for “foul play”, placed an emergency call to the family's PCP to see if she would sign the death certificate (otherwise the county medical examiner would have to become physically involved). The PCP called back, thankfully rather promptly, agreeing to sign the certificate so a (police) call to the medical examiner produced the number to provide the funeral home. Note: if she were in the hospital or being attended to by hospice, much of this police work would not have been necessary. The officer then waited at the house to verify we were calling the funeral home to arrange pick up.

The pick-up was done by two well dressed men who closed the bedroom door to discreetly placed mom’s body in the body bag / on the gurney – this was a considerate action. She was taken away in a minivan with no commercial markings and this was appreciated as well.

THEN, there was the pressure to come down to the funeral home to make the gut-wrenching final arrangements! “Come down tonight (few hours after her death) if possible or first thing tomorrow morning!!!”  We felt, AKA: need to decide quickly while the emotional quotient is at it’s peak! The family opted for the next day and then, next morning, it was two plus hours of picking out the casket/ vault (from plain, which they didn’t have on display, to waterproof / virtually gold-plated). . . Smooth comforting talk while the dollars add up and up and you show respect for your loved one!!! Hmmm, maybe it’s just me but personalizing the vault who no one sees except the grave digger? Additionally surprising, somewhat even above most of the rest, a deceased’s noble gesture of “donating tissue” is an additional ($250) charge tacked on to the embalming fees (was not applied in this case but I did notice on the extensive price sheet!)! So be aware, if there is a thought / idea of it, there seems to be a standard charge for it. The funeral arrangements (choices) made this time could be considered average for a “traditional” church funeral.

The cemetery BTW required the gravesite “opening / closing” fee by cash or check ($1200+) by the day of the funeral – guess they were scared they might go in the hole – lol!

Flowers need to be chosen too, might as well get it done before stopping for some needed, but not really desired, nutrition.

OK, worst part over, only two more arrangements before going back to the house to gather pictures / memorial items for the upcoming visitation.

Off to the church to schedule,  arrange the mass and surprisingly there was another hour and a half-ish for picking out songs, going over the Standard Operating Procedures (SOP) for the funeral mass and understanding the fees (organist. . .) and donation expectations.  

Last on the list, restaurant reservations for the gathering of friends and family after the funeral. Picked up a banquet menu from the restaurant on the ride home (was also available on the web, if desired/needed) and after making a relatively easy decision, a simple phone call completed that task. That was the most painless / almost least expensive of the arrangements!

The rest of the evening and part of the next day was spent on trying to relax a bit, going through old photo albums, reminiscing and creating the photo memory boards for the funeral home viewing.

The following couple days, a day of visitation/rosary and the funeral, were an indescribable emotional roller coaster followed with mental / physical exhaustion and restless sleep. Sadness, brought on by so many memories that rudely jolt us into the reality that this is the end of making more memories with this person that so dearly touched our lives.

We know there will be more of the tough moments ahead, choosing / buying the memorial stone, spending the times alone, the holiday gatherings, the paying off the funeral bills that are currently tipping a tad over $15K (yep that’s $15,000.00+ in a few days time) -  but that’s life (and death)!

The parents were/are really well prepared for this final episode in life considering all that was described above. They already had their cemetery burial plots chosen and paid for (note; this cost not included above), they have their “legal papers/ wishes” documented, the funeral home / church were/are pre-chosen, their obituaries were/are written (with appropriate blanks left open), clothing/ jewelry set aside, contact list made and their photo albums. . . are well organized.

So what does this all have to do with health and healthcare outside of the obvious emotional / physical strain that is enough to put some into cardiac arrest or an emotional/mental breakdown?

It’s about advance preparation of records / arrangements (not necessarily pre-pay but pre-arrange) before the event happens.

My Green Smart LLC team and I have been strong advocates of creating / maintaining Personal Health Records (PHRs) where your medical data is in one or two places, either on-line and/or a memory stick / card you carry with you, so when the emergency/medical situation/s happen there is the best, most complete medical data available to efficiently and accurately address / assist your situation – regardless of where you are or what you were doing before that time.

After this past experience, I’m believing final wishes / arrangements (funeral. . .) need to be part of an “enhanced” PHR record as well, especially if you are an organ. . . donor.

I now know for myself that there are further details in this area that I need to address ASAP and I, personally, do not want to be one that brings great financial / unnecessary “emotional decision-making” burden on those I love and will be leaving behind – Grief is tough enough! My wishes won’t be “guessed about or made under peak emotional pressure” as they will be pre-arranged for a “natural burial - http://www.michigannaturalburial.com/ ” first take what organs. . . are useful, place the rest in a cardboard box and bury me directly in a field w/o embalming or viewing. In lieu of flowers, please plant a tree in my memory! My final request will be to take some of the extra insurance money that there should be left and throw an open bar party reminiscing our good times we had together – my fill-in-the-blanks obituary, contact list and photo slide show will be on my PHR memory card! A toast! - Then I’ll see you someday on the other side!

One final point I feel I need to make clear and that is I really don’t carry any grudges, chips-on-my-shoulder or vendettas against funeral directors, cemeteries or related services / professions having been part of this experience. These are legitimate professions performing a needed service and they need to make a living like everyone else! I can only say it’s not a profession / philosophy I could feel the least bit comfortable doing! The biggest point / advice I am trying to make here is to be prepared before the emergency / rush happens, whether it is with creating your “enhanced” PHR / EMR connection, compiling a emergency plan/kit or any other situations where irrational / emotional decisions could unnecessarily be required to be made in haste.

Rest in peace Katie, you will always be in our hearts!

Poly A. Endrasik Jr.

Please feel free to email me if you wish to discuss PHRs or. . . further.

PEndrasik@GreenSmartLLC.com

Update as of 9/11/2011: Visited the father-in-law this past weekend and he brought up will, Power of Attorney (PoA). . . what is a Trust / what are it's benefits and it appears there may be further research, discussions and preparations there too for both him and myself / family. 

Have to have those documents done and somehow recorded (scanned /map storage location/s) somewhere on the PHR (maybe some info only saved on the "home" PHR stick but the Medical PoA info for sure on the wallet / mobile card!)

Funeral Arrangements – A Health Changing Experience!  -  http://goo.gl/WJHx8

How many times have we seen workflow and work process used almost interchangeably? Example: “When implementing an EMR, a doctor’s workflow will have to change” – versus – “When implementing an EMR, a doctor’s work process will have to change”. Well it seems to mean the same and if used in an article or blog intermixed you probably wouldn’t even pay any attention to it.

So how are these two term actually defined:

Wikipedia defines workflow as: “A workflow consists of a sequence of connected steps. It is a depiction of a sequence of operations, declared as work of a person, a group of persons, an organization of staff, or one or more simple or complex mechanisms. Workflow may be seen as any abstraction of real work, segregated in workshare, work split or other types of ordering.”

Wikipedia defines process (work process is not defined) as: “Process or processing typically describes the act of taking something through an established and usually routine set of procedures to convert it from one form to another, as a manufacturing or administrative procedure, such as processing milk into cheese, or processing paperwork to grant a mortgage loan.”

When you read the definitions they “kinda” look the same but I see a very significant distinction. A distinction that I see is important when assessing a medical practice for EMR implementation.

One key EMR implementation complaint that has been expressed by doctors is the  “workflow” has to change, sometime drastically to be successful with the EMR deployment. I agree process change occurs when an EMR is implemented but I believe the workflow should not have to unless it is viewed beneficial by everyone. I profess the work processes, which I see are subsets to the workflow, will definitely change!

A doctor will still see a scheduled patient, refer back to their files, whether they are using paper charts or electronic records, the doctor will still record the findings via pencil or keystroke / speaking. . . this is workflow and should not be required to change! The work process/es are what changes, paper and pencil are replaced by a tablet PC and may use speech recognition for documenting the visit and then move electronically into e-prescribing, billing, patient portal / PHR.

The key point that needs to be made here is the doctor has a great responsibility in providing the best treatment / care for their patients and should not be required to change their workflow if it works best for their environment but change only their work process/es to take advantage of electronic medical records.

Well, you may be saying, “hmmm, that makes common sense and is no big deal” but let me illustrate through one example we discovered during the physician interviews we conducted over the past year and a half. After several months of using a prominent EMR product, one doctor revealed to us that they were still using their paper charts to record information on the patient visit and during after-hours or during lunch or breaks entering the data into the EMR. WHY!!!! Several reasons were given, among them were the network was too slow (BTW: laptop was “verified as very fast!”) to keep up with the pace of the doctors, they didn’t have their old records scanned into the EMR yet so it was easier to just use the old system, typing took too much doctor face time away from patient, too many screens were required to re-enter the same data and it was difficult viewing on-line lab reports with the patient on the laptop much less having a printed copy to give to the patient on request.

So what happened here?

Process changes forced a change in workflow by adding to it. The added processes being EMR records being updated after the patient had left the appointment and the “new” data being taken off paper records which feeds another continued, unneeded process of continued maintenance / access of the paper records. This workflow did not have to change if the network was adequately capable or preloading of scheduled patient records were done locally and the short-term required strategic scanning strategy, possibly using outsourced resources, was implemented.

Another key “quality healthcare” workflow change (some would argue it is a process) is the reduced ratio of personal focused “face time” attention to the patient. The new process of “typing / computer engagement” now bides for the patient’s time and could justifiably provide a reason for the doctor to not give up the paper! Proper user-friendly templates and/or typing training and/or speech recognition could provide a good solution here.

If an EMR requires the same data to be added to different screens thereby adding cumbersome workflow steps and it cannot be reprogrammed otherwise then the fault lies with choosing the product that is not a fit for your practice. Sorry about that! Research, research, research and asking questions of friend / colleagues. . . versus just EMR salespeople, could have helped here.

Having done a proper infrastructure (hardware, software, peripheral. . .) assessment and training, as would have been done as part of professional managed project, would / could eliminate the difficulty of sharing electronic data with the patient.

Everything patient related could / should be done before the patient leaves the examination room and that’s the way workflow was done in the “old days” or less!

This touched the tip of an iceberg, there are more examples but the underlying premise is the work processes will definitely change but the workflow may not need to or will naturally change for the better. The amount of research, whether you do it yourself or use consultants, and the project management strategy you use or hire in will ultimately determine how successful your EMR process change-over will be.

Wow, what a life awakening experience!

This past year after falling from a ladder I had the experience of being taken to an ER at a large local hospital, admitted and then being transferred to another larger hospital’s neurological ICU section. Being involved on HIT (my company assists small practices with implementing minimally invasive IT, EMRs and business related products / process solutions) it turned out to be quite an education but because of the “health circumstances” I had it is a lesson I would never want to learn / experience again.

                So in a nutshell what happened is I was on a ladder about 7’ up, apparently fell (I actually to this day do not remember anything beyond being up on the ladder) and my wife, out of the corner of her eye, saw me fall. She dragged me into the house, onto the couch where I remained out for about 5 minutes and then we proceeded to our local large hospital ER where I walked in to get checked out. A CT scan showed I had a small bleed on the brain and a decision was made to transfer me to an even larger hospital that has a dedicated neurological ICU floor. The HIT person inside me asked if they were electronically transferring my EMR records / scan to the other hospital’s EMR system and they then stated they would fax the report there because their EMRs were incompatible. Figures!!! I later found out the first hospital was using C*****, the other one was using E*** and that also turned out to be a reason for a whole lot of duplicate questions being asked of me by countless numbers of healthcare pros- uggh, my head hurts!

                Ambulance arrived to take me to the next hospital and during the directions that my wife was writing down on how best to get to there a question arose of how I got to this first hospital, to which she informed them “I drove him here”.  I/she was surprised to hear a “non- appreciated” response of “you shouldn’t do that, that’s our job” – hmmm – somehow we missed reading that “rule”! Then the rest of the transport was uneventful.

                Arriving at the next hospital was met with scores of healthcare pros asking tons of questions, many repetitive from the other hospital, then scheduled for another CT scan before being taken to a room on their ICU floor. Finally a chance to get some sleep, my sweet wife slept in the chair next to me all night while a caring neighbor watched our children, but bright and early the morning were more health care pros, doctors, med students, new nurses coming on shift, blood drawers, deliverer of meds. . . asking more information or providing information of which I believe I remember hardly a 1/5^th. I do know there was a fair amount of questions asked concerning pre-existing conditions I had, meds / supplements I was taking and any / all drug allergies. When I finally did “wake up” (sorry, no coffee or food yet till they determined I didn’t need surgery – that came 2 days later) I asked my very kind ICU nurse: “Just what information would you say is critical for doctors to have when a person is admitted to ER, especially if unresponsive?”. She kindly gave me a short list which I committed to memory and promised myself to make it the “initial” part of my ICE (In Case of Emergency) PHR (Personal Health Record) wallet card / I-Phone too in case this ever happened again. Then my only concern will be is the health care facility going to be able to review it first and save me a ton of repetitive ER/ICU questions. 

                After 2 full days in ICUs, another (3^rd) CT scan the second day that shown no further bleeding, I was released to a room in the general section, my first hospital breakfast and COFFEE. I again was visited from early morning on by more doctors, med students, nurses of various types, blood drawers (which none could tell me any test results of previous draws – hmmm?) and nutrition support (brought the food trays).

                I guess I realize that all these health professionals have vital parts to play in patient care and I am truthfully not knocking them for that but as finally (hopefully not again) being a patient I really don’t know who I can call as my primary care doctor for this condition/stay that I can call or e-mail to answer any follow-up questions I may have. The head RNs were great and could check into the hospitals EMR information and print out some reports / answer basic questions (God love them – they were His / my angels) but they couldn’t answer “reason for certain medication” questions or “discuss CT scan results written in DReze”.  . . I did have the name of a doctor written on my board in my room but honestly I don’t remember actually meeting / talking with her – there were just so many professionals coming all times of day and night. I did have a Dr that I needed to follow-up with the following week (different than the name on the “board”) that I can’t remember meeting in the hospital. I had a neuro-medication prescribed by yet another person, not the filling pharmacist either, that was meant to prevent seizures that states under “Uses: . . . It is not known how it works to prevent seizures.” and I wanted to ask the doctor about that and why it is prescribed to me. This med also caused me drowsiness, dizziness and weakness (known / documented side effects) but my discharge instructions state to contact my personal primary care physician with questions if these side effects occur. My personal primary care physician (PCP) typically doesn’t specialize in this area, is not really familiar with this med and why it was prescribed so who do I call, the pharmacist, the person that prescribed it, the person who’s name was on the board or the doctor who discharged me (yes, this was yet another doctor) or my RN or ????  

                I know it is probably hoping for too much but wouldn’t it be nice (accountable) if when you were admitted to the hospital you were assign one (“1”) primary care doctor with maybe a resident / intern collaborator / back-up that would co-sign-off reviewing your scans, labs. . . and then during pseudo-regular daily scheduled rounds (so “the family” can be present if it warrants) these scans, labs. . . can be reviewed, with you, family and this 2 person doctor / team, on the computers that already are present in the rooms or maybe even projected on the patient’s room TV? Additionally wouldn’t it be nice (efficient) if this primary doc/ intern / resident team be the ones that ingest your ICE PHR information into their EMR, explain the meds, review diet recommendations (and why do you always seem to get overcooked veggies with hospital meals? – but maybe that’s just another future blog topic!), review with you / sign-off your discharge instructions, be the one/s you have follow-up appointments with, help coordinate the paperwork necessary to insure you have all the EMR e-records that are essential for you to have included in your Personal Health Record (PHR) as you leave the hospital, make sure you have their business cards, with contact info, to be able to e-mail them with follow-up questions and be the primary contact/s for your personal primary care physician to me able to collaborate with for your on-going care / treatment plan? Hmmm, must have been hit on the head to think that might someday come true. BTW, come to think of it, why doesn’t your personal PCP make hospital visits any longer? Hmmm, that must have gone the way of “house calls” too!

                As it stands today, is it truly possible too many docs. . . will spoil the patient care broth?

In 2000, a movie came out called “The Perfect Storm”, wow - almost 11 years ago now and still remembering it well! This was a sea-faring disaster film starring George Clooney, Mark Wahlberg and Diane Lane. In summary a small commercial 40-foot fishing boat, with Captain “George Clooney”, heads out of port one more time to prove they still have what it takes to bring in a respectable load of fish and make the money they need to live on. They venture out to some new waters and catch a boat load of fish but their ice machine fails so rather than wait out rough weather they decide to head back to port, through it, so the catch/cargo doesn’t spoil. To add to it all, on the way back they lose radio contact which was kinda predictable.

                The weatherman was tracking the confluence of two major storm fronts and a hurricane at which point he states, excitedly, it will create “the perfect storm” . You can probably guess that the fishing boat ended up in the middle of this massive storm and was last seen trying to ride over an enormous 100ft+ wave. Sadly but expectedly the boat overturns with boat and crew being lost. The movie ends with a memorial service for those that went out to sea but never returned.  

                So what the heck does this have to do with telemedicine today? From my observations, research and tracking there is a perfect storm brewing but rather than being negative, it could build into an enormous wave of opportunity for the advancement of healthcare.

                Besides the already existing sea of opportunity in telemed consultations being held from a local or remote practice / clinic / hospital / emergency in-field laptop to a specialist(s) or specialty hospital(s) virtually anywhere around the world there will soon be an expanded prescribed at-home and mobile patient monitoring / consultation / treatment planning opportunity.

So what are these storm fronts / pressure cells that will create this massive opportunity wave?

Let’s list some:

• Because of U.S. government legislation / incentives that push the conversion of paper medical records to digital, aka EMRs, which therefore provide ready access to / video display of electronic health records / information (HD digital x-rays. . . ).
• Registration opened on January 3, 2011 for the Medicare and Medicaid EHR Incentive Programs.
• Up to $44,000 in incentives available for non-hospital doctors / practices.
• Penalties!!! Medicare payment reductions if doctors haven't achieved "meaningful use" of an EMR by 2015.
• As CMS transitions from a fee-for-service to a health quality business model, doctors will feel the need  to improve productivity in which telemed could offer opportunities.
• Because of U.S. government legislation that pushes doctors to adopting EMRs many doctors are or will be retiring or leaving the profession causing a shortage of healthcare professionals to provide care for a growing “insured” and an older American population. “Surviving” doctors will have to find newer efficient methods to provide quality care to more.
• September 30^th, 2010 “(Reuters) - The U.S. healthcare reform law will worsen a shortage of physicians as millions of newly insured patients seek care, the Association of American Medical Colleges said on Thursday.

The group's Center for Workforce Studies released new estimates that showed shortages would be 50 percent worse in 2015 than forecast.

"While previous projections showed a baseline shortage of 39,600 doctors in 2015, current estimates bring that number closer to 63,000, with a worsening of shortages through 2025," the group said in a statement.

"The United States already was struggling with a critical physician shortage and the problem will only be exacerbated as 32 million Americans acquire health care coverage, and an additional 36 million people enter Medicare."”

• The teleconferencing technologies advancements providing better resolution over slower "dirtier" general purpose internet or wireless networks.
• Utilizing the newest ITU H.264 SVC standard: “May 12, 2010 – Vidyo®, Inc., the first company to deliver personal telepresence, today introduced VidyoHealth™, an affordable scalable telemedicine videoconferencing suite that leverages the Internet and other general purpose IP networks, for a broad range of applications such as telepsychiatry, home-health and eldercare, speech therapy, and specialist consultations. . .”
• December 2010, Skype unveiled a video-calling application for Apple Inc.'s iPhone
• Federal funds becoming available for improving broadband telehealth networks.
• March 2010, a prime example, the Federal Communications Commission (FCC) allocated $145M to telehealth projects providing high speed network linking hundreds of hospitals in 17 states. This is an expansion of FCC’s Rural Health Care Pilot Program, started in 2007.
• The hurricane of mobile devices / medical apps / plug-and-play medical devices. 
• December 2010, CTIA (The Wireless Association, Nielsen Co., International Telecommunications Union) data: 93% Americans have cellphones / wireless, 29.7% are smartphones and 90% of the global population has access to mobile networks.
• September 2010, articles published revealing 3 million doctors had already downloaded a 59p app that converts an iPhone into a stethoscope.
•  December 2010, Mobisante, an mHealth company, revealed a prototype of an ultrasound probe / peripheral connected to a smartphone and is seeking FDA approval.
• Way too many more examples to mention but additional resources are listed at:  http://goo.gl/ZEkBh
• The acceptance by consumers of to-the-home high speed networks, high definition TV / theater systems, mobile devices and V/C technologies. Technology acceptance also as “employees” in their corporate environments.
• October 2010, Cisco Umi was rolled out as its consumer telepresence offering.
• Again, December 2010, Skype unveiled a video-calling application for Apple Inc.'s iPhone, this can connect to Skype running on your home computer / laptop.
• Vidyo, Polycom, Tandberg, Oovoo, Lifesize, Webex, Google Video, and I’m sure I missed a few hundred more.

                Only a small sampling of excerpts of related newsworthy articles were presented here, to try to present all or most would just be impossible and probably boring. As you can see by what was presented and the dates of publishing, the storm fronts are developing, intensifying and converging. Technology, hardware, software, infrastructure (networks), necessity for healthcare professionals to become more efficient/improve quality and consumer accepting technology are creating an enormous wave of exciting opportunities, limited only by money and the imagination, for the consumer/patient, healthcare professional and technology services/products provider. The disaster will ultimately be for those who ignore or try to hold back the perfect storm (there still remains some issues of some insurers not paying for telemed services but that is currently under active discussion / negotiations / lobbying).

                If there are opportunities you would like to explore with me / Green Smart Consulting LLC, please don’t hesitate to contact me at pendrasik@GreenSmartLLC.com.   

                To learn more about telemedicine the American Telemedicine Association (ATA), http://www.americantelemed.org/ , is the leading resource and advocate promoting access to medical care for consumers and health professionals via telecommunications technology.

Recently I read and tweeted this article: “GrnSmart_Health    http://bit.ly/9kJCgd - UT ophthalmologist develops program to automate the analysis of potential eye problems” and it got me thinking what medicine will be like in 50 years. What IF this huge database of upcoming patient information is data mined and research technology is applied like in the article.

            Early in my career I started working on cars, granted they were simpler back then (carburetors et al), but as a mechanic I was kinda like a doctor. If these problems / conditions existed or were expressed then based on my knowledge, shop manuals, other mechanic’s consultations then a series of tests would be run to diagnose the cause and fix the problem. I know at times it seemed like just a guessing game but in the end it really was about “if” and “then” analysis based on past data. Although I don’t work much on cars now I know they have systems where they plug the testing instruments into the vehicle’s diagnostic connector, the diagnostic computer analyses the inputs and through it’s internal “if / then database” reports fault codes for the mechanic to address.

            Within 50 years will this new “standardized” database of health information complete with digital x-rays, high definition imagery, digital lab reports. . . be combined with centuries of medical knowledge to produce an in-home “Dr ADAPT (Automated Diagnosis And Patient Treatment)” room? Will you simply stand on a platform or sit in a chair (they already have a chair to develop from, for telemedicine:  http://www.commwellmedical.com/index.php?option=com_content&view=article&id=17&Itemid=21) and the diagnostic computer analyzes the inputs then creates a custom treatment / e-prescription plan / regime for the day, week or month? Then will your EMR information be automatically uploaded to the central research database where the central computer system continually refines standardized medical treatments based on these additional “ifs / thens”?

            Hmmm, makes me wonder what medicine might be like in 2110? Will implanted devices automatically keep you disease / illness free? If manual intervention be required will it be done with absolute precision by automated robots? Will there be a need for doctors or simply researchers?

            OK, it’s time to return to reality, call / schedule my appointment with my doctor to get my scripts renewed, add my new organic supplements that I read about and am taking to my PHR stick and pay some doctor / dentist bills.

            Come to think about it, if dental health has been shown to significantly contribute to a person’s health, shouldn’t they be part of this EMR. . . initiative? Shouldn’t I add those records to my PHR stick?  Will the docs / hospitals use this data or know how to? What about chiropractic data? Guess I will have to save these topics for a future blog.