- Implement framework page plans
Plan for a web page to support the release of certain
aspects of an agents plan to facilitate coordination while
Frame program within the awffw business and its proximate
Web page SWOT analysis
Business planning vision process defines vision. The web
site should demonstrate that focus.
Creating an adaptive planning hoshin network.
Each page in the web is defined by an instance in the content
list. The web consists of frames
(built by the same istrings file) which are made up of pages
with the same within frame navigation.
the informational pages that link from the web page framework:
- glossary: plan, 12 awffwwgl.htm 
Framework page plans
Each of the frames
that you decide will support your business should be constructed
in its own section below. Currently there are three
samples of RSS pages representing the how to page, the
references page and the glossary page. The items in the
glossary can be deployed automatically into an active glossary.
Glossary of terms
Terms are either outlined here or in their own page on the site
and have a link here. It is assumed that the frame
has been deployed with the frame name 'frame name'.
is the American
academy of Dermatology.
is alpha 1-antitrypsin, an enzyme produced in the liver which protects the lungs from
- A1AT deficiency is a deficiency in the liver's production of A1AT and consequent failure to protect
the connective tissue in the lungs from neutrophil elastase disruption
resulting over time in emphysema.
test is a blood test that assesses a person's
average level of blood glucose over a 3 month period.
Because glucose attaches to hemoglobin the 3 month lifetime
of red blood cells can be used as a buffer of blood
ascending aortic atherosclerosis,
is considered an independent predictor of long-term
neurologic events, peripheral embolism
is the American academy for the Advancement of
is the American Association for Cancer Research.
is the Associaton
of American Medical Colleges
is the American
Academy of Ophthalmology.
is adeno-associated virus, which affects humans and other
primates. It used in genetic engineering to deploy
gene insertion tools into animal
cells. It was used in constructing optogenetic tools.
- Activity based cost accounting
identifies the process based flow of activities used to
perform a task and the cost of each activity to effectively
is a nucleoside reverse transcriptase inhibitor, an ARV medication, branded as Ziagen,
which is used in the prevention and constraint of AIDS. It is a WHO
essential medicine. Its use is problematic in about 6%
of the patient base. Pharmacogenomics
allows these patients to be identified and treated with an
- ABCDE Bundle in critical care nursing means
Awakening and Breathing Coordination, Delirium monitoring
and management, and Early mobility. The goal is to
improve ventilator weaning, delirium, and mobility in the ICU.
patient experience standards, after founder Abigail
- Abiraterone is a steroidal androgen
synthesis inhibitor used in androgen
deprivation therapy for prostate
is a gene on human chromosole 22. In the majority of
cases of CML part of ABL is coppied
into a merged chromosome with part of BCR
from chromosome 9, in a transformation initially noted by
Dr. Janet Rowley and colleagues and called the Philadelphia chromosome.
is classically the removal of body tissue by surgery, such
as endometrial ablation to treat uterine bleeding, but there
are special cases:
- Cardiac ablation is the deployment of catheters into the heart to
is a Medicare advance
beneficiary notice of non-coverage issued by a provider who
believes Medicare will not reimburse
1203 is an act that requires non-contracted general
acute care hospitals (not E.D.)
billing HMOs for post-stabilization
services to on stabilization:
- Seek the name and contact information of the patient's
health care service plan
- Call the plan
- Upon request provide the patients diagnosis, and other
information required by the plan so it can decide on
authorizing post-stabilization care or require transfer of
- Request the patient's medical record from the health
- The non-contracted health plan must
- Be available 24/7 to respond to AB requests within 30
- Arrange for and effect transfer promptly.
- Pay for all authorized services, and for all services
provided prior to transfer.
- Abuse-deterrent pharmaceuticals are
formulated to make crushing or altering the pills
harder. However, abuse-deterrent opioids when
swallowed can still induce addiction.
Some experts consider conflating abuse-deterrent with less
additive as misleading (Nov
is an affiliated contractor. Fiscal intermediaries and
carriers that use a PSC for Medicare benefit integrity
protection are termed ACs.
is the Patient Protection and Affordable Care Act amended by
the Health Care and Education Reconciliation
Act of 2010 (Obama care). In part it is designed to
make the health care system costs grow slower. It aims
to do this by: increasing competition between insurers and
providers, offering free preventative services to limit the
development of serious illnesses, constraining patients' use
of expensive services, constraining the growth of payments
to Medicare providers and
piloting new ways for PCPs to manage
patient care to keep patients away from costly E.D.s. It funds these changes with
increased taxes on the wealthy.
It follows an architecture developed by Heritage
Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel
Emanuel & architect Jeanne
Lambrew. The Obama administration drafting team
Kocher; allowing it to integrate ideas from: Dartmouth
Institute's Elliot Fischer (ACO).
The ACA did not include a Medicare
buy in (May
2016). The law includes:
- Alterations, in title I,
to how health care is paid for and who is covered.
This has been altered to ensure
- Americans with preexisting conditions get health
insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to
have insurance but the requirement was supported by
subsidies for the poor (those with incomes between 100
& 400% of the federal poverty
- Children, allowed to, stay on their parents insurance
until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with
incomes below 138% of the federal poverty line; an
expansion which was subsequently constrained by the
Supreme Court's ruling making expansion an optional state
- Hospital Readmissions
Reduction Program (HRRP) which was
enforced by CMS mandated rules
finalized in 2011 and effected starting Oct
- Medical home models.
- Community transformation grants support the
transformation of low income stressed neighborhoods to
improve their lifestyles and health.
- Qualifications for ACOs.
- Establish a formal legal structure with shared
governance which allows the ACO to distribute shared savings payments
to participating providers and suppliers.
- Participate in the MSSP
for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for
patient population (> 5000) assigned to the
- Be accountable for the quality and cost of care
provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based
medicine, Patient-centeredness, Quality reporting,
Cost management, Coordination
- Demonstrate it meets HHS
patient-centeredness criteria including use of patient
and caregiver assessments and individualized care plans.
- CMMI Medicare payment
- Requirements that pharmaceutical companies must report
payments made to physicians (Sunshine
- A requirement that chain restaurants must report calorie
counts on their menus.
- ACA title I is ACA
quality affordable care for all Americans. It mandates
community rating & essential health
benefits. It includes:
- Subtitle A: Immediate improvements in health care for
- Subtitle B: Immediate actions to preserve and expand
- Subtitle C: Quality health insurance coverage for all
Americans. Which reforms the health insurance
markets and prohibits preexisting condition exclusions and
forms of health status discrimination.
- Subtitle D: Available coverage choices for all
- Subtitle E: Affordable coverage choices for all
- Subtitle F: Shared responsibility for health care which
mandates individuals and employers to pay for
- The employer mandate requires employers with more than
50 full-time workers to offer most of their employees
insurance or face penalties.
- ACA title II is ACA
role of public programs. It includes:
- Subtitle A: Improved access to Medicaid.
- Subtitle B: Enhanced support for children's health
- Subtitle C: Medicaid and CHIP
- Subtitle D: Improvements to Medicaid services.
- Subtitle E: New options for states to provide long-term
services and support.
- Subtitle F: Medicaid prescription drug coverage.
- Subtitle G: Medicaid disproportionate share hospital (DSH) payments.
- Subtitle H: Improved coordination for dual
- Subtitle I: Improving the quality of Medicaid for
patients and providers
- Subtitle J: Improvements to the Medicaid and CHIP
payment and access commission (MACPAC)
- Subtitle K: Protections for American Indians and Alaska
- Subtitle L: Maternal and child health services.
- ACA title III is ACA
improving the quality and efficiency of the health care
- Subtitle A: Transforming the health care delivery
- Part I: Linking payment to quality outcomes under the
Annual pay raises to hospitals were cut.
- Part II: National strategy to improve health care
- Part III: Encouraging development of new patient care
- Subtitle B: Improving Medicare of patients and
- Part I: Ensuring beneficiary access to physician care
and other services.
- Part II: Rural protections.
- Part III: Improving payment accuracy.
- Subtitle C: Provisions relating to Part C.
- Subtitle D: Medicare Part
D Improvements for prescription drug plans and MA-PD
- Subtitle E: Ensuring Medicare
- Subtitle F: Health care quality
- Subtitle G: Protecting and improving guaranteed Medicare
- ACA title IV is ACA
preventing of chronic disease and improving public health.
- Subtitle A: Modernizing disease prevention and public
- Subtitle B: Increasing access to clinical preventative
- Subtitle C: Creating healthier communities.
- Subtitle D: Support for prevention and public health
- Subtitle E: Miscellaneous provisions.
- ACA title V is ACA
health care workforce.
- Subtitle A: Purpose and definitions.
- Subtitle B: Innovations in the health care
- Subtitle C: Increasing the supply of the health care
- Subtitle D: Enhancing health care workforce education
- Subtitle E: Supporting the existence health care
- Subtitle F: Strengthening primary care and other
- Subtitle G: Improving access to health care
- Subtitle H: General provisions.
- ACA title VI is ACA
transparency and program integrity.
- Subtitle A: Physician ownership and other
- Subtitle B: Nursing home transparency and
- Part I: Improving transparency of information.
- Part II: Targeting enforcement.
- Part III: Improving staff training.
- Subtitle C: Nationwide program for national and state
background checks on direct patient access employees of
long term care facilities and providers.
- Subtitle D: Patient-Centered outcomes research.
- Subtitle E: Medicare, Medicaid, and CHIP program integrity
- Subtitle F: Additional Medicaid program integrity
- Subtitle G: Additional program integrity
- Subtitle H: Elder justice act.
- Subtitle I: Sense of the senate regarding medical
- ACA title VII is ACA
improving access to innovative medical therapies.
- Subtitle A: Biologics price
competition and innovation.
- Subtitle B: More affordable medicine for children and
- ACA title VIII is ACA
- ACA title IX is ACA
- Subtitle A: Revenue offset provisions.
- Subtitle B: Other provisions.
- ACA title X is ACA
strengthening quality, affordable health care for all
- Subtitle A: Provisions relating to title I.
- Subtitle B: Provisions relating to title II.
- Subtitle C: Provisions relating to title III.
- Subtitle D: Provisions relating to title IV.
- Subtitle E: Provisions relating to title V.
- Subtitle F: Provisions relating to title VI.
- Subtitle G: Provisions relating to title VIII.
- Subtitle H: Provisions relating to title IX.
is an ONC-Authorized Certification
Body which certifies tested EHR
technology as Certified
EHR Technology under the ONC HIT
- Access Management is the
front end part of RCM.
Scheduling is a significant part of this.
is the Accreditation council for CME
which regulates CME for physicians in the US.
is advance care directive.
is an Accountable Care Organization. These are accredited
bundles of companies which together try to offer Dartmouth-Hitchcock
2016) focused on wellness,
improving the provision of primary care to a large group of
Medicare patients, and rewarding
doctors for preventing problems. Advocate
health illustrates the idea. Robert
that the transition is difficult: hospitals that find their
efficiency improving should reduce the number of doctors
they utilize. But any doctors that are pushed out of
the ACO will likely take their patients with them,
undermining the revenues that support the FFV
business. The ACA regulates
qualification to be a Medicare
ACO. Individual organizations within a Medicare shared savings ACO continue
to submit their own claims and are paid by Medicare for FFS. But the ACO is eligible for
Within the shared savings program the CMS
innovation center has
setup advanced payment
ACOs. As an alternative to shared savings, in a
Pioneer ACO, over time
50% of the FFS payments flow directly to the ACO as a bundled payment. CMS has established quality measures
for ACOs for Medicare. The
CMS program's purpose is to reward providers for reducing
total cost of care for patients through prevention, disease
management, and coordination.
- CMS initiated its Physician Group
Practice Demonstration in 2005. By 2008 the
congressional budget office reported on Bonus-eligible
- CMS defines ACOs as organizations that "create
incentives for health care providers to work together to
treat an individual patient across care settings -
including doctors' offices, hospitals and long-term care
- CMS has developed APMs which
include ACOs, and advanced APMs
where the ACOs must be risk bearing.
- CMMI accepts providers' proposals
to test various payment systems including shared savings and partial
- Private market ACOs have formed including: Providence
Health & Services, Blue
Shield California, Anthem Blue
Health Care, BCBS Minnesota,
Humana, CIGNA, Main
Health Management Coalition, BCBS
is actual cash value.
- An acute care episode. CMS
has used an ACE demonstrator to explore the value of bundled payments.
The demonstrator covered 37 cardiac
and orthopedic procedures
including: bypass surgery, hip replacements, pacemakers,
and cardiac stents; in 11
hospitals. It saved $319 per person, across over
12,000 cases, on average.
- ACE inhibitor is
angiotensin-converting-enzyme inhibitor. They help
relax blood vessels and are used to treat hypertension and CHF.
- Acetaminophen is a generic analgesic (pain
killer) marketed by many companies including J&J's
Paracetamol; discovered in 1877. At high doses there
is risk of liver failure.
Acetaminophen is the most common cause of acute liver
failure in the US in 2017.
is the HHS Administration
for Children and Families. The ACF includes: ORR;
is the American College of Gastroenterology.
is the accreditation
commission for health care. It is recognized by
the federal government for:
is the American
College of Healthcare Executives.
is advanced care information.
- ACID transactions are
Atomic, Consistent, Isolated and Durable, allowing the user
of the transaction a simple operating paradigm. In
particular if the transaction fails there are no
ramifications outside of the local transaction.
is the CDC's Advisory Committee on
Immunization Practices. It includes medical and public health experts who
recommend how to use vaccines to
control disease in the US.
is the HHS Administration for
is the American
College of Medical Genetics and Genomics.
is the American
Congress of Obstetricians and Gynecologists.
is the American College of Physicians.
is the American
College of Radiology. It is HHS's
PAMA applicable imaging services appropriate use
criteria standards body.
is Ambulatory care sensitive condition
- Active surveillance is
an approach to early-stage prostate
cancer which replaces treatment, such as surgery or
radiation, with monitoring to ensure the cancers aren't growing
rapidly. It started to be used in about 2000 and so
will take time to build a predictive history of the success
of the regimen (10 year longitudinal study results Sep
2016). Active surveillance treatements include:
Oncotype DX, PSA, STHLM3;
- Activist strategy is
where a hedge fund invests a
large enough amount in a public company to obtain an
influence in a firms decision
making and leadership portfolio.
is either the Americans with
Disabilities Act of 1990 or a label for the gene that
encodes the enzyme adenosine
is the Anti-Drug Abuse Act of 1988, which established the ONDCP.
- Adalimumab is a TNF-inhibiting
anti-inflammatory. It reduces the immune system's response
because it binds to TNF-alpha inhibiting binding to its
receptor and reducing inflamatory response. Abbvie markets a biologic instance of adalimumab, Humira.
There are a variety of biosimilars.
is a disintegrin and
metalloproteinase, a protein family combining cell-surface
adhesion and proteinase activity. They are
zinc-dependent metalloproteins. They are controlled by
is attention-deficit/hyperactivity disorder, a chronic
condition including hyperactivity, impulsiveness and low
response profiles to temporal discounting tasks are abnormal
for ADHD sufferers. Imaging studies show differences
in the brains of ADHD sufferers. Stimulants have been
found to have a calming effect on ADHD sufferers.
seems likely, with a strong correlation of diagnosis to age
at time of school admission! Causally associated
- Family history
- Environmental factors - a consistant daily schedule,
praise for good behavior, clear bondaries, enough sleep
and limiting distractions are all part of behavioral
therapy for ADHD.
- CNS developmental
is a strategy or tool that modifies a primary plan. In
cancer treatment adjuvant
pharmaceutical and immunological agents modify the effects
of other treatments.
is activities of daily living. These are daily
self-care activities that are used as measures of the
functional status of a person.
is accelular dermal matrix, generated by a soft tissue
matrix graft where decellularization leaves the
extracellular matrix intact.
is absorption, distribution, metabolism and excretion of a
pharmaceutical compound within the organism. These
aspects all influence the drug levels and kinetics of drug
exposure to the tissues.
- Adenocarcinoma is a cancer of mucus-secreting glands. It can
occur thoughout the body including the lungs, where 40% of cancers are
adenocarcinomas. Genes ERBB2
and VEGF are often amplified in this
is alternative dispute resolution, an alternative to
litigation for resolving disputes regarding treatment or
payment. Arbitration and mediation are two of the most
common ADR processes. In each case a completely
neutral third party is becomes the dispute resolver.
is admit, discharge, transfer, a backbone HIS
allowing the sharing of patient information with other
health care providers. It has a corresponding HL7 message that reports a status
change for a patient.
big selling respiratory medicine.
- Advance directives
specify patients decisions about how they wish to be cared
for as they die.
- Advanced APM is a CMS
regulated group of APMs that
effectively uses FFV. The list
includes: Risk-bearing ACOs,
Comprehensive end stage renal disease care, Comprehensive
primary care plus, Oncology care model.
- Adverse drug reactions
result from various causes of drug treatments including:
- Individual pharmacogenomics
differences altering the metabolic processing chain of
- Pharmacists' miss-understanding handwritten
- Patient's miss-interpreting their treatment
- Complex interactions of multiple drugs being taken by a
- Underlying illnesses, especially of the liver & kidneys
altering the metabolism and clearing of drugs in the
is the American Board of Family Medicine.
- Advance payment ACO is a
center has developed a model of an ACO for
physician-owned and rural providers participating in the Shared Savings Program who
would benefit from additional start-up resources to build
the necessary infrastructure, such as new staff or
information technology systems.
- Advanced kidney cancer -
There are expected to be 61,560 new cases of kidney cancer in the US and 14,080 deaths in 2015. Drug
treatments have increased survival from 10 - 12 months to up
to 30. Exact causes are unknown but risk factors are:
smoking, obesity, high blood pressure, genetic
mutations and heredity.
is an F.D.A. adverse event, a problem
identified in a medical process involving a patient or
clinical investigation and reported to the
is atrial fibrillation, an abnormal heart rhythm: rapid,
- .ind.include ('html/awffwglossary.html', 'glaf1', 'glaf1',
is Aid to Families with Dependent Children program, created
by the SSA, that ran from 1935 to
1996 when it was replaced by TANF. The values provided
declined over the years.
is Advanced Functional Fabrics of America.
- Affinity maturation is
the process by which the immune system develops improved
antibodies on repeated exposure to an antigen. The
process involves two interrelated transformations:
Aflatoxins are a family of complex aromatic
toxins and carcinogens produced by certain Aspergillus
molds. They are amongst the most carcinogenic
substances known. They are metabolized in the liver to reactive intermediates that
mutate p53. They are regularly
found in improperly stored commodities such as chillis,
peanuts, rice and wheat. And they flow through the
food distribution system when contaminated food is
processed. Higher animals fed on contaminated food can
pass aflatoxin transformation products into the food
chain. They have been found in feed stock, eggs, milk
products and meat. The most toxic aflatoxin can
permeate the skin.
Age-related memory loss,
also called benign senescent forgetfulness, is a different
condition from Alzheimer's
disease. It initially occurs in the dentate gyrus, reflecting osteocalcin related reduced
synthesis of CREB complex's
RbAp48 protein. CREB is critical for controlling the
conversion of short-term memory to
long-term memory. Ramping up RbAp48 production in old
mice eliminated age-related memory loss. This suggests
that vigorous exercise, which maintains bone density and
osteocalcin levels, can help limit age-related memory
- Clonal selection -
but the cloned cells must compete for antigen and Tfh cell paracrine signals. There is
positive selection of the B cell progeny with the greatest
affinity for the antigen based on cross talk between the
Tfh cells and their cognate antigen presenting germinal
center B cell. There are only a limited number of
Tfh cells in the germinal center ensuring only highly
competitive B cells stably conjugate with the Tfh cells
allowing them to survive.
is the American_hospital
is American health care act. The House version (May
2017): removes the ACA's
progressive taxes on the wealthy
enabling the rest of the Republican's tax cut strategy a
chance of passing in the Senate, Cancels the ACA: Medicaid
expansion - stripping coverage from 23 million Americans (May
conditions constraints, Employee mandate; Provides
grants to states to help offset lost ACA federal funding.
is advanced health care directive detailing an incapacitated
patients health care goals.
is the association of health care journalists.
was the American
health information community. It has become the
NeHC. It is a federally
chartered advisory committee making recommendations to the
Secretary of HHS, on how to
accelerate the development and adoption of health information technology and the nationwide health information network.
is the American health information management
association. It has been contracted by HHS to identify best practices for
state-level RHIO development.
is association health plan:
is Area health resource file
- .ind.include ('html/awffwglossary.html', 'glahp1',
is the Agency for Healthcare Research and Quality. It
provided the definition of a medical home (PCMH) as both a place and a model of
the organization of primary care
that delivers core functions of primary health care.
is the Leahy-Smith America Invents Act of 2011 which aimed
to modernize the patent system. A key provision of AIA
was the creation of the Inter Partes Review process which
third parties can use to contest the validity of a patent
(for not being novel & non-obvious) within 9 months of
its issuance to the Patent Trial and Appeal Board.
Aid-in-dying is physician assisted
termination of life by application of lethal
medications. It was legalized in Oregon by the Death with Dignity act
and other states have followed that blue print (Jan
- activities that initially create awareness and then
interest, desire and subsequently action.
is acquired auto-immune deficiency syndrome, a pandemic
disease caused by the HIV. It
also amplifies the threat of tuberculosis.
Initially deadly, infecting and destroying the T-lymphocytes of the immune system, it can now be
treated with HAART to become a
chronic disease. And with an understanding of HIV's
mode of entry into the T-cells, through its binding to CCR5 and CD4
encoded transmembrane proteins, AIDS may be susceptible to
treatment with recombinant DNA to
alter the CCR5 binding site, or with drugs that bind to the
CCR5 cell surface protein preventing binding by the virus. Future optimization of
drug delivery may leverage nanoscale research (May
Health's Advanced Illness Management, a home-based primary care program for
treating its frail elderly hot spot
patients. By keeping patients out of the hospital
whenever possible, it saves Medicare
> $2000 per patient per month.
is anterior intraparietal area of the intraparietal sulcus.
It is involved in grasp planning.
is the American immunization registry association.
is the autoimmune regulator protein. It is a
factor targeting specific histone
markers that indicate transcriptionally inactive chromatin,
expressed in the thymus and lymph nodes. In
cooperation with 50 other partner molecules it causes
T-cells to be exposed to self-antigens presented by mTEC in the thymus. Any T-cells
that react are signalled to destroy themselves. In the
lymph nodes other Aire dependent tissue-restricted antigens
are presented and reactive T-cells are inactivated.
architecture and techniques for using Web technologies to
provide client server communications without reloading a web
page or refreshing the browser.
is the American joint commission on cancer
is acute kidney injury, where a
kidney suddenly fails. It results in the build-up in
the blood of waste products.
is anaplastic lymphoma kinase is a RTK
which affects specific neurons in the brain. Fusion
mutations of the ALK gene are oncogenic.
Significant types of induced cancers
are: anaplastic large-cell lymphoma
caused by 2;5 chromosome translocation, non-small-cell lung cancer (adenocarcinomas) due to
EML4-ALK fusion, neuroblastomas, inflammatory
myofibroblastic tumors, renal cell carcinomas,
esophageal squamous cell
carcinomas, inflammatory breast
cancer, colonic adenocarcinoma, glioblastoma,
anaplastic thyroid cancer.
ALK inhibitors target mutated oncogenic ALK.
These include: crizotinib (Xalkori), ceritinib (Zykadia),
alectinib (Alecensa), brigatinib (Alunbrig);
is acute lymphocytic/lymphoblastic leukemia.
The cancer starts in the lymphocytes of the bone
marrow. Too many lymphocytes are produced instead of
mature white blood cells. In 2010 combination chemotherapy, including
6-mercaptopurine, cures 85 to 90% of children suffering from
All-or-nothing measures set
because it closely matches the wants and needs of patients
to slow chronic disease progression and prevent additional
diseases and their impacts by delivery of optimal treatment,
and drives care givers to achieve all goals. It also
provides a sensitive scale for measuring improvements.
Not all patients will achieve every measure, but the set
encourages the patient, their family, the PCP
and specialists to engage and develop a shared
Allergies include various
conditions: hay fever, food allergies: MMA, Peanut;
atopic dermatitis, asthma, and
anaphylaxis; caused by over activity of the immune system in response to
antigens in the proximate environment. Initially
associated with the English upper-class, allergies have
spread across the population with general adoption of: small
family size, cleanliness, antibiotic
use, public health
programs; in line with the hygiene
hypothesis, with newborns no longer getting exposed to
antigens by their older siblings and proximate higher
Alpha-gal is short for
galactose-alpha-1,3-galactose. It is a sugar which is
a component of cell membranes.
Alpha-synuclein is a protein found mainly in
the presynaptic terminals of neurons. It is important in
maintaining the supply of synaptic vesicles - it interacts
with tubulin. It simultaneously binds to phospolipids
of the plasma membrane and to synaptobrevin-2
becoming a chaperone. It is encoded by the SNCA
gene. It is a major constituent of Parkinson's disease Lewy bodies. Knockout
mice with targeted inactivation of the expression of
alpha-synuclein show impaired spatial learning and working
is amyotrophic lateral sclerosis which selectively destroys
Alternative quality contract
Alveolate are eukaryotes
which include flattened vesicles in the outer cortical
- A 2009 payment arrangement developed by Blue
Cross Blue Shield of Massachusetts. It was
developed to support change. It differs from capitation in including upside
measures for patient safety, appropriateness of care and
patient satisfaction. Its key components are:
- Integration across the care continuum
- Accountability for performance measures for ambulatory
and inpatient care. Includes a 10% incentive for
- Performance measures are selected that are:
Nationally accepted, Vary across providers, Include
sufficient data on provider being measured, measured
at the level that can influence the outcome.
- Global payment for all medical services with health
status adjustment and with margin retention.
- Five year contract to create a sustained
Alzheimer's disease is a
dementia which correlates with
deposition of amyloid plaques in the neurons.
As of 2015 there are 5 million Alzheimer's patients in the USA. It was originally defined as
starting in middle age which is rare, so it was a rare
dementia. But in 1980s it was redefined as any
dementia without another known cause. Early indications
include mood and behavioral changes (MBI)
and declarative memory
and thinking problems (MCI).
Specific cells within the hippocampal
circuitry and its gateway, the entorhinal cortex, are
damaged. The amygdala, cerebelum and other areas
supporting implicit memory
are not impacted during the early stages of the
disease. Grid cell
destruction results in a sense of being lost. The default mode network
is disrupted. Variants include: late-onset sporadic;
with risk factors - ApoE4 for late
onset Alzheimer's, presenilin,
deprivation therapy (Dec
2015), type 2 diabetes.
There are multiple theories of the mechanism of Alzheimer's
during aging: Allen
Roses argues that it is due to gene alleles that limit
the capacity of mitochondria
to support neuron operation,
Neurons of sporadic Alzheimer's sufferers show greater APP gene diversity due to somatic recombination;
It may be initiated by: stress
induced HHV-6a, HHV7 herpes
2018) and or an increasingly leaky blood-brain
barrier; and a subsequent innate immune response to the
2016). The Alzheimer's pathway follows:
is the American
- Plaques form. These are seen in fMRIs 10 to 15 years prior to
detecting memory and thinking changes. APP deployed in the cell membrane is
cut into three parts. The external part becomes
amyloid-beta peptide which aggregates into Amyloid
plaques, external to the neurons, if too much is generated
or it is not removed fast enough.
aimed to inhibit plaque formation but clinical trials
- Encouraging the garbage collection of amyloid and tau
with gamma rhythms
stimulation retards Alzheimer's in mice studies (Mar
- BACE inhibitors block an enzyme
needed to form amyloid.
- Mutation driven misfolded Tau proteins can form tangles
within the cytoplasm of neurons. The Tau tangles
kill nerve cells. LMTX is a
drug treatment targeted at these tangles.
- The brain becomes inflamed resulting in the killing of
many more nerve cells. The hippocampus disintegrates
and the brain loses critical functions and memory loss
is Academic medical center. They perform education,
research and patient care. They include one or more
health professions schools, such as a medical school and a
hospital. The major AMCs are represented by the United
HealthSystem Consortium. The costly strategies
of the AMCs and increased difficulty of finding enough
targeted patients for research studies (Aug
2017) is forcing integration with larger hospital systems.
AMCs offer researchers clinical research support: Virus vectors (Nov
is age related macular
degeneration which is the leading cause of vision loss
and blindness among Americans over 65. It is
associated with a damaging buildup of drusen pigments in the
dry form and
additionally, blood vessels in the wet form. It
is associated with a variety of genetic mutations.
Using HapMap data it was realized
that two gene variations on separate chromosomes, both
involved in inflammatory response carry high risk for this
disease. These two genetic factors along with smoking
and obesity infer 80 percent of
the risk. Treatments can thus target the inflammatory
blocks the VEGF stimulated growth of
blood vessels that occur in the wet form.
is acute myocardial infarction which means that some of the
heart muscle has died from a blocked blood supply. AMI
is hard to measure. Nanosensors offer a possibility (May
Amiodarone is a drug used to treat irregular
heartbeats including: VT, VF, AF, wide
complex tachycardia, and
paraoxysmal supraventricular tachycardia.
is acute myelogenous leukemia is
a set of eleven disorders of the bone marrow. Parents
of platelets, white and red blood cells fail to
differentiate properly and instead replicate wildly.
Patients are at risk of massive bleeding and sepsis.
One of the causes is mutation of the genes for IDH-2.
Ambulatory blood pressure
monitoring uses a device, worn for 24 hours, that
automatically measures blood pressure every 15 to 30 minutes
during the day and every 30 to 60 minutes at
Amputation is a surgical technique to remove
damaged body parts. The regular method was developed
by the 1800s and leaves considerable scope for increasing
support for bionic devices: rebuilding agonist antagonist
muscle group feedback etc.
is alternative minimum tax
is the American
Anal cancer is very rare. The cancer typically develops in the
squamous cells of the anus. It has been associated
with HPV. It is distinct from colon cancer.
Anaplasmosis, in humans, is a lxodes ricinus
tick vectored disease caused by Anaplasma phagocytophilum
bacteria infecting neutrophils.
Ancillary - an agreement eliminating
competition is ancillary if it is subordinate and collateral
to a separate legitimate agreement. Otherwise the FTC views the agreement as per se
illegal under the Sherman
Andexanet alfa, developed by Portola
Pharmaceuticals and branded Andexxa,
acts as a Xarelto/Eliquis
(factor Xa inhibitor) bleeding
antidote. It acts as an alternate receptor for these
activated factor X inhibitors, freeing the factor Xa to
Androgen deprivation therapy
lowers the levels of male sex hormones.
These hormones stimulate the growth of prostrate cancer
cells. But the treatment: Bicalutamide, Lupron; is
associated with increased rates of: Depression (Apr
2016), Dementia (Oct
2016) including Alzheimer's
is a decrease in the number of red blood cells or the amount
of hemoglobin in the blood. There are various types: Fanconia anemia, Iron-deficiency anemia,
Pernicious anemia, Sickle-cell anemia;
Anesthesia is the temporary removal of
sensation. It can be local, regional or general.
Anesthesiologist is a
physician who has completed an accredited residency program in anesthesiology and is
trained in anesthesia and perioperative medicine.
Anesthesiology is a four year accredited residency including a one year
medical or surgical internship, and three years of
anesthesiology training. This includes specialized
testing in anesthesia as well
as tests of physiology, pathophysiology, pharmacology and
other medical sciences. There is a board exam at the
completion of residency to obtain certification as an anesthesiologist.
Practices as an anesthesiology
Anesthesiology kits are
Anesthetist is used to describe anesthesia providers without the
qualification of physician. Often these are CRNAs.
Angiogenesis is the formation of new blood
vessels from existing vessels. It is important in
growth, development and wound healing. To become
malignant many tumors stimulate
Angiogram is a diagnostic test where a
doctor threads a narrow catheter
up from a blood vessel in the groin to the heart and squirts
in a dye that allows a cardiologist to see blockages in the
arteries on X-ray displays/films.
Angioplasty involves inserting a catheter, inflating a balloon to
expand a narrowed artery, and inserting a stent to keep the area propped
argues angioplasty should be part of a radically lower cost
business which should disrupt
the solution business of the general hospital.
Angiopoietin is in a family of vascular growth factors, signalling embryonic &
Angiotensin receptor blockers
block hormone signals (angiotensin II) from
causing the contraction of muscles surrounding blood vessels
and so stop the blood vessels contracting, lowering blood
is angiopoietin-like 3, a
protein encoded by the ANGPTL3 gene, that participates in angiogenesis in the liver. The preprotein is
proteolytically processed into active proteins which inhibit
triglyceride metabolism. Gene knockouts result in
reduced plasma lipid concentrations.
is a gene encoding ankyrin-3.
GWAS suggest ANK3 SNPs
are involved in bipolar
Ankyrin-3 is a linker between integral cell
membrane proteins and the spectrin-actin cytoskeleton, found
in neurons in both central and
peripheral networks. It is also spliced and then found
in other tissues.
nervosa is an eating
disorder. As of 2015, 50 percent of hospitalized
anorexic patients who are discharged at a normal rate
relapse within a year. It has the highest mortality of
any mental illness. It involves brain circuits
involved in habitual behavior. The initial weightloss
acts as a reward with compliments relieving anxiety and increasing
self-esteem. Diet gets paired with weight loss (the
reward) in the ventral
striatum and eventually dieting becomes the reward as
the dorsal striatum gets
involved in the patient's decision
making making it a habit.
Anti-Kickback Statute of the SSA criminally prohibits giving a
kickback for a Medicare or Medicaid service referral.
Antibiotics are compounds which kill
bacteria, molds, etc. Sulfur
dye stuffs were found to be effective antibiotics.
evolved antibiotic discovered was penicillin. Antibiotics
are central to modern health care supporting the processes
of: Surgery, Wound management, Infection control; which
makes the development of antibiotic resistance
worrying. Antibiotics are:
results from evolutionary
pressure of antibiotics,
supported by plasmids
and R factors: NDN1; which
properties for otherwise lethal antibiotics.
World leaders hope cooperation
can preserve the power of last resort antibiotics: Carbapenems, Colistin (Oct
2016). Worrying trends include: C. auris resistance to
medical antifungals: itraconazole;
as well as azole agricultural fungicides (Apr
2019), CRE (May
2016), C. diff
2015), MDR & XDR TB;
resulting in increased risk of sepsis
and death. The World Bank
estimates full resistance would reduce the global economy in 2050 by between 1.1 and
- Economically problematic to
develop and sell.
- Congress enacted GAIN to
encourage development of new antibiotics. But it
has not developed any market-entry award scheme, which
seems necessary to encourage new antibiotic
- Medicare has required hospitals
and SNFs to execute plans to
ensure correct use of antibiotics & prevent the
spread of drug-resistant infections.
- C.D.C. is acting to stop the
spread of resistant infections and reduce unnecessary
use of antibiotics.
- F.D.A. has simplified approval
standards. It is working with industry to limit
use of antibiotics in livestock.
- BARDA is promoting
public-private partnerships to support promising
- Impacting the microbiome
of the recipient. Stool banking
is a solution (Sloan-Kettering
- Associated with obesity,
although evidence suggests childhood obesity relates to
the infections not the antibiotic treatments (Nov
- Monitored globally by W.H.O.
- Regulated in the US by the F.D.A. who promote voluntary labeling
by industry to discourage livestock fattening (Dec
- Customer demands have more effect - Perdue shifts to
no antibiotics in premier chickens (Aug
treatments for hypertension
including: diuretics, ACE inhibitors, calcium channel
blockers, beta blockers
Antineoplastic is a treatment that inibits
or prevents the growth and spread of tumors and malignant
Antitrust Procedures and
Penalties Act of 1974 was introduced by John
is the Brazilian government's public health surveillance
- .ind.include ('html/awffwglossary.html', 'gltunney1',
Apalutamide is a non-steroidal androgen
receptor competitive inhibitor developed to treat prostate cancer. It
is structurally similar to enzalutamide.
Apicomplexa are a group of parasitic alveolates, obligate
endoparasites, which are distinguished in developing a
unique organelle used to penetrate host cells within which
the apicomplexa live.
is a direct inhibitor of free and clot-bound
is alternative payment model, Medicare's
risk based payments to organizations set up as ACOs. It includes track 1 ACOs
which are not risk bearing. APMs have to report
various measures to CMS.
is a gene encoding the APOBEC-3B cytidine to uracyl RNA editor. It is postulated to
have a role in cell growth and the cell
cycle. It has been associated with mutagenesis
in bladder and breast cancer.
is a gene encoding the apo-CIII protein. Apo-CIII is a
component of VLDL. Increased levels of Apo-CIII induce
is Apolipoprotein E which
is essential for normal catabolism of triglyceride-rich
lipoproteins. It is used by the liver,
macrophages, and central nervous system where astrocytes use
it to transport cholesterol to neurons
via APOE receptors.
is a gene variant which produces the E4 variant of APOE. It is a risk-factor for
late-onset sporadic Alzheimer's
disease. Being homozygote for E4 does not imply
getting Alzheimer's but does increase the risk 20
fold. ApoE2 may reduce the risk of Alzheimer's.
It appears that ApoE4 differentially affects women.
Apoe4 is known to be broken down into fragments which impare
mitochondrial operation. It also promotes amyloid
plaque buildup. Therapies are being developed based on
small molecules which reshape ApoE4 to be more like ApoE3
reducing the breakdown.
Apolipoproteins are lipoproteins without the
lipid bound. They allow lipids to form into
water-soluble complexes and can thus act as lipid transfer
carriers, and are also found operating as enzyme cofactors
and receptor ligands.
Appraisal arbitrage is a
hedge fund strategy where shares are purchased after a
takeover bid has been announced with a plan of suing the
companies for agreeing too low a price.
Appropriate use criteria
are PAMA required, CMS driven specifications of when it is
appropriate to use a particular procedure.
is an advanced practice RN, is an RN
with a masters and licensing in midwifery, nurse
practitioner, clinical specialist or
alternative quality contract is:
is a Medicare benefit integrity
Aripiprazole is a partial agonist of dopamine D2 receptors. It is believed to
lower transmission in the mesolimbic pathway
and enhance transmission in the mesocortical
- .ind.include ('html/awffwglossary.html', 'glaqc1',
is annual recurring revenue or Admission-Readmission revenue
Arden Syntax is an HL7 standard. It is
a grammar for representing medical conditions and
is an inhibitor of acetylcholine breakdown. It is a
treatment for classical Alzheimer's
limit the synthesis of estrogen by aromatase. Breast and ovarian cancers grow more
stimulated by estrogen.
is the American Recovery and Reinvestment Act of 2009.
It included health care provisions:
is the American
Society of Anesthesiologists.
- COBRA payments
- Funds to help states with Medicaid.
- $20 billion to modernize health care IT
- $10 billion for health care research
X12N is the insurance (N) subcommittee of the X12
EDI and XML ASC accredited by
- An ambulatory surgery center providing same day surgical
- The accredited standards committee responsible for
is the Administrative Simplification Compliance Act of
2002. Public Law 107-105 implemented as regulation 42
CFR 424.32. It alters the SSA
to make electronic claims submission a mandatory requirement
for some classes of health care providers, health plans and
health care clearing houses.
is autism spectrum disorder.
All these disorders are characterized by difficulty
connecting with others. People who suffer from ASD
show a reduced fusiform
response to faces. ASD is linked to gene variants
affecting oxytocin and vasopressin, to nongenetic
mechanisms that silence the oxytocin receptor gene and to
lower levels of the receptor
is the American
Society of Human Genetics.
(acetylsalicylic acid) is a pain,
fever and inflammation medicine. It is a platelet
aggregation inhibitor. While its NNT is 2000 for cardiovascular disease
prophylaxis, it is
so cheap that this strategy is still important. It has
been found beneficial in limiting esophageal cancer.
is a protein based hormone
produced in white adipose tissue that signals the brain and liver to release glucose into the
blood stream. It is encoded by the FBN1
gene. cAMP is the second
messenger in the signalling network.
is the American
Society for Radiation Oncology.
Assisted living is an alternative to parents
joining their children's nuclear family or entering a SNF, or Greenhouse Nursinghome.
Gawande's Being Mortal describes the situation.
Federal Medicaid does not
directly cover assisted living. State Medicaid adds
coverage through a federal waiver. Congressional
legislation covering assisted living is limited. Assisted
living providers are represented by the National
Center for Assisted Living.
Association health plans
is an ARV therapy for H.I.V. ART is a cocktail of
drugs, such as the three in HAART,
which prevents the virus from
replicating leaving it dormant so AIDS
does not develop.
- Allow small businesses and individuals in particular
professions, trades or interest groups to join
associations that offer insurance to members.
- Are a form of MEWA
is antiretroviral treatments for H.I.V.
infection, such as abacavir.
secretary for preparedness and response
is inflammation of the airways resulting in their narrowing,
swelling and generating additional mucus
which inhibits breathing. Its prevalence doubled in
the US between 1980 and 2000. Asthma is the most
common chronic disease in childhood, the most common reason
for being away from school and the most common reason for
hospitalization. 10 to 13% of children's asthma cases
are due to obesity. Among
obese children 23 to 27% of asthma cases are due to
obesity. Diagnosis: Propeller
Health; Treatments include: Xolair;
is associate clinical social worker.
is anaplastic thyroid cancer.
Atezolizumab is a MAB
of lgG1 targeting the apoptosis
ligand PD-L1. It is marketed as Tecentriq.
It blocks PD-L1's interaction with PD-1
and B7.1. PD-L1 expression reduces the activation of
cytotoxic T-cells (immune checkpoint inhibition).
is an NVLAP Accredited Testing Lab tests EHR
technology against the certification criteria.
is a serine/threonine kinase, that
binds onto DNA double-strand
breaks. It phosphorylates proteins including: p53, CHK2, BRCA1,
NBS1 and H2AX; in networks activating the DNA
damage checkpoint, resulting in cell
cycle arrest, DNA repair or apoptosis.
is the American taxpayer relief act of 2012. This made
the EGTRRA and JGTRRA tax cuts permanent for single
people earning less than $400,000 and couples earning less
than $450,000. The highest marginal income tax rate
returned to 39.6 percent. President Obama signed the
act into law in Jan 2013.
- A serine/threonine-specific kinase,
that binds to single-strand DNA
breaks coated with RPA, with
partner ATRIP, sensing DNA damage and activating the DNA
damage checkpoint, through a signalling
for Tax Reform, Grover Norquist's powerful
conservative-Republican advocacy group. Norquist
- Taxpayer Protection Pledge in 1986. Republican
Newt Gingrich and GOPAC ensured
it became a mandatory step for Republicans seeking
- Wednesday morning stategy meetings in 1993, to
undermine the Clinton administration and weaken the
Democrat's hold on power.
Atopic dermatitis, is
also called eczema is a long
lasting inflammation of the skin. It can be
successfully treated with dupilumab.
Atrial fibrillation is
an irregular heart rate associated with poor blood
Atrophic gastritis is a
condition of aging where the acid-producing cells in the
stomach gradually cease to function. It is associated
with chronic inflammation of the stomach mucosa, leading to
loss of gastric glandular cells and their replacement by
intestinal and fibrous tissues.
- Can lead to blood clots, stroke, CHF,
dementia and other
- Fibrillations allow blood to pool in the heart
chambers and form small clots which can then lodge in
small arteries and block blood flow.
- Has become much more common being induced by endemic
diseases: hypertension, obesity and type-2-diabetes.
- Cocoa reduces risk of AF (May
- Treatments include: digoxin;
is the HHS agency for toxic
substances and disease registry
Attribution in deep neural networks, aims to
understand the flow of information, so as to help explain
the networks predictions.
extends reality providing computer support to human
is a major hereditary mental disorder that starts before
age three when it features: a strong preference to be
alone, a desire for things to stay the same, and areas of creative ability - they
see the ordinary as beautiful and have special talents for:
poetry, foreign languages, music, art, and
calculations. They generate less but more original
ideas. It occurs as a spectrum of symptoms, from mild
to severe, across the population of sufferers (ASD). Before age two the
circumference of an autistic child's head is larger than
typical and regions: amygdala, frontal lobe; develop
prematurely, altering activity in other regions.
Autism highlights aspects of the brain's specialized regions
and processes for interacting with other people.
Autistic's interests are restricted. They struggle
with social interactions & verbal and nonverbal
communications. Autistics do not attribute minds to other people:
attributing mental states to others allows us to predict
their behavior; a critical skill for social learning and
interaction. While their visual area
MT detects motion, the superior temporal
sulcus does not respond to biological motion in
autistics, undermining the understanding of intention.
And they gaze at mouths rather than eyes
when looking at faces. The default mode network
is disrupted. Autistic adolescents
have unusually large numbers of synapses,
because of a failure of synaptic pruning. Autistics
almost never pretend. They can't explain the
difference between an instance of an object
and a memory of it. Mild
autism still maintains some pressure to conform socially and
often results in depression
and anxiety. Autism occurs
in every country and social class. It lasts a
lifetime. It has genetic and neurological
causes. Identical twins are 90% likely to both have
autism if one of them does. With 50% of genes active
in the brain, mutations are likely to impact the development
and operation of the brain. The genes: SHANK3, CDH10;
are involved but account for a very small percentage of the
risk. Facial gaze studies indicate a high genetic
influence and an opportunity to identify more genes
associated with autism (Jul
number variations: an extra copy of a segment of 25
genes of chromosome 7
increases the risk of ASD, while deletion of the segment
causes Williams syndrome;
and de novo mutations
which drive up the number of autism cases as paternal age
has increased in the US. ASD is
associated with a reduced fusiform
face area response. Tests [in development] for autism
include: celiac disease, eczema, IBD, lupus, multiple sclerosis, type-1-diabetes; are often
debilitating and life long conditions. Autoimmune
diseases are increasing in prevalence rapidly over two
or three generations in advanced societies. One in
thirteen Americans has an autoimmune condition. Some
are associated with gene alleles encoding the immune
system. Stress is associated
with increased autoimmune problems (Jan
Autophagy is the cellular network that
breaks down aged and problematic cellular infrastructure and
foreign agents. The genetically encoded facilities are
present in yeast and humans. Dr. Yoshinori Ohsumi's
research on yeast autophagy showed: During starvation,
proteins and nonessential components are broken down to
provide energy; Cells use the autophagy infrastructure to
destroy invading viruses and
bacteria. When the process goes wrong autophagy
contributes to: Premature aging, Cardiovascular disease,
skeletal weakness, glucose intolerance, Cancer, Infections, Immunological
diseases and Neurodegenerative disorders.
is arteriovenous malformation, where the usual capillary
network between arteries and veins is bypassed. It is
usually genetically determined via mutations that affect the
vaccine research committee of the NIH.
is a HIPAA business
Babesiosis is a parasitic disease, vectored
by ticks, transmitting babesia protozoa blood parasites in
the human infection.
is B-cell activating factor, supports the development and
survival of B-cells. In SLE
BAFF is overexpressed.
Balance billing is when an out-of-network
provider bills the patient for the balance of the bill not
covered by the insurer. These charges are not capped
by the ACA's out-of-pocket
Banking Act of 1933 was New Deal legislation that reformed
the banking system: limiting commercial bank securities
operations, constraining integration of commercial banks and
securities firms; and created the FDIC.
It was sponsored by Senator Carter Glass and Representative
Henry Steagall (Glass-Steagall)
and was initially resisted by the FDR
Bankruptcy is a legal status for an entity
that cannot repay its creditor's loans. It holds
creditor lawsuits in abeyance while the restructuring
process proceeds to allow the entity to continue
operations. It also has legal tools for forcing
holdout creditors to accept repayments that are lower than
the bond sale initially promised.
Banyan Brain Trauma Indicator
is a blood test for mTBI that
measures the levels of UCH-L1 and GFAP that are released
into the blood stream when brain tissue is damaged. It
is approved for marketing by the F.D.A.
and should reduce the need for CT
scans of those with suspected brain injuries by a
is the biomedical advanced research and development
authority, an HHS ASPR
office responsible for procurement and development of vaccines, drugs, therapies and diagnostic tools
for public health
Basal cell carcinoma is
the most common form of cancer.
It rarely metastasizes or kills unlike melanoma. It does cause
destruction and disfigurement by invading surrounding tissue
so it is considered malignant. There are a number of
types: Aberrant, Cicatricial, Cystic, Fibroepithelioma of Pinkus,
Infiltrative, Micronodular,Nodular which can become a Rodent
ulcer, Pigmented, Polypoid, Pore-like, Superficial.
Thomas was an 18th century clergyman who wrote "An Essay
toward Solving a Problem in the Doctrine of Chances" in
which he argued that the way we learn about the world is
through approximation, getting closer and closer to the
truth as we gather more evidence. Laplace developed
this idea into the Bayesian
statistical method. The method is iterative and
is an iterative form of statistics invented by Thomas Bayes. It uses a 'prior'
statistic to represent the prior situation and then performs
a calculation that integrates the probability of new events
occurring into a 'posterior' probability. This
posterior becomes the prior for the next iteration with the
application of the Bayesian identity xpost =
xprior*y/(xprior*y + z(1-xprior)). The magic in
Bayesian statistics is in accurately generating the prior
xprior and the current event probabilities y and z. R. A. Fischer was so skeptical of
the legitimacy of the prior that he advocated an alternative
statistical framework and experimental process.
Bayh-Dole Act is the Patent and Trademark
Law Amendments Act which allowed universities, small
businesses and non-profits working with federal researchers
to elect to pursue ownership of an invention in preference
to the government taking ownership.
is the Balanced Budget Act of 1997. This act aimed to
balance the federal budget by 2002. It was enacted
using the budget reconciliation
process. In part it reduced Medicare
(replacing MVPS with the SGR and commissioning the MedPAC) and Hospital inpatient and
outpatient payment cuts to do this. It also enacted Medicare Advantage and SCHIP. BBA mandated risk
adjustment and the HCC coding payment
model, through CMS rules.
BBA of 2018 is the Bipartisan Budget Act of
2018, increasing spending caps imposed by the BCA of 2011, and including as part 3,
the CHRONIC care act.
is the budget control act of 2011. It was agreed
between House leader Boehner
and President Obama to:
is the Bacille Calmette-Guerin vaccine
for tuberculosis. It
has unpredictable results and is not fully protective for
severe forms of the disease. It is also being used to
treat bladder cancer.
- $1.2 trillion deficit reduction by joint agreement or
- $900 billion in cuts over 10 years.
is a gene on chromosome 22 which normally codes the
breakpoint cluster region protein which is a
GTPase-activating protein for RAC1
and CDC42. In many cases of CML part of the BCR gene gets
translated onto an additional Philadelphia chromosome
along with part of gene ABL from
is the federal bureau of economic analysis
Beacon Community is
supported by the ONC because of its
cutting edge use of EHR adoption and
HIE. Their grantees are acting
as test sites for Health IT to analyze disparities due to
race, gender, language or disability.
are biliary epithelial cells which are part of the adult liver. They are derived from
Bedaquiline is an oral prescription
treatment for tuberculosis,
discovered by Koen Andries at Janssen Pharmaceutica.
It affects an ATP synthase proton pump. It is
specifically approved by the F.D.A.
to treat MDR TB and is a WHO essential medicine.
Behavioral hazard is
Sendhil Mullainathan, Katherine Baicker and Josh
Schwartzstein's name for patients underuse of highly
effective drugs so they can avoid constraining copayments.
assumes the fundamental unity of the mind and body. Formally
established in 1977 it explicitly recognizes that people
need to be active participants whenever possible in their
own health care by learning more about health and how to
maintain and optimize it. It also recognizes the
importance of people learning to communicate more
effectively with their doctors. This helps ensure
their needs are honored. It is accepted that science
can't fully describe a complex dynamic process such as
health without representing the whole organism.
Equally how people perceive
and represent the world is revised allowing more
effective conceptualizing of problems and how to cope with stress and illness. The
process of paying attention and how the body and mind
interact to influence health and illness are
highlighted. It is based on:
Belimumab is a human MAB,
marketed as Benlysta,
which binds and inhibits BAFF.
It is used to treat SLE lupus.
- Our bodies are self-organizing and self-healing.
Science has a limited understanding of the overall
- Our inner balance is accomplished through feedback loops
that interconnect all aspects of the organism.
- Our models
of ourselves and our emotions
play a significant role in health and disease. When
these provide a sense of coherence about ourselves and the
world they help us cope with stress.
- On every level of organization, from the molecular
biology of our cells to the functioning of whole organs
and larger systems, our biology is regulated by
information flow, which connects each part of the system
to those other parts that are important for its
- Connectedness is crucial for physical, psychological and
social health. People who feel unloved and
unlovable, with a lack of attachment
to their parents are statistically relatively cancer-prone.
- Our senses allow us to connect with the external
environment as well as with our internal states.
They give us essential information about the environment
and about other people that allows us to organize a
coherent impression of the world, to function in
"psychological space," to learn, to remember things, to
- Patients being active participants in their health care,
helping develop personalized strategies that they actively
participate in rather than depending on 'experts to fix
them'. Success with these strategies can improve self-efficacy. Hardiness helps ensure
BKM frameworks are Best-known-Method
frameworks, where rules are used to encode effective
Beta blockers stop the action of
beta-adrenergic signals and
hence slow the heart.
is a key symbiont in the human
infant microbiome. It is
selected for by breast milk's array
of oligosaccharides. This structures the microbiome
and helps bootstrap the immune
system. Its growth limits the opportunities for
pathogenic bacteria to occupy the infant lower
intestine. But its transmission to further generations
may depend on large families where the children typically
cross infect. It appears to be collapsing in western
societies with small nuclear families and a focus on
Data encompasses the IT systems and processes
necessary to do population based data collection, management
and analysis. The very low cost, robust, data storage
organized by infrastructure: HADOOP;
data to be stored en mass. Data scientists then
apply assumptions about the world to the data, analogous
to evolved mechanisms in vision, in the form of
medicine, Protein folding
2019) assumes coevolutionary
methods can be applied to identify contact points in a
protein's tertiary structure. Rather than depending on
averages, analysis at Verisk
drills down to specifics and then highlights modeling problems
by identifying the underlying CAS.
For the analysis to be useful it requires a hierarchy of
supporting BI infrastructure:
Billed charge is a hospital's undiscounted chargemaster bill for a
procedure. In the ED it will
include a high facility fee, and each seperate procedure,
which may be due to strategic
billing, can be upcoded (1 - 5) depending on its
complexity. It is found that hospitals are
increasingly upcoding to level 4 or 5 (serious auto
accident) for provision of basic care. While
in-network insurance constrains the actual charges a
hospital can make, the use of ED contract staff, not bound
by the patients insurance contract with the hospital, can
result in surprise billing.
- Analytics utilization and integration delivered via SaaS and the Cloud to cope with the
silos and data intensive nature.
- Analytics tools (BI) for PHM will
be hard to develop.
- Complex data models must include clinical aspects of
the patient specific data, including disease state
- A key aspect is providing clear signals about the
nature of the data using data visualization.
- Data communication with the ability to exchange and
transact. HIEs and EMPI alliance approaches are all
struggling to provide effective exchange.
- Data labeling and secure access and retreival.
While HIPAA was initially drafted
as a secure MPI the index was
removed from the legislation
leaving the US without such a
tool. Silos imply that the security architecture
will need to be robust.
- Raw data scrubbing, restructuring and
standardization. Even financial data is having to be
restandarized shifting from ICD-9 to
-10. The intent is to transform the
unstructured data via OCR and NLP to structured records to support
the analytics process.
- Raw data warehousing is distributed across silos
including PCP, Hospital system and
network, cloud and SaaS for process, clinical and
- Data collection from the patient's proximate environment
as well as provider CPOE, EHRs, workflow and process
infrastructure. The integration of the EHR into a
big data collection tool is key.
is a sheet of bacteria that have invaded the mucus epithelium
covering an organ.
Bioinformatics develops techniques for
storing, retrieving, organizing and analyzing biological
describes lighting systems and LED bulbs which can regulate
the body's natural 24 hour cycles by stimulating receptors
in the eyes which signal the brain about when it
is time to sleep and get up. Standard LEDs by
stimulating the receptors with short-wavelength light
suppress melatonin release. Biological
lighting products aim to undo the damage that
traditional lighting has done to the body's natural
rhythms. By releasing longer range yellow light after
sunset these bulbs assist the body in maintaining its
natural sleep cycle.
Biologics are drugs made in living
cells. Typically they are proteins
developed using genetic engineering to develop the cellular
host, and to customize animal
source, DNA to produce human target
proteins. Such biologics partially
solve the problem of previous protein sources, extracted
from animals or human sources, of contamination and immune responses. The
strategy is very effective for blood transported proteins
such as antibodies (MABs), hormones
and blood factors. But intra-cellular proteins still
demand delivery and accurate cell targeting. This
creates analogous problems to those of gene therapy.
Biomarkers are signals
that indicate the presence or severity of a physiological
state, or disease in an organism. The marker can be
generated by the body or introduced into it. They are
seen as key to personallized
medicine. There are various classes:
is biomedical/biological microelectromechanical
systems. It is related to LOC
and MTAS but focuses more on the
mechanical parts and microfabrication instead of the flows
and lab processes.
- Diagnostic biomarkers signal that a disease exists
within a patient.
- Drug related biomarkers indicate if a specific drug will
work in a specific patient.
- Predictive biomarkers indicate the most likely response
to a particular treatement regime.
- Prognostic biomarkers show the progress of a disease
with or without treatment.
Bio-printing utilizes computer controlled
three-dimensionall printers for rapid and high-precision
construction of synthetic human tissue. It typically
fabricates biological constructs by dispensing cells on a
biocompatible scaffold using a successive layer-by-layer
approach to generate three dimensional structures. It
is costly and does not currently represent the natural
compartmentalization of different cell types in a natural
Biosensor is an analytical device used to
detect a biomarker. The
device combines a biological component with a
Biosimilars are generic drugs made to copy biologics. They could
undermine the pharmaceutical industry's biologic profit
model and so are subject to trade constraints:
- Biological component may be a tissue, microorganism,
organelle, cell receptor, enzyme,
antibody, nucleic acid etc..
- Detector is an optical or electrochemical element that
converts the response of the biological element into a signal that can be processed
by a reader.
Biopsychosocial model of
Dr. George Engel places the patient's social and
psychological well being at the core of any medical
Bipolar disorder also
termed manic-depression is an episodic developmental disorder
beginning in late adolescence,
which can stimulate great creativity
during the manic phase and suicide
in the depressive phase.
Vincent van Gough suffered from
depression for much of his adult life, and killed
himself at thirty seven. He produced three
hundred of his greatest art works, using color to convey
mood, while struggling with psychotic
depression and mania in
the last two years of his life. Only the first
manic phase requires a significant positive or negative
stressful situation. Type I bipolar includes more
manic situations which may include psychosis.
Type II does not include psychosis. Some people suffer
'mixed state' where mania and depression occur at the same
time. Sleep deprivation
activates the amygdala and can
induce mania in some people with bipolar disorder. It
affects 3 million Americans. The amygdala is more
active in people with bipolar disorder. Franz Kallman
found identical twins are likely (70% chance) to share the
disorder. Genetic analysis of 2.3 million different
regions of DNA of 9,747 people with bipolar disorder and
14,278 comparable people without, found five regions that
appear connected with bipolar disorder. Gene ADCY2, was identified, supports
production of an enzyme
facilitating neural signalling, and correlates with
observed impairment of communication in certain brain
regions in bipolar disorder. GWAS
implicate ANK3 and CACNA1C SNPs
in bipolar disorder. And de Novo mutations
increase the risk. Lithium
limits the extremes of the mood swings in some patients but
has side effects. Anti-psychotic
medications are prescribed.
is a set of open-source software, used to provide
infrastructure that supports a distributed cryptocurrency
and payment system, based on the blockchain.
All transaction inputs are unspent outputs from
previous transactions. All transaction inputs are
signed. Change is provided in an additional output to
is best practices intervention package for transitional care
is a set of discharge
improvement strategies for hospital to HHAs.
Bladder cancer affects 77,000 new people
each year in the US. And there are 16,000
deaths. It is typically fast growing, and is often
associated with mutated Ras, which
may indicate it can be treated by reducing the methylation
of the DNA (Dec
2015). A rare form is plasmacytoid.
Bladder cancer is traditionally treated with surgery, chemotherapy and radiation but
these have not been effective with the advanced
disease. New treatments are being deployed:
is basic local alignment search tool. It allows
researchers with protein or nucleotide sequences to match
them to a database of comparative sequences.
Blockchain is a bitcoin
distributed database technology that allows several bitcoin
operators to keep a shared, cryptographically verified,
ledger and consensus mechanism to allow agreement on what
transactions have happened and in what order. It
implements a Merkle tree.
Six times an hour on average, a new group of validated
transactions, a block, is created, added to the local block
chain and published to all nodes. Paraphrasing breadwallet's
Aaron Voisine, publishing is robust because: Each operator
has connected via references from its initial peers to a
random subset of all the other operators; and the new block
is offered to the connected peers who can both ask for it if
they have not seen it previously from some other source and
pass it on to their other peers in a cascade (a gossip
network). To build new blocks an operator must have
all the prior blocks in the chain. All unspent
bitcoins are represented [only] in the blockchain. Miners keep the blockchain
consistent by verifying that a new block has a
proof-of-work. This requires that miners find a nonce that multiplied by the block
hash is smaller than the network's difficulty
Blocker corporations are
used to place a legal entity between the highly leveraged
activities of hedge funds and
private equity companies
and their clients. The structure avoids a federal tax
on returns derived from borrowed money, which was designed
to prevent nonprofits from competing unfairly with
for-profit businesses. It effectively blocks any
taxable income from flowing to the clients who include US
2017). The blocker corporations are setup in a
low tax domicile such as the Cayman Islands or British
is the federal bureau of labor statistics
- Immuno-oncology immune
2016) is approved for locally advanced or metastatic
urothelial carcenoma which accounts for 90% of bladder cancers, where the disease is not
controlled by platinum chemotherapy. Bladder cancer
tends to result in many mutations which typically present
to the immune system
making it a good candidate for immuno-oncology.
Blue Button is a web-based patient portal. A tool
that patients can use to download, view, print and transmit
personal health information. It was specified
and developed by the VA, HHS and DOD.
There are multiple versions:
Blue Cross initially developed in the early
1930s to provide health insurance for hospital
Cross introduced the mechanism of individuals paying
premiums into a collective pool that a third party can then
use to pay for medical expenditures. The subscriber
base was limited until World War 2 when wages were frozen
and employers offered a benefit of health insurance tied to
employment. Being associated with employment made the
facility regressive since those working part-time or in
small businesses had to pay for services out of pocket and
could induce bankruptcy.
- First version is download only, with an unstructured
format and best for reading and printing on
- '+' version supports effective download and transmission
bringing Blue Button in line with MU2. It uses a
structured format (C-CDA + electronic EOB). It transmits
via Direct messaging.
It supports automation via triggers. The
automation/changes to data require multipe
transmissions. Third party applications holding data
that is sent as a trust bundle will
Blue Shield initially developed in the early
1930s to provide health insurance for physician
Blue Slip is a blue form that Senators use
to sign off on nominees for judgeships in their
states. With the Senate Judiciary chair requiring two
positive blue slips for a judge to be appointed, the
President is forced to negotiate with the two Senators from
the state. Since the Senators may be from another
party, the Presidential nomination is often focused onto
candidates that hold moderate views.
is body mass index.
Body scan is a mindfulness
meditation exercise where the attention is moved around the
body noticing the sensations of the visited part. At
the same time the brain models the visited part
participating in flows in and out of the body with tensions
and pain signals flowing out.
Move the mind to each part and feel it. Breath in to
and out from each region. Imagine breathing in
vitality and relaxation on each in breath. Imagine the
tensions are exhailed with the out breath. As you let
go of the sensations the muscles also let go of
tensions. First from the toes of the left foot to the
pelvis and then the right foot to the pelvis. From
there move up through the torso, lower back and abdomen,
upper back and chest, sholders. Then from the fingers
of both hands move simultaneously up both arms returning to
the shoulders. Then move through the neck and throat,
all regions of the face, back of the head and top of the
head to an imaginary hole at the top of the head where we
release our breath.
is borderline personality
disorder a mental illness marked by unstable moods,
behavior, and relationships. Typically have
co-occurring disorders: depression,
anxiety disorders, substance abuse
and eating disorders,
and self-harm/suicidal behavior. BPD is strongly
inherited, but dependent on unstable family
relationships. BPD is treated with DBT.
is business process management.
is breast cancer
type 1 or 2 susceptibility gene. The two types provide
related cellular functions maintaining the validity of the
cell. If either gene product fails there is an
increased likelihood of cancer.
Still individuals with mutations in BRCA1/2 genes account
for only 5 to 10 percent of breast cancers.
- Goals include:
- Common language across business, including IT.
- End-to-end management of customer-facing processes
- Understanding of current processes and improvement of
- Increasing the flexibility of current infrastructure
through process abstraction and standardization
- Integrating with legacy systems and service oriented
- Consolidating silos of data
- Technology generically includes:
Breast cancer is a variety of different cancerous conditions of the breast
tissue. World wide it is the leading type of cancer in
women and is 100 times more common in women than men.
260,000 new cases of breast cancer will occur in the US in
2018 causing 41,000 deaths. The varieties include: Hormone sensitive tumors that test
negative for her2 (the most common type affecting three
quarters of breast cancers in the US,
BRCA1/2 positive, ductal carcinomas
including DCIS, lobular carcinomas
including LCIS. Receptor presence on the cancer cells
is used as a classification: Her2+/-,
estrogen (ER)+/-, progesterone (PR)+/-. Metastasis
classes the cancer as stage 4. Genetic risk factors
include: BRCA, p53, PTEN, STK11, CHEK2, ATM,
GATA3, BRIP1 and PALB2.
Treatments include: Tamoxifen,
Raloxifene; where worrying racial disparities have been
2013). International studies indicate early
stage breast cancer typed by a genomic test: Oncotype DX, MammaPrint;
can be treated without chemotherapy
Breast implants are silicone medical
devices, used to replace or enhance breast tissue after
cosmetic surgery or mastectomy.
ADM has allowed improved surgical
strategies to be used with implants (Sep
2018). There are contoured and smooth silicon
shells filled with silicone or brine. Contoured
implants have been associated with anaplastic large cell lymphoma. Breast implants
have a history of inducing medical problems in
patients. Manufacturers include: Allergan, Mentor,
- Type 1 gene codes for a protein that supports DNA repair and where this is not
possible can stimulate cell death.
Hence if the protein becomes defective one or both of
these key caretaker functions may stop and increase the
susceptibility to cancer. The BRCA1 protein has
multiple actions. It:
- Combines with other tumor suppressors, DNA damage
sensors and cellular signal
transducers to form the BASC surveillance complex
monitoring the health of the cells DNA.
- Associates with RNA pol II to support transcription.
- Interacts with histone
deacetylase to regulate transcription.
- It is a marker of high risk of breast and uterine
- It was collaboratively researched by Dr.
Mary-Claire King and Francis
Collins's labs studying chromosome 17 using genomics.
- In 1990 Dr. King had reported to ASHG
evidence of 'this' single gene linked to a highly
heritable form of breast cancer.
- Over the next two years the labs gathered details of
BRCA1, allowing families with the mutation to
understand their individual risk and plan for their
- In 1993 BRCA1 was identified by Mark
Skolnick of Myriad
- Type 2 gene codes for a protein that binds both single
stranded DNA and the recombinase RAD51 to facilitate
- Advice from Dr. Collins, for families who have a history
of breast or ovarian cancer includes:
- Counselling women with the high risk BRCA mutations,
about the risk of breast and ovarian cancer and the
- Telling women who choose watchful waiting to have
periodic MRIs. And warn
that watchful waiting is unreliable for ovarian cancer
allowing metastasis before detection.
- Prophylactically removing the ovaries and Fallopian
tubes on completion of childbearing.
- Teaching about breast reconstruction and recommending
- Males with BRCA mutations should have careful
surveillance for: Prostate,
- No one being given the test without being fully
counselled beforehand about the implications of the
result. Negative results may bring survivor guilt
while positive results will need careful
Breastfeeding is a mammalian adaptation
which delivers breast milk to the
infant and supports the mother's body in its transformation
after birth. It is known to reduce the risk of: breast cancer: BRCA1, triple negative tumors; ovarian cancer, type 2 diabetes, rheumatoid arthritis;
and may reduce the risk of cardiovascular disease.
Bridges to Excellence is
a set of programs of the health
care incentives improvement institute focused on
recognizing and rewarding clinicians who deliver superior
care for patients with chronic conditions.
is the budget neutrality adjustment a BBA
budget neutral provision for CMS to
define how Medicare should
hospitals for uncompensated care. CMS proposed BNA
which eliminated rural and urban reimbursement and created
fixed costs (DRG) for hospital
in-patient programs, including a wage index and other
factors. The courts concluded that CMS had underpaid
the providers and CMS agreed in Sep 2011 to a schedule of
incremental reimbursements to compensate the providers for
underpayment from 1998-2011.
Bundle CPT is where insurers pay for only
one of the performed services, described by CPT code, which are deemed
Bundled Payments is
where the purchaser disburses a single predefined payment to
cover certain combinations of hospital, physician,
post-acute, or other services performed during an episode of care relating to
a particular condition (unlike capitation).
This bundling is
2018) to allow the value
delivery system to optimize around low cost high
quality long term health care. With one bundled
payment physicians & hospitals must coordinate care and
reduce the unit costs to remain profitable. And to
avoid taking on risk of expensive complications physicians
& hospitals are incented to standardize and focus on
quality. This optimization is dependent on quantifying
the value of the outcome of the episode of care.
Previously FFS payments induced
excessive treatment activity. Bundled payment is
included in CMS ACE
demonstrations and BPCI
initiatives. There are significant impacts on
is an indication of the seriousness of getting a
Collins explains the significant burden of type 2 diabetes:
- It is argued that effective pricing of the bundle
requires marketing data which must be extracted from the
historic transaction base.
- Billing and payment systems must be updated to handle
the receipt and distribution of the bundled
- Care delivery must be re-architected to reduce costs and
- Monitoring sensors can be used to feed reports to ensure
re-architected operations conform.
Business process engine
executes business process workflows allocating activities to
human and machine resources based on the current decision
state and the workflow description. Resources are also
dynamically associated based on the resource state and
process rules. The transactional nature of the
decisions in a business workflow must be specifically
managed or be supported by a long transaction
framework with compensating transactions.
- Being a chronic condition it is often accepted while
people cope with other acute issues.
- While the onset is slow the consequences are severe or
- It is implicated in many early deaths. The risk of
death at any particular age is about twice that of people
without the disease.
Business rules engine
rules management for production applications
centralizing the business constraints and customizing
software applications to the specialized work flows of the
bundled payments for care improvements is a CMS initiative to explore bundled payments.
Its purpose is to incent multiple types of provider to
coordinate care reducing expenses associated with care episodes. CMMI accepts providers' proposals to
test the four different bundled payment models. The
program consists of:
is business intelligence. Compliance is demanding
providers measure, understand and respond to the data about
their patients and care. Hospital groups know they
must take steps to allow their data silos to integrate, even
as they must take care to follow HIPAA
requirements. And global networking and CMS policies on providing access to
their population data creates new business intelligence
opportunities and threats. CMS incentives to adopt ACO structures similarly will require
inter-business data visualization to be able to spread costs
and revenues among the partners. Patients are using
social networking to review their symptoms, diagnosis and
treatments forcing providers to respond. But providers
may also obtain behavioral signals
from social media allowing them to better understand chronic
diseases. Providers must also avoid drowning in the
rapidly expanding volume of data. And it will be
essential to adopt predictive statistical models to avoid
the increasing likelihood of invalid sampling resulting in false positives and regression-to-the-mean.
So providers must decide on effective governance structures,
priorities and effective coherent strategies. They
have lacked the analytics infrastructure to support rapid
effective decision making. This likely requires tools
that can do 'what if' analysis and other forms of
sophisticated modeling and visualization.
But integration and analytics tools
and methods have improved recently. And the
development of OpenStack and equivalent infrastructure
presents opportunities for associative searches to integrate
disparate data sources from across the medical
neighborhood. Genome data may allow precision medicine to
disrupt previous intuitive medicine businesses.
- Seeking voluntary participation in four bundled payments
- Model 1: 3 days pre-acute + hospital inpatient
- Model 2: 3 days pre-acute + hospital inpatient stay +
inpatient MD services + post-acute facility services +
post-acute MD services + related readmissions.
- Model 3: Post-acute facility services + post-acute MD
services + related readmissions.
- Models 1 - 3 provide retrospective reimbursement.
- Models 2 - 3 include post episode
- Model 4: 3 days pre-acute + hospital inpatient stay +
inpatient MD services + related readmissions.
- Model 4 offers a single prospective payment.
- Acute care hospitals, physicians groups, health systems
eligible for all models; post-acute facilities may
participate without hospitals in Model 3.
- Physicians eligible for gain sharing bonuses up to 50%
of traditional fee schedule.
- For all models, applicants must propose quality
measures, which CMS will use to develop a set of
is business process outsourcing.
is a human gene that codes for the protein B-Raf.
Bronchitis is an inflammation of the medium
size airways in the lung. It is defined clinically as
a persistent cough with mucus.
is Bruton's tyrosine kinase
which supports the operation of the B cell antigen receptor.
When the B cell has become cancerous
- a lymphoma, the signalling from the receptor
will support the extended life of the cell. BTK
inhibitors are used to inhibit the signalling.
Buspirone is an anti-anxiety
medication, marketed as Buspar, which is not a GABA receptor
agonist, minimizing potential for physical dependence and
withdrawal. It is used to treat: GAD,
major depressive disorder
where it augments antidepressents.
32 is component 32, a form of CCD,
designed for supporting summary documents as specified by HITSP.
is the complement component C4 gene. It generates
complement proteins C4-A and C4-B.
is an anaphylatoxin.
is forms part of C3-convertase.
is the clean air act of 1963. It controlled air
quality at the national level. Air pollution laws
followed. The CAA amendments of 1970 expanded the
mandate at the federal level and required federal and state
regulations for stationary and mobile pollution
refers to Coronary artery
bypass grafting, a treatment provided by cardiac
surgeons. Lower cost angioplasty
has disrupted this
business but both have been provided by general
argues angioplasty should be part of a radically lower cost
business which should disrupt
the solution business of the general hospital.
is computer assisted coding.
is a gene encoding a subunit of a voltage dependent calcium
channel protein which supports heart muscle, neuron, fibroblasts,
smooth muscle and pancreatic cell polarization. GWAS suggest CACNA1C SNPs are involved in bipolar disorder.
is coronary artery
disease, also called heart
disease or CHD. It
of the coronary arteries.
Cadherin-10 is a cell adhesion
protein. Cadherins form junctions which bind cells
together. They undergo many post-translational
modifications to become the specific mediators of cell-cell
adhesion and recognition.
is a gene encoding the cadherin-10
cell adhesion protein.
is the consumer assessment of healthcare providers and
systems (also known as HCAHPS) a CMS survey which asks consumers and
patients to report on and evaluate their experiences with
- Critical access hospital, a CMS
designation to certain rural hospitals, authorized by
Congress (BBA) to limit further
- Congenital adrenal hyperplasia, which results in
abnormally high testosterone
levels about 8 weeks after conception, and causes girls
brains to be deploy male attributes: making them identify
as boys, and act like them - showing reduced eye contact,
nurturing, and empathy and good
spatial awareness; but they still like dresses and being
treated like a girl. It affects 1 in 10,000 infants
in the US.
Calcium channel blockers
make blood vessels expand. They have four main
California provider fee
is a California legislated program to deliver matching funds
for the safety net
hospitals. Fees are assessed on all California
hospitals to draw down federal matching funds which are then
issued as supplemental payments to hospitals.
Canakinumab is a human MAB
that binds with interleukin-1 beta. It is used to
treat inflammation and problem immune
system responses. It is marketed by Novartis as Ilaris
to treat: CAPS, rheumatoid
arthritis, COPD, Gout, CAD, Schizophrenia.
- Reduce contraction of arteries by blocking calcium gates
in vascular smooth muscle.
- By blocking calcium gates in cardiac muscle they reduce
the force of contraction of the heart.
- By slowing the conduction of electrical flows within the
heart they slow the heart beat.
- By blocking the calcium signal
on adrenal cortex cells, they directly reduce aldosterone
production reducing blood pressure.
is the out-of-control growth of cells, which have stopped
obeying their cooperative schematic
planning and signalling
infrastructure. It results from compounded: oncogene, tumor suppressor, DNA caretaker; mutations in
the DNA. In 2010 one third of
Americans are likely to die of cancer. Cell division
rates did not predict likelihood of cancer. Viral
infections are associated. Radiation and carcinogen
exposure are associated. Lifestyle impacts the
likelihood of cancer occurring: Drinking alcohol to excess,
lack of exercise, Obesity,
Smoking, More sun than your evolved melanin protection
level; all significantly increase the risk of cancer
Candida auris is a fungus resident in soils,
which has developed resistance
to medical antifungals: itraconazole;
as well as azole agricultural fungicides. 90% of C.
auris infections are resistant to an antifungal. 30%
are resistant to two of the drugs. Genome analysis
indicates four ancient strains persist. It has been
assisted by the widespread use of fungicides enabling it to
opportunistically migrate to niches cleared of its normal
competitors. C. auris was first identified in an ear
infection of a Japanese patient in 2009. But it had
subsequently colonized all proximate surfaces and was
detected in the air. It infects the very ill and those
with weakened immune systems.
50% of those infected die within 90 days.
is a thin tube that is inserted into the body to deliver or
remove fluid or gather samples.
Capitation is a global payment for all care
for a patient during a specified time period. It
forces the provider of care to take a high risk. Managing the risk implies
is the council
for affordable quality healthcare. It includes CORE.
is chimeric antigen receptor. Killer T lymphocytes are genetically
engineered to produce a novel protein, composed of pieces
from different parts of the immune
system such as: antibody
components to construct a new receptor binding site on the T cell that targeted an antigen
exposed on the cell surface of cancer cells, and two
receptor associated signals
that switch the T-cell into kill mode and sustain it in that
mode. Small clinical trials of CAR-T cells have shown
substantial remissions among patients with various blood
2017). But there are severe side
is the comprehensive addiction
and recovery act of 2016. It authorizes $181 million
to respond to the opioid epidemic, to boost prevention and
treatment programs. Congress must appropriate the
funds through the budget process. The bill was
introduced by Senator Sheldon Whitehouse &
Representative Jim Sensenbrenner.
is computerized axial tomography otherwise termed CT.
is the care
Carbapenems are a class of beta-lactam antibiotics with a broad
spectrum of antibacterial activity. Some bacteria
(such as CRE) have developed resistance due to the
development and r-factor
distribution of carbapenemases. This is a huge problem
as carbapenems have been used as the last resort antibiotic.
Carcinomas are cancers formed by epithelial cells.
Cardiac arrest is a sudden halt in the
effective blood circulation due to the heart not contracting
effectively. This prevents delivery of oxygen and
glucose to the body. It can be caused by a heart attack. CHF in contrast, typically has
substandard circulation but the heart is still pumping
sufficient blood to sustain life. Cardiac arrest may
be reversed with effective treatment. The treatment
regime and effectiveness vary significantly. They can
Cardiac arrhythmia is
irregular heartbeat, a very common problem where the heart's
electrical cells malfunction. It can be diagnosed and
treated by electrophysiology.
- CPR which needs endurance training
to sustain for at least 45 minutes of deployment needed
for success. If no pulse is detected after 20
minutes more powerful treatments should be deployed.
- ECMO which is more widely used in
Japan and South Korea than in the US.
- Once circulation is restored additional interventions
are required for success, but their application is not
benchmarked, standardized or regulated:
- Therapeutic hypothermia - people who remain comatose
after being in cardiac arrest should be cooled for at
least 24 hours to a temperature between 89.6 and 96.8
- Avoiding toxic amounts of oxygen
- Maintaining normal co2 levels
- Maintaining high blood pressure
- If needed cardiac
is a procedure for diagnosis and treatment of cardiovascular
conditions where catheterization
through the groin, neck or arm, is used to access blood
vessels in the heart.
is the study of the heart's electical circuits.
Electrophysiologists diagnose and treating the electrical arrhythmias of the
Cardiac tamponade is a
buildup of fluid in the pericardium
surrounding the heart, which results in pressure impacting
the hearts operation.
Cardiology is the diagnosis and treatment
of: Congenital heart defects, CAD, Heart failure, Valvular heart disease; by
Cardiomyopathy is a set of diseases of the
heart muscle. It can have many causes, symptoms and
treatments. The main types are:
Care coordination aims
to transfer information between the patient and each care
participant as required and establish accountability by
defining who is responsible for each care delivery activity,
the extent of that responsibility and when that
responsibility will be transferred to other care
participants or the patient and family. Successful
care coordination requires face-to-face interactions.
It also requires aligned incentives (ACO,
AHRQ defines quality measures for
care coordination. The situation is usually complex and adaptive
due to the interactions of all the providers, settings, the
patients' preferences, and the number of physical health
problems, treatments, and the patients' social
situation. The potentially exponential increase in
complexity as the number of these factors present increases
leads to patient hot spots
requiring explicit proactive coordination of care. It
is argued that care coordination must include six specific
- Conditions where narrowed and blocked blood vessels
result in angina, hypertension,
CHD and heart
attacks and hemorrhagic/ischemic strokes.
Mutations of the gene PCSK9 have
been implicated in cardiovascular disease. Rare
families with dominant inheritence of the mutations have
an overactive protein, very high levels of blood
cholesterol and cardiac disease. Other rare PCSK9
mutations result in an 88% reduced risk from heart disease.
Inflammation is associated with cardiovascular disease (Aug
Care Management is transitioning to mean an
aggregate of utilization
management, and independent review for
populations. But it sometimes refers to geriatric care
management which is the process of planning and coordinating
long term care of the elderly. Such care managers have
typically been trained in nursing, social work, and
gerontology. They integrate health care and
psychological care with other services such as housing, home
care, nutrition, socialization, financial and legal
- Determination and updating of care coordination needs:
Needs assessment should identify preferences and goals,
current situation and past history. It needs to be
updated periodically and after new diagnosis and other
changes in health or functional status.
- Creation and updating of proactive plan of care
- Facilitation of transitions: typical transition problems
are detailed by Project Boost.
A challenging issue with transitions is what to do when
there is no resource to take over the coordination role in
- Connection to community resources: Community resources
are any service or program outside the health care system
that may support a patient's health and wellness.
- Alignment of resources with population needs: need to
see the system-level, assess the needs of populations to
identify and address gaps in services.
Care Plans outline the patient's current and
long-term needs and goals for care, identifies coordination
needs, and addresses potential gaps. This is
consistant with the biopsychosocial
model. It also clarifies how the patient will
reach the goals and who is responsible for implementing each
part of the plan. HL7's FHIR has defined a CarePlan
Carotid arteries are
located on each side of the neck where they divide to supply
the scalp, face, neck (external) and brain (internal) with
Carotid Doppler ultrasound
is used to evaluate atherosclerosis
of the carotid artery.
The two-dimensional gray scale provides a measure of the
Carried interest is a
fund manager's share of the earnings from a profitable
investment. It is a performance fee, charged by
venture capital firms and private
equity firms in addition to the smaller management
fee. There is a congressionally granted tax loophole
which keeps the tax rate on carried interest low - 15% in
2016. This loophole on capital gains was setup to
encourage people investing their own capital to take more
risk. But general partners at venture
equity firms do not have the associated risk.
The loophole reduces US tax receipts by $2 billion each
Carrier screening can
provide powerful information for recessively inherited
conditions. It has been used for: Tay-Sachs disease, sickle-cell trait, cystic fibrosis, spinal
muscular atrophy; with differing effects. As more
people have complete DNA sequencing
carrier screening prior to pregnancy will make increasing
sense. Carrier screening:
Carrier Status describes whether people have
genetic mutations that could lead to a disease in their
offspring if they inherit the gene from one or both
- Is being considered for:
- SMA but this requires a
complicated and costly genetic test,
- Fragile X syndrome
may be offered to all females,
- Requires informed consent since it can result in
- Test reliability depends on the number of potential
mutations are involved and how many of these are tested
for in the screen. As of 2010 even cystic fibrosis CFTR gene screening only looks at
the 23 most common of the 1000 potential mutations.
Case Management is defined by American Case
Management Association as a collaborative process of
coordination, evaluation, and advocacy for options and
services to meet an individual's and family's comprehensive
health needs through communication and available resources
to promote quality cost effective outcomes. Case
management productivity, discharge planning, utilization, coding and documentation, denials (RAC), Patient satisfaction (HCAHPS) and performance improvements
are often measured to constrain overheads. Patient
flows can be assessed via numbers of: admissions,
observation days, patient days, outpatient visits,
discharges, E.D. volumes, occupancy,
and denial rates.
are mediators of apoptosis.
Castleman disease is a
rare condition with symptoms of: Enlarged lymph nodes,
hyperactivation of the immune
system, excessive releases of cytokines,
proliferation of lymphocytes
and organ disfuction. It can affect subcomponents of
the body or be multicentric when it is severe and
deadly. Its cause is not defined: some argue it is
viral, others an inherited genetic disorder or a cancer. It has been treated
with: steroids, chemotherapy,
targeted neoplastic disease therapy Sylvant (siltuximab) & Pfizer's Rapamune
lab is a catheterization
laboratory which is an examination room with diagnostic
imaging equipment for visualizing the arteries and chambers
of the heart so that can treat problems
is a thin tube that can be inserted into the
Catheterization is the insertion and routing
of a catheter to a target area
of the body where it enables diagnosis or treatment of a
is catheter associated urinary
is the F.D.A.'s Center
for Biologics Evaluation and Research
Act is the Congressional Budget and Impoundment
Control Act of 1974. It modified the role of Congress
in the budgetary process. It created a standing budget
committee in both the House and Senate. It established
the CBO. It moved the fiscal
year to start in October.
is the congressional
- Title III introduced a budget reconciliation process
that includes fast tracking.
is cognitive behavioral therapy. It was originally
designed to treat depression.
patients demonstrated problems with how they perceived
themselves in the world (cognitive style). Aaron Beck
proposed to identify their negative beliefs and then replace
them with more positive thoughts. CBT leverages
cognitive and behavioral principles to cope with behaviors,
induced by prior conditioning, which cannot be managed
directly with rational thoughts. Instead it assumes
that one's relationship with maladaptive thinking and emotional bindings can
be changed through antecedent strategies. CBT is
problem focused and action oriented. Errors in
thinking like: overgeneralizing,
magnifying negatives, minimizing positives and catastrophizing
are replaced with more realistic and effective
thoughts. CBT has been extended with prolonged
exposure therapy and virtual reality exposure therapy, which
have been used to treat PTSD, where
the BLA learns the signals are no longer
is certified community behavioral health clinic. These
are responsible for directly providing nine required types
of service including:
Screening, assessment and diagnosis including risk
Patient-Centered treatment planning
Outpatient mental health and substance use services
Outpatient clinic primary care screening and monitoring
of key health indicators (May use a DCO)
- 24 hour crisis care
Targeted case management
(May use a DCO)
Psychiatric rehabilitation services (May use a DCO)
Peer support and counselor services and family support
(May use a DCO)
Intensive, community-based mental health care for
members of the armed forces and veterans. (May use a
is comprehensive care for joint replacement (subsequently
relabeled CJR), a Medicare CMMI
program that randomly assigned 75 markets to be subject to bundled payments for knee
and hip replacements and 121 markets to use FFS payments
is CMS certification number
is a gene that encodes the CD195 cell membrane
receptor. The receptor is part of the target cell
binding strategy of HIV. Phase
shift mutations of CCR5 have provided immunity to AIDS.
is a transcription factor
that acts as a transcriptional repressor. It is an
11-zinc finger protein. It regulates the 3D structure
of chromatin. It binds together strands of DNA to form chromatin loops and anchors
DNA to cellular structures including nuclear
is chronic condition warehouse
is case mix index. This is a relative value assigned
to a DRG or RUG.
The CMI of a hospital reflects the diversity, clinical
complexity and the needs for resource in the population of
all the patients in the hospital.
is the commission on
accreditation of rehabilitation facilities. It
is an international non-profit. Certification is often
required or mandated. An alternative may be Joint Commission
accreditation. The CARF accreditation themes are:
is a gene that encodes a cell surface glycoprotein called
CD4. It is expressed on the surface of T-lymphocytes. It is part
of the binding target strategy of HIV.
- Consumers define quality outcomes
- Field-driven standards
- Consultative, not inspective
- Peer review survey process
- Accreditation of organizations services
- Continuous quality improvement
is a cell-surface glycoprotein involved in cell-cell
interactions and migration.
is a gene (KIT oncogene) which
encodes stem cell factor, a trans membrane receptor
including an internal tyrosine
kinase which mediates hematopoietic
is HUD's community development block
grant program. Block grant programs have limited
federal oversight allowing states and local governments
considerable discression. CDBG is one of HUD's longest
running programs funding:
is the F.D.A.'s Center
for Drug Evaluation and Research.
is the F.D.A.'s center
for device and radiological health.
- Affordable housing
- Anti-poverty programs
- Infrastructure development
is either the:
Ceftriaxone (Rocephin) is a cephalosporin antibiotic.
- Commodity exchange act of 1936, which supported
interstate commerce in grains and other commodities and
regulates transactions on commodity futures exchanges to
limit short selling and manipulation.
- White House Council
of Economic Advisers, an agency established in 1946,
to advise the President on economics
in the formulation of domestic and foreign economic policy
is certified EHR
Cell therapy captures cells from a
particular patient, modifies them, clones them and then
deploys them back into the patient. Platforms include
CAR and TCR.
In 2016: The pricing schemes for cell therapies have not
been announced but are expected to be expensive, The
therapies are successful between 25 and 90% of the time for
lymphoma and leukemia but patients may relapse
after months or years of remission; There are a number
of challenges to the approach, some of which may require
treatment in an ICU, including:
Cerebral edema is swelling of the
Certified EHR technology
(CEHRT) is defined by CFR 45CFR
Part 170's final rule to be either:
Cervical cancer is mostly caused by HPV infection. Cervical cancer
surgery performs a radical hysterectomy, where the uterus,
part of the vagina and other surrounding tissues are
removed. In 2017 it was concluded that the rates of
cervical cancer had been previously under estimated and far
more black women were impacted (Jan
2017). Prophylactic vaccination
of young girls is dramatically reducing occurence of this
is the comprehensive economic
and trade agreement between the EU and
Canada signed in October 2016. The EU argue there will
be half a billion euros in taxes saved yearly by EU
exporters. It was framed by TIEA.
It does not alter EU non-tariff barriers such as: GMO and growth hormone constraints,
Environmental protection. The EU argues it: helps
generate growth and jobs, ends customs duties, lets EU
businesses bid for Canadian public contracts, Increases
regulatory cooperation, Protects EU innovations, Streamlines
trade in services and promotes and protects
investments. It includes:
- A complete EHR that
meets the requirements included in the definition of a qualified EHR and has been
tested and certified in accordance with the certification
program established by the National Coordinator as having
met all applicable certification criteria adopted by the
Secretary of HHS; or
- A combination of EHR modules
in which each constituent EHR
module of the combination has been tested and
certified in accordance with the certification program
established by the National Coordinator as having met all
applicable certification criteria adopted by the Secretary
of HHS, and the resultant
combination also meets the requirements included in the
definition of a qualified EHR.
is cholestrylester transfer protein facilitates the transfer
of cholesteryl esters and triglycerides between very low
density and high density lipoproteins.
- Trade in goods
- Tariff elimination on trade in goods
- Rules of Origin
- Technical barriers to trade made more transparent and
conformity assessed by protocol.
- SPS rules
- Customs and trade facilitation
- Services and investment facilitation
- Government procurement
- EU law on designations of high quality agricultural
products will hold
- Trade and sustainable development (trade and labor)
- Non-tariff barriers on cars (UN-ECE), pharma practices,
culture and media, competition,
state owned enterprises
- Intellectual property rights
- Copyright provisions
- Investor-state dispute settlement procedure
- Visa restriction removal by Canada on Czech, Romania and
as a terminator in medication names indicates the drug is a
CETP inhibitor. These drugs are taken orally
unlike the PCSK9 inhibitors of
cholesterol which have to be injected.
refers to 'Continuity of Care Documents' which are defined
within the HL7 CDA.
refers to Consolidated-CDA a HL7 standard used to meet 2014 EHR Certification Criteria for MU stage 2.
Consolidation pulled together disparate HL7 IGs to stop them diverging and
drive a single source for CDA templates.
is the certification commission for health information
technology. HHS provided
funding for CCHIT to develop standards certification
guidelines and evaluation criteria for HIT
products including EHR and NHIN architectures.
is a coordinated care organization. CCOs are a network
of all types of health care providers who have agreed to
work together to serve people in their community funded by
Oregon's Medicaid. CCOs
are focused on prevention and helping people manage chronic
conditions, like diabetes (1
is an HL7 standard - clinical context
object workgroup, an interoperability specification for the
visual integration of user applications.
refers to 'Continuity of Care Records' which are defined by
ASTM international, Massachusetts Medical Society, HIMSS, AAFP, AAP and others.
The CCR standard is a patient health summary standard
designed to create flexible documents that contain the most
relevant and timely core health information about a patient,
and to send these electronically from one care giver to
another. It contains various sections such as patient
demographics, insurance information, diagnoses and problem
list, medications, allergies
and care plan. The standards purpose is to permit easy
creation by a physician using an EHR
at the end of an encounter.
is a critical care unit.
is an HL7 standard - clinical
document architecture, an exchange model for clinical
documents based on HL7 messaging standard version 3.
It defines the encoding of documents for transfer in terms
of XML structures. It does not specify how the
documents are transported.
is the HHS's center
for disease control and prevention based in Atlanta
is the gene encoding Cdc42, cell division control protein 42
involved in regulation of the cell
is the clinical data repository/health data repository, a
database and interoperability infrastructure supporting
sharing of EHR between VA and DoD
systems. It includes a gateway translator between all
the vocabularies of the information being transmitted.
This allows all of the VA facilities to access and interpret
is clinical documentation improvement. Hospitals have
traditionally done this as a retrospective improvement where
physicians' clinical documents are reviewed by specialists
tasked with identifying improvements in coding, quality
measures, and overall care
management of the patient. It is hoped that
going forward natural language processing will be able to
identify the important data elements, run those across all
cases and identify a prioritized list of cases to
review. And to make the operation real-time CAC can be integrated with EHRs and appropriate physician
diagnosis workflows to ensure that documentation has the
correct ICD 10 codes.
is clinical decision intelligence system, a clinically rich
data warehouse supporting evidence based
is either clinical database or chronic disease management
is either a:
is Clinical decision support system. These support
clinicians decision making
by combining patient data with known medical knowledge to
provide alerts, such as drug combination interactions or
remiders of best care practices.
- Complementarity-determining region, a part of the
variable chains in antibodies
and T cell receptors, where
these molecules bind to their specific antigen, or a
- Clinical document repository
is the comprehensive environmental response, compensation
and liability act of 1980, which funds the cleanup of sites
that hvae been contaminated by hazardous substances and
pollutants. Sites managed by the act are called
Superfund sites. E.P.A. cleanup
can draw funds from the Superfund trust fund when the
parties responsible for the contamination can't
Cetuximab is an EGF receptor inhibitor. It is a
humanized mouse MAB branded as
Erbitux. It used to treate metastatic cancers: colorectal, non-small
cell lung, neck, head.
Cetuximab was developed by John
Mendelsohn, at UC
San Diego, with ImClone
Systems which was later purchased by Eli Lilly.
Being mouse originated, it has induced MMA
- Radiology CDSS order interactions are governed by PAMA and will use ACR
is the commodity futures modernization act which constrained
derivative market regulation, catalyzing the derivative
fueled housing boom and 2008 recession. It was
supported by Senator Phil Gramm and the Republican led
Congress, Federal reserve Chairman Alan Greenspan and the
Clinton Administration's Treasury
Department led by Larry Summers. Former Treasury
Secretary Robert Rubin also lobbied to over-rule Brooksley
Born, the dissenting chair of the CFTC.
President Clinton signed the act into law in
is chief financial officer
is the Code of Federal Regulations or in OKR
terminology it is Conversations: about optimizing
performance, Feedback: in all directions to evaluate
progress and guide improvement, Recognition of individuals
for their contributions.
is the commodity
futures trading commission, the regulator of the
futures and options markets, was created in 1974. It
enforced the CEA for these
is a gene coding for a cell membrane salt plus water
transporter, the cystic fibrosis transmembrane regulator,
which induces cystic fibrosis
following any of over 1000 alternative single point
mutations on both instances of the diploid somatic
chromosomes. Example mutations include:
Challenge is an aspect of psychological hardiness where change is
accepted and viewed as offering possibilities of development. New
situations are seen as opportunities rather than
- Deletion of phenylalanine 508; the most common cause of
- Replacement of Guanine by Adenine at amino acid position
551. This variant is being successfully treated with
- Some of the less common mutations do not damage the
Chargemaster is a hospital specific mapping
of chargeable ICD procedure codes to
the description and list price set by the hospital.
Chronic kidney disease
or CKD is
Chagas disease is a parasitic infection, due
to Trypanosoma cruzi, which can cause serious heart
is the California
- .ind.include ('html/awffwglossary.html', 'glckd1',
is the community health
accrediation program, one of three federally
recognized HHA focused programs along
with those provided by the Joint
Commission and ACHC.
Chapter 224 is Commonwealth of Massachusetts
chapter 224 act: In response to continuation of escalating
costs Massachusetts passed an act to improve the quality of
health care and reduce costs. The act included linking
the annual growth in health care spending to the gross state
is a consortium cohorts for heart and aging research in
Health Care Management, a company focused on relationship-based care
is coronary heart disease, also called heart disease or CAD. It reflects atherosclerosis of the
is the Community Health Data Initiative, a public-private
partnership committed to innovation through the use of
release the immune system's
checkpoints: PD-1, CTLA-4; on attacking host cells: by
1) stopping T-cell division and 2) reducing their life
spans. They are used in immuno-oncology
where, in 2016: They are approved for treatment of: Advanced
lung, kidney, liver cancer; They have a
general success rate of 20 - 40% and higher for melanoma. Checkpoint
inhibitors work best for tumors that have many mutations:
melanomas, lung and bladder
cancers. They are enhanced by adjunct treatments
that kill tumor cells generating debris to stimulate the
immune system. The drugs include: ipilimumab (CTLA-4 inhbition), nivolumab, pembrolizumab, atezolizumab (PD-1
inhibitors); They are costly and often have high copayments. They cause
auto-immune side effects including inflammation, rheumatoid arthritis
and damage to glands: Adrenal, Thyroid,
steroids such as prednisone can help reduce the
inflammation. Damaged glands require sustained hormone treatment.
Checkpoint inhibitor research is funded by the CRI.
Chemotherapy is the treatment of cancers by
highly cytotoxic chemicals: Paclitaxel,
Platinum, 6-mercaptopurine; assuming that cancer cells are
unusually active and will be differentially poisoned.
It has been successful in offering treatments when no other
course was available, but non-specificity means that healthy
cells also get poisoned resulting in side effects which
increase with age: Permanent nerve damage, heart failure (4-5%) and leukemia (0.5-1%).
is congestive heart failure which occurs when the heart is
unable to generate enough blood flow to meet the body's
demands. There are two main types: failure due to left
ventricular dysfunction and abnormal diastolic function
increasing the stiffness of the left ventricle and
decreasing its relaxation. Heart expansion in CHF
distorts the mitral valve
which exacerbates the problems. MitraClip
surgery trials found effective in correcting the mitral
valve damage (Sep
2018). Treatments include: digoxin;
Chikungunya is a mosquito vectored viral
infection in humans, causing fever and joint pain.
is the Children's Health Insurance Program Reauthorization
Act of 2009. It strengthened and extended CHIP. Georgetown's analysis
lists the main provisions of the law:
- The Children's Health Insurance Program started in 1997
as part of the BBA as SCHIP. It provides health
insurance coverage for children in families with income
below 200 percent of the poverty
line. The coverage is focused on care
specialized for children including: developmental delays,
chronic conditions including asthma
and obesity. CHIP's
funding must be iteratively re-authorized by
Congress. CHIP is financed federally, but states
must enroll eligible children. In many states one
agency administers CHIP and Medicaid.
CHIP is leveraged by families that have employer based
insurance with costly premiums, so the families only cover
- Clonal Hematopoiesis of Indeterminate Potential, where stem cells develop a somatic mutation cluster pair
often found in leukemia, which
is expressed in white blood cells they produce. The
mutation clusters give these stem cells a competitive
advantage and they accumulate over time. The white
blood cells form inflammatory plaques. CHIP
increases with age, increasing the risk of dying, of clot fragment induced heart attacks and stroke, over the subsequent 10
years by 54%
Chlorpromazine mitigates or stops schizophrenia's delusions,
hallucinations and some disordered thinking. But it
has problematic side effects: inducing neurological symptoms
like those of Parkinson's
disease. It blocks D2 dopamine receptors.
- Significant new CHIP funding through 2013
- Initiatives to enroll the lowest-income uninsured
children in coverage
- State option to cover legal immigrant children and
- State option to cover pregnant women
- New rules on covering moderate-income children
- Elimination of adult coverage
- New provisions for premium assistance.
- Improvements in the quality of care and benefits for
children, a provision that included the establishment of MACPAC.
is a community health needs assessment which is required by
the ACA (IV)
for tax exempt 501(c)(3) hospital status.
Cholangitis is an infection of the bile
ducts connecting the liver,
gallbladder and intestines.
CHRONIC care act of 2017
is Ron Wyden & Orrin Hatch's Creating High-Quality
Results and Outcomes Necessary to Improve Chronic Care Act
signed into law by President Trump as title III of the BBA of 2018.
'See-I-Care' is a UCLA health
acronym (described in Prescription
for Excellence) for:
is the Common Industry Format a standard for developers to
report usability test findings and demonstrate evidence of
usability of their products.
- Connect with the
patient or family member using Mr./Ms. or their preffered
- Introduce yourself and
- Communicate what you
are going to do, how it will affect the patient, and other
- Ask for and anticipate
patient and/or family needs, questions, or
- Respond to patient
and/or family questions and requests with
- Exit, courteously
explaining what will come next or when you will
is a non-small cell lung cancer
immuno-oncology vaccine. It is an active
vaccine, containing the ligand EGF
and P64k and Montanide ISA 51 which together stimulate the
immune system to generate antibodies targeted at EGF.
This results in the EGF concentration in the blood
dropping. Many cancers:
Lung, Colon, Kidney, Head,
Neck; leverage EGFR to stimulate
Circadian clock is a biochemical agent that cycles with a phase
locked to solar time. There are three major
components: 24 hour central oscillator, input pathways for signalling the agent, output
pathways that support coordination of the biochemistry,
physiology and behavior of the network of agents making up
the CAS; as identified by
Hall, Rosbash & Young. The human clock shifts as
we age (Dec
Circadian rhythm is a CAS process that has a 24 hour
oscillation driven by a circadian
clock. In humans there are many such processes:
sleep cycle (Dec
2015), liver, metabolism, immune system, oxidative
Cirrhosis is collapse of liver cell
from long term damage due to: hepatitis, chronic alcoholism,
fatty liver disease, hemochromatosis,
obesity, and many other causes;
with normal liver tissue being replaced by scar
is critical incident stress debriefing a technique developed
to support workers in high-risk occupations from developing
PTSD. Its value is debated
is the Convention on International Trade in Endangered
Species of Wild Fauna and Flora. It has gained teeth
from TPP provisions that enforce
Cites constraints on illegal smuggling with economic sanctions.
Citizens United is a 2010 legal case,
between the nonprofit and the FEC,
decided by the US Supreme Court, which restricts the
government from constraining independent expenditures of
nonprofit corporations, for-profit corporations, labor
unions and other associations from political campaign
spending, based on the free speech clause of the First
Amendment to the Constitution.
is CMS's comprehensive care for joint
replacement bundled payment
model (formerly CCJR). It is
limited to performing surgeries at hospitals rather than ambulatory
surgery centers, and paying only hospitals. It
is chronic kidney disease
- CJR is mandatory at 800 hospitals. It randomly
assigned 75 markets to be subject to bundled payments for
knee and hip replacements and 121 markets to use FFS payments. In
2017 the Trump CMS allowed hospitals in half the
bundled payments markets to opt out and three quarters of
the hospitals did so, obscuring the impact of bundled
payments in the experiment (Sep
- The episode payment covers inpatient hospital services,
physician fees, & 90 days of care after discharge.
- The bundle encourages post-acute care reform to reduce
variation in quality & risk.
is central line associated blood stream infection. Johns Hopkins
showed that central line infection rates can be driven to 0%
- Where there is permanent damage to the Kidneys. Diabetes and high blood pressure are the
leading causes of CKD. This has driven up the
percentage of American's suffering from CKD.
- CKD is diagnosed via a GFR
of less than 60, or another marker such as protein in the
urine, for atleast three months.
- The disease, classed as having five stages, causes no
symptoms until the later stages. The fifth stage of
CKD is ESRD. CKD is
associated with: Atherosclerosis,
deficiency anemia from reduced EPO
synthesis, Fluid volume overload, Hyperphosphatemia, Hypertension, Metabolic
acidosis, Mineral bone disorder, Potassium accumulation,
& Urea accumulation.
Claims Attachments is an
HL7 standard - a standard attachment
to augment a health care transaction.
act. This is the community living assistance services
and supports act. It is title
VIII of ACA. It
establishes a national, voluntary insurance program for
purchasing community living assistance services and supports
refers to a contractual requirement between a payer and provider or retailer
(pharmacy), where the cost of the goods supplied to a
subscriber is lower than the reimbursement
contracted with the payer, and the payer requires the
difference to be refunded.
- All employees are automatically enrolled, but are
allowed to waive enrollment.
- Payroll deductions pay monthly premiums.
- Benefits under a CLASS independence benefit plan provide
individuals with functional limitations with tools that
will allow them to maintain their personal and financial
independence and live in the community.
Clayton Antitrust Act of
1914. It aimed to prevent anticompetitive
practices. It specifies particular prohibitied
conduct, a three-level enforcement scheme, exemptions (labor
union and agricultural organization safe harbor, and major
league baseball exemption) and remedial measures. It
has four sections which modify the Sherman Act:
Clinical announcement is
an NIH special alert for advances so
important that they should change medical
Clinical endpoint in a
research trial is among the study objectives and is the
occurence of a disease, symptom, sign or laboratory
abnormality which can be measured indicating the
intervention is worthwhile.
Clinical engineering is
the maintenance of clinical infrastructure.
- Section 2 controls price discrimination between
purchasers if it lessons competition.
- Section 3 controls exclusive dealings where purchasers
are required to buy a tied product.
- Section 7 control mergers and acquisitions where the
effect substantially lessens competition. It allows
the government to regulate all mergers and gives the
government discretion whether to approve a merger or
not. Section 7 was later strengthened to cover asset
acquisitions by the 1950 Celler-Kefauver amendments.
Section 7a requires companies considering a merger to
inform the FTC and DOJ.
- Section 8 limits people from being directors of two or
more competing corporations if those two corporations
would violate the anti-trust criteria by
Clinical IT is
Clinical integration is
as an active, ongoing cooperation with a high degree of
interdependence among physicians to control costs and ensure
quality where joint negotiations will be evaluated by the 'rule of reason' finding
considerable procompetitive benefits to consumers enabled by
ancillary price coordination and
dependent on this cooperation. It can include:
Clinically integrated network
is a legally acceptable clinical
integration of hospital, physicians and/or other
dedicated health care providers who deliver services focused
on quality, performance, efficiency and value to the
patient. In comparison with a SuperGroup it also increases
market power while sustaining expert agent
independence. But it is hard to manage and requires
significant infrastructure expense to support clinical
integration and management of utilization and financial
uncertainty. Initial setup will have to manage the
problem of prior contracts the new members have with IPA, PHO or ACOs. An alternative to a
clinically integrated network is a messenger model network.
The Joint Commission
specified an OPPE requirement for
general performance improvement. Network providers
must develop and sustain clinical initiatives that enhance
access to care, clinical quality, cost control and the
patient experience by:
- Establishing mechanisms to monitor and control
utilization of health care services that are designed to
control costs and assure quality of care;
- Selectively choosing network physicians who are likely
to further these efficiency objectives;
- Significant investment in capital,
both monetary and human, in the necessary infrastructure
and capability to realize the claimed efficiencies.
are clinical laboratory improvement amendments (1988)
federal regulatory standards that apply to all clinical
laboratory testing performed on humans except during
clinical trials and basic research. I-SPY 2 uses CLIA approved
biomarkers when they show promise in predicting which
patients will respond to which treatment agents but have not
been FDA approved yet.
- Coordination across the network,
- Implementing evidence-based
- Improving efficiency in the delivery of care,
- Partnering with payers to
develop contracts that drive definable clinical
improvement and add value to patients.
Clinical mobility is M-health.
Clinical pathway is a
standardized care strategy based on a task-oriented care
plan, detailing essential steps in the care of patients with
a specific condition. The plan details the expected
clinical path. It was initially adopted to guide EBM and was implemented in most
hospitals during the 1980s. But the implementations
were piecemeal. As recent reimbursement
changes require hospitals to control resource consumption,
standardized clinical pathways can help. Five criteria
have been derived. The intervention:
is chronic lymphocytic leukemia,
a blood cancer which begins from an acquired mutation of the
DNA of stem cells that generate
lymphocytes in the bone marrow. Some CLL grow fast,
others grow slowly and may be responded to with watchful
- Is structured as a multidisciplinary plan of care
- Channeled the translation of guidelines or evidence into
- Detailed the steps in a course of treatment or care in a
plan, pathway, algorithm, guideline, protocol or other
'inventory of actions'
- Had timeframes or criteria-based progression
- Aimed to standardize care for a specific clinical
problem, procedure or episode of health care in a specific
Clonal selection is
Frank Burnet's highly regarded model of how the immune system responds to
antigens. B lymphocytes,
which each produce only a specific antibody,
respond to matching antigens by cloning themselves in the
secondary lymph organs: spleen and lymph nodes.
Clopidogrel is a platelet
aggregation inhibitor, branded as Plavix.
Its action as an inhibitor is dependent on CYP2C19.
Closed model plan is a
type of HMO where the physicians are
constrained to see only patients contracted with the
HMO. These plans include:
usually competes with other bacteria in the human gut microbiome. But antibiotic treatments provide
it with an advantage where it becomes the predominant gut
bacteria causing diarrhea,
abdominal pain, and toxic megacolon. Repeated
treatments select for infections that are progressively more
difficult to treat. C. difficile infections kill more
than 25,000 people a year in the US. Fecal
transplants, especially enabled by stool-banking,
reintroduce competitive bacteria that limit the success of
C. difficile and cure patients with previously recurrent
infections. But the F.D.A. has
not approved such transplants as a treatment and the
procedure is not covered by insurance.
- Staff model physician contracts where the physicians are
paid by the HMO and work in its buildings.
- Group model where the physicians contract with a
multi-specialty physician group
practice. These can be:
- Captive group model where the physician group
contracts to only treat the HMO's patients. Kaiser
has used this model extensively.
- Independent group model where the physicians continue
to treat non-HMO patients. This is not a closed
or coagulation is formation of a clot:
Club for Growth is a right-wing conservative
501 political action group, founded in
1999 by Harlan Crow, Thomas Rhodes, Richard Gilder and
- Platlets become activated, adhere and aggregate
- Fibrin polymerization,
deposition and maturation.
is continuing medical education - training updates to keep
knowledge current. It is developed and delivered by
Professional associations, Medical education agencies,
Hospitals, Educational institutions and hoe study nursing
continuing education providers. There are:
is chronic myelogenous leukemia.
It is a leukemia characterized by the unregulated growth of
myeloid cells in the bone marrow. The growth is
encouraged by the cellular signalling
system (gene change that generates a faulty tyrosine kinase) being
locked on. Visual methods allowed Dr. Janet Rowley's
team to recognize that most CML includes the Philadelphia chromosome.
It encodes the chimeric always on tyrosine kinase protein
seen only in CML. Targeted treatments such as Gleevec block the pathway for the
- Formal learning activities including planned programs,
enduring materials (DVD and web), Process improvement CME;
- Informal Internet-point of care research and decision making, and
journal clubs where published research is evaluated by the
is the center for Medicare and Medicaid Innovation. It is a
test bed for new ways of financing and delivering
care. It allowed Congress to institutionalize innovation sending a signal to providers that they
would be participating in CMS driven
programs that could become mainstream. It funds
evaluations of innovative health care models. Under
the ACA if the HHS
secretary finds any of its projects would reduce Medicare
spending without harming the quality of care the projects
may be expanded nationwide. The CBO
estimates the CMMI will save $34 billion between 2016 and
2026. CMMI projects include:
is the Civil Monetary Penalty Statute, part of the SSA, which prohibits a hospital from
knowingly paying [in]directly a physician as an inducement
to reduce or limit services to a Medicare
or Medicaid beneficiary who is
under direct care of the physician.
- Chief medical officer or a
- Care maintenance organization or in finance a
- Collateralized mortgage obligation. The
collateralized mortgage obligation was invented by Larry
and team while they were at First Boston in 1983.
The key innovation was that the risk in these contracts
was more predictable than in an MBS
due to the presence of a trust that guaranteed payments to
the bond holders. The risk was separated into
tranches with different credit ratings and yields.
The structure was used by the banking
and securities companies to finance the subprime housing boom.
is the centers
for Medicare and Medicaid services.
is either: a controlled medical vocabulary or cytomegalovirus.
is a certified nursing assistant. CNAs helps patients
with health care under the supervision of an RN.
is chief nursing officer
is certified nurse, OR
CNOR Strong is a credential from the CCI
awarded for having an OR staffed with a team that have CNOR skills.
is a copy number variant where the DNA
of a chromosome includes portions that is repeated many
extra times. These can be large enough to include
whole genes. Data suggests that CNVs account for some
cases of autism and schizophrenia.
Co-management is an arrangement (direct
contract or joint venture) between various medical groups
and physicians (inpatient, outpatient, ancillary,
multi-site) which recognizes and appropriately rewards each
for participating without breaking regulatory requirements (CMPS, Anti-Kickback
statute, Stark law, False Claims Act, Tax Exemption
intermediate sanctions, provider-based
status rules). It requires a board predefined
valuation of the contracted process accomplishments.
As such growth of the service
line cannot result in additional rewards to the
physicians. It requires physicians to document
details. It constrains hospitals service lines from
providing other similar services. Typical service line
co-management arrangements listed by healthcareappraisers
Coagulation is the formation of a
- Development of Service Line
- Medical Director services
- Budget process
- Strategic/business planning process
- Community relations and education
- Patient, physician and staff satisfaction surveys
- Development of clinical protocols and performance
- Ongoing assessment of clinical environment and work flow
- Physician staffing
- Patient scheduling
- Staff scheduling and supervision
- Human resource management
- Case management
- Materials management
- Medical Staff related activities and committee
- Credentialing assistance
- Coordination with and reporting to hospital
is the consolidated Omnibus Budget Reconciliation Act of 1985
with amended ERISA to give some
employees the ability to continue health care coverage after
is the American Joint Commission on Cancer
(AJCC). It was formed in 1958 to formulate and publish
systems of classification of cancer
for the medical profession. It focuses on cancer epidemiology, patient care,
cancer control, cancer registration, professional education,
research and biostatistics.
- .ind.include ('html/awffwglossary.html', 'glclotting1',
Code trays are pharmacy
proposes that more education leads to more brain patheways
which compensate longer for cognitive decline.
Coinsurance is where a patient's contract
with the insurer requires the patient to pay a percentage of
the amount billed for a particular drug or sevice. It
may vary across the various networks and out of network
Colectomy is the complete surgical removal
of the colon.
Coleman model is a care transition
program lead by Dr. Eric Coleman. Transitional
care is based on a plan of care and the availability of
practitioners who are well-trained in chronic care and have
current information about the patients' goals, preferences,
and clinical status. It includes logistical
arrangements, education of the patient and family, and
coordination among the health professionals involved in the
is an old antibiotic that is
held in reserve in the US to treat especially dangerous
infections (CREs) that are resistant
Colon cancer is a major hereditary cancer also called colorectal cancer.
Colorectal cancer is
also called colon cancer.
- Follows a slow, many yearlong, progression from a benign
polyp to a localized cancer to an invasive one. Two
bacteria: Bacteroides fragilis, Escherichia coli variant;
from the gut microbiome have
been implicated in the early stages of tumor induction (Feb
- Is often associated with Ras
mutations and the high risk allele TCF7L2.
30 to 50% of colon cancers have KRAS
mutations. Intensive medical surveillance and
removal of polyps can be lifesaving for those at high
risk. Types of colon cancer include the single gene
mutation hereditary: FAP, HNPCC;
- Is linked to obesity.
Commerce department - U.S. Department
Common Framework is the
Markle common Framework used by connecting for health.
The common framework provides information about setting up
the agents of a CAS based electronic
health network that allows emergence of the NHIN. It includes:
- .ind.include ('html/awffwglossary.html', 'glcoloncan1',
Community health workers
are trained lay people who share socioeconomic backgrounds
with the patients they help address the underlying social,
financial, and behavioral causes of their health problems, according
Emanuel. They focus on poorer patients with
complex conditions and few social supports. At University
of Pennsylvania they follow the IMPaCT model. They:
- Policy guides for how information is protected
- The architecture for privacy in a networked
- Model privacy policies and procedures for health
- Notification and consent when using a record locator
- Correctly matching patients and their records
- Authentication of system users
- Patients access to their own health information
- Auditing access to and use of a health information
- Breaches of confidential health information
- A common framework for networked personal health
- Technical guides for how information is exchanged
- Technical issues and requirements for common framework
- There is an architected hierarchy. The NHIN is
viewed as a network of SNOs -
while entities within an SNO are free to communicate
directly with other entities in the SNO, inter SNO
communications is required to go via an ISB so that all flows between
SNOs can be observed.
- HIE architecture implementation
- Medication history standards
- Laboratory results standards
- Background issues on data quality
- Technical background of record locator service
- Consumer authentication for networked personal health
- Model contractual language
mandates health insurers charge the same price to people of
the same age living in the same geographic area.
- Track down or obtain key resources for living: Birth
certificate, social security card, Utility bill, help
apply for housing, daycare, food-stamps, home ramps &
other social services
- Health system navigation: Apply for health insurance,
find PCP, Schedule appointments,
travel support, obtain health records
- Medical assistance: Obtain medications and DME, Coach patients on appointment
strategies, Get patients to write down questions for
physicians, Accompany patients to grief & addiction counseling
- Lifestyle change: Exercising, Encouragement with
weight-loss and smoking-cessation strategies
- Psychosocial support: Take patients to enjoyable events
and encourage them to sign up for community volunteer
Compensation in workflow provides a service
to execute a compensating transaction which initiates
actions that undo all the completed activities of a long transaction that has
been abandoned. It is a complex problem to architect
and implement effectively because undoing completed actions
can result in a cascade of additional long transaction
Complete EHR is CFR 45CFR
Part 170's definition of an EHR
technology solution which is able to perform, at a minimum,
all of the applicable capabilities required by certification
criteria adopted by the Secretary of HHS.
Compounding pharmacies make
unique prescription drugs to order when doctors
conclude that standard formulations are not effective
is certificate of need, a legal document required in many US states and some federal jurisdictions
before proposed acquisitions, expansions, or creations of
facilities are allowed. It was initially developed in
health care in New York in 1964 and then became federal law
in 1972. States were concerned that in an over
saturated field competitors would over charge patients to
cover costs, or unnecessarily treat them. In effect
current market participants are granted monopoly rights!
Connect Project uses open source Java to
implement the architectures of eHealth Exchange. It
was sponsored by a variety of federal agencies which wanted
one implementation of eHealth Exchange to operate
across. The agencies now use the connect gateway for
at least demonstrations. The architecture includes a
gateway and adapter. These use lower level core
components to perform operations:
Connecting for Health is
Foundation public-private collaboration.
Connecting for health conducted a three state prototype of
electronic health information exchange based on Markle's Common Framework in
2004. The three SNOs were Mendocino
California HRE, Indiana HIE
providing an implementation of the NHIN.
is chief operating officer
Copayment is a fixed payment for a covered
service after any deductible has been met. It is a key
strategy of the ACA to make
subscribers aware of the costs of treatment and to put
pressure on high cost health services. As such
suppliers and providers are keen to undermine the copayment:
health insurance, Paying the copayment (Oct
2015), Place on the USPSTF
list of preventative services (Sep
- Gateway - Network orchestration components, gateway
processes responsible for accepting messages from the NHIN and processing them or passing
them through to the adapter.
- Adapter - uses entity orchestration components which
orchestrate the request and send the message and SAML
assertion through the message proxy component.
- Message proxy components must properly handle the SAML
security layer. Once it has constructed a valid
SAML message it submits it to the NHIN and waits for the
- Adapter services: adapter, adapter document query,
adapter document retrieve, adapter document submission,
Adapter master patient index, Adapter notification
processing, Adapter policy, Adapter re-identification,
Adapter subscription management
- NHIN orchestration, Entity
orchestration, Message Proxy all contain,
- Audit reporting component
- Document query component
- Document retrieve component
- Document submission component
- Notification processing component
- Patient discovery component
- Core components:
- Audit log data transfer engine
- Audit recorder facade
- Audit repository
- Connection manager
- Patient correlation
- Patient correlation facade
- Property accessor
- Subscription repository
is chronic obstructive pulmonary disease. It is one of
the most common lung diseases. Chronic bronchitis and emphysema are the major
is the CAQH's committee on operating
rules for information exchange. It was accepted as an
NCVHS operating rule
authorizing entity. Its HHS
accepted rules are:
Coronary artery is an artery supplying the
heart muscle with oxygen and other resources.
- Claim Submission ASC X12N 837
- Eligibility and Benefit Verification ASC
- Eligibility and Benefits Real Time Companion Guide
- Eligibility and Benefits Connectivity Rule - specifies
a common connection that will be provided by all
- Eligibility and Benefits Data Content Rule - minimum
requirements of the request and response to inquire
about health plan insurance coverage request using ASC X.12 005010X279A1 Eligibility
benefit req/res and the responding ASC X.12 005010X279A1
eligibility Benefit req/res. The rule includes:
- Dates of eligibility for contract and benefit level
- Patient financial responsibility for each specified
benefit at the base contract amounts for both
in-network & out-of-network.
- Name of the health plan
- Eligibility and Benefits Batch Response Time Rule - A
request sent by 9pm Eastern must be returned by 7am
Eastern next business day.
- Eligibility and Benefits Real Time Response Time Rule
- Maximum of 20 seconds.
- Eligibility and Benefits System Availability Rule -
requires 86% availability per cal week for realtime and
- Claim Status Rule
- Eligibility and Benefits 270/271 Normalizing Patient
Last Name Rule - this aims to improve unique
identification but not fully.
- Eligibility and Benefits 270/271 AAA Error Code
Reporting Rule - allows consistant feedback on failure
to uniquely identify the individual so the inputs can be
corrected/updated and the transaction resubmitted.
- Eligibility and Benefits 270/271 Data Content Rule -
requires the provision in the eligibility response of
the remaining patient deductible amounts for certain
service type codes.
- Eligibility and Benefits 270 Connectivity Rule -
requires use of tow message envelope standards submitter
authentication (user name, password, digital
certificates) and metadata.
- Prior Authorization
ASC X12N 278
- Claim Status Inquiry ASC X12N 276/277
- Claim Payment NACHA Corporate Credit or Deposit Entry
with Addenda Record (CCD+)
- Remittance Advice ASC X12N 835
- Acknowledgements are currently voluntary.
Coronary occlusion is a
partial or full obstruction of blood flow in a coronary artery.
Cost sharing is the requirement for patients
to pay a portion of the cost of their health care
services. Such out-of-pocket payments include: copayments, deductibles and coinsurance.
Cost sharing subsidies
are part of the ACA legislation that
requires the government to pass-through CSR
subsidies via their insurers to patients who cannot afford
to pay their cost sharing
Cost shifting is the practice of:
Costa-Hawkins is the Costa-Hawkins Rental
Housing Act of 1995, a California state law which constrains
municipal rent control ordinances. Cities are
prohibited from using rent control for single family
dwellings, condominiums and newly constructed apartment
units. And the law prohibited municipalities from
applying rent controls to new tenants. Before the law
passed, cities had responded to high rental increases driven
by demand generated by high house prices, with rent
- States to shift dual
eligibles from Medicaid
to Medicare federal funded
- Hospitals to maintain margins, when under pressure from
reduced reimbursement, by
increasing charges for services provided to
non-contractually protected patients.
is a brand name for warfarin.
is the CMS comprehensive
primary care initiative. Medicare
is working with commercial and state health insurance plans
and offer bonus payments to primary care doctors who better
coordinate care for
their patients. PCPs that
participate are given resources to better coordinate primary
care for their Medicare patients.
is computerized provider order entry. Certified EHR
technologies are required to support CPOE ordering of
medications, laboratory and radiology/imaging. CPOE
can provide physician support reducing medication errors
significantly, as illustrated at Beth
Israel. ISVs such as Surescripts
can then route the order to the pharmacy.
is cardiopulmonary resuscitation aims to restore a flow of
oxygenated blood to the brain and heart to delay tissue
death. For adults the procedure involves 100 to 120
chest compressions a minute of 5 to 6 cm depth. The
procedure should be administered for about one hour.
Pushing oxygen into the patient's lungs can be added where
the rescuer has been trained. If the pulse is checked
it should be done only for 10 seconds at a time.
is VistA's graphical user interface
and stands for computerized patient record system. It
allows health care providers at the VA's
more than 1000 facilities to review and update a patient's EHR.
the AMA specified procedure treatment
codes for medical and psychiatric procedures performed by
physicians and surgeons used when billing for
procedures. The AMA operates a $70M business which
develops the classifications in secret. Doctors are
not informed of changes. Insurers 'bundle' and 'downcode' treatments that have
been performed. Potentially doctors may lose money on
the overall treatment.
is the community reinvestment act of 1977 which requires
banks to help meet the credit needs of low-income
neighborhoods in areas they serve.
provision requires creditors to accept a bankruptcy court imposed
restructuring of debt.
Crash carts are pharmacy
Enterobacteriaceae. When carbapenem fails to treat an
infection the patient is in serious trouble. The CDC estimated CRE accounts for around
9,300 infections and 610 deaths yearly in the US in 2010-15. However the CDC also
is a gene involved in the embryogenesis of the premigratory
neural crest domain of the ectoderm supporting migration
after which expression is downregulated. In normal
mature skin cells, bone cells or tooth cells the crestin
gene is shut down.
is the Conscience
and Religious Freedom Division of HHS's
- In July 2010 the state of Florida instigated procedures
that reduced the number of patients with CRE from 60% to
less than 10% at a problem LTCH.
The improvement was based on
- Detecting and protecting - Screening, isolating, and
grouping patients with CRE to prevent spread to other
- Reviewing staff operations for 40 hours checking hand
hygene, glove and gown use and other practices during care
- Iterative communications between the problem facility
and local, state and federal public
is a certified registered nurses trained in anesthesia.
is the cancer
Crime Bill is a popular term for President
is Chesapeake regional information system for our patients
is clustered replicating interspersed silent palindromic
repeats; a technique for exact targeting, cutting and
editing of DNA based on leveraging
bacterial enzymatic defenses against viruses
generalized to any DNA sequence in a prokaryotic or eukaryotic cell. It was
identified during studies of a bacterial adaptive immune system. In that
system bacterial proteins grab parts of a virus that has
infected them and record it within the palindromic
structures that mark an array of inserted viral DNA used as
a log persisted over generations. If a new infection
occurs the viral DNA is compared with the sequences and if a
match exists the CAS proteins break up the viral DNA
initiating its destruction. This bacterial system was
then updated and repurposed by the researchers to support
targeted genetic engineering. As explained by Dr.
Doudna, the CRISPR proteins and the 20 nucleotide RNA
template migrate into the nucleus where they rapidly target
DNA which complements the RNA template and the Cas9 enzyme
performs the edits. Being a bacterial system CRISPR
Cas9 does not target eukaryotic
heterochromatic DNA well.
It is not fully understood how they find the target sequence
so quickly. It has been shown that Cas9 will bind to
sites with a 5-8 base match but then it releases rapidly
without cutting. To cut, Cas9 has to reconfigure,
which does not occur in the mismatch situations.
Crohn's disease is an IBD
which results in abdominal pain, diarrhea,
weight loss, anemia, skin rashes,
arthritis, colon cancer.
There are genetic risk
factors: PD-1 failure, and
mutations of LRRK2, SLC11A1. Treatments include:
Cross contact is a manufacturing problem of
cross contamination caused by two food products being
developed on the same manufacturing line. Allergens
from one product may be picked up by the second
is the Congressional Research Service.
allows non-crystalline proteins
to be viewed, by freezing the molecules and surrounding
water layer, without crystallizing, in liquid nitrogen, and
gathering electron scattering from the protein molecules and
then recombining all the different orientations captured
into a 3D model by computer modeling.
is the chemical safety improvement act of 2016 (formerly the
Frank R. Lautenberg Chemical Safety for the 21st Century
Act), which updates the TSCA with
is central sterile services department performs
sterilizations and other maintenance to medical devices,
equipment and consumables.
- EPA mandated to evaluate existing
chemicals with clear and enforceable deadlines
- Chemicals evaluated against a risk-based assessment
- Unreasonable risks identified by the assessment must be
- Increased authority to require development of chemical
is the Actuarial Standards board's Commissioners Standard
Ordinary mortality tables. A model is defined by the
actuarial standards as an information structure and a
mathematical representation of a phenomena or
is cost sharing reduction, a
by the ACA individual
insurance market providers
with reduced subsidies and offset repayments required
by the law so that they can remain profitable during the
bootstrap phase of participation.
is computerized tomography in which a series of X-ray views
taken from many angles are combined by computer processing
to create 3-D images. It is very useful for examining
people who have been subject to trauma such as car
accidents. The high dose of radiation is a cause for
concern with over use of CT scanning (Jan
2014). The Banyan Brain
Trauma Indicator blood test should help here.
is Care Transitions Intervention, an 'evidence
based model' of effectiveness in reducing hospital readmissions of patients
discharged to home. Randomized control trials have
shown significant improvement in following discharge
procedures and reducing readmissions from CTI.
Transition coaches teach the patient the skills to manage
the patient's own needs effectively during the transition
period after discharge. The coaching consists of five
is expressed on the surface of helper T
cells and transmits inhibitory 'checkpoint' signals to T cells. It is
part of the immunoglobulin superfamily.
- In the hospital before discharge,
- During a home visit,
- - 5. Telephone calls.
is Eric Coleman's three
item care transition measure. It is a survey of a
population with a model of scoring and sampling to generate
a statistical assessment of the patient population's
transition experience. It includes the training on
giving the survey, and constructing and applying the
is a clinical trials management system
is current product engineering.
is cardiovascular disease which refers to:
is a coding representing every US
licensed vaccine. MCIR recommend using CVX coded vaccine
descriptions in transfer files (EHT, HL7
- .ind.include ('html/awffwglossary.html', 'glcardiovas1',
is the clean water act of 1977 amended by the Water Quality
Act of 1987. The CWA amended the Federal Water
Polution Act of 1948 rewrite of 1972. The CWA is the
primary law covering water pollution. It aims to
sustain the integrity of US waters by
preventing pollution, assisting with treatment, and
supporting wetlands. It does not cover groundwater
contamination, which is protected by: SDWA,
is a gene in the cytochrome P450 gene family which codes for
a liver enzyme
which is used by pharmaceutical companies to metabolize
drugs to their active form: clopidogrel,
mephenytoin, omeprazole, proguanil;
is a gene in the cytochrome P450 gene family which codes for
a liver enzyme
which is used by pharmaceutical companies to inactivate
drugs. More than 50 SNPs in
regulatory and coding regions of the gene alter the
processing. Some SNPs are associated with reduced
enzyme activity which can result in adverse drug reactions.
is a gene in the cytochrome P450 gene family which codes for
cytochrome P450 2D6 enzyme
primarily in the liver, but also in
the substantia nigra.
It is used by pharmaceutical companies to activate drugs
including: Codeine, Tamoxifen.
Cystic fibrosis is a deadly, recessive
genetic disease caused by a variety of single gene mutations
in the CFTR gene, most commonly
occurring in people of northern European background.
Screening would work best if applied to couples prior to
conception but this is not how carrier screening is
organized as of 2015. Cystic fibrosis can result in:
fibrous cysts in the pancreas; which does not secrete its
normal digestive enzymes inducing serious malnutrition, intestinal
blockages, infertility in males and lung damage due to
accumulation of a thick, sticky secretion followed by
recurrent infections. Symptoms vary among sufferers
Cytokines control the development of hematopoietic cell
lines. They regulate the immune
response and are involved in the development of
Cytomegalovirus or CMV, is a robust herpes virus
that can leave babies with brain damage, vision
abnormalities, microcephaly and deafness. 20,000 to
40,000 babies are born each year with CMV. More than
20% develop permanent disabilities. Nearly one in
three children are infected by age 5 and more than half of
all adults by age 40. CMV is transmitted by contact
with infected saliva and urine. Pregnant women are
often infected by toddlers. Day cares act as a
powerful infrastructure amplifier where young children chew
and share toys. In 2016 there is no vaccine or standard
is disability adjusted life years.
Darbepoetin alpha is a
- Modifier genes which vary between individuals.
- Environmental differences:
- Second hand smoke exposure is a significant
contributor to cystic fibrosis effects
- Medical interventions such as: pancreatic enzyme
capsules, chest physical therapy, antibiotics, aerosolized
enzyme therapy, saltwater mists and double lung
transplants; can reduce the effects
Dartmouth Atlas is the Dartmouth
Institute's map of the US on which is documented
spending by Medicare. As
of 2015 it demonstrates extraordinary variation in spending
on health-care from place to place with a negative
correlation between expenditure and quality of
Dartmouth Clinical Microsystem
is a small group of people who work together on a regular
basis to provide care to discrete subpopulations including
the patients. It has clinical and business aims,
linked processes, shared information environment and
produces performance outcomes. They evolve overtime
and are often embedded in larger organizations. They
are viewed by the Microsystem
academy as a Complex
Adaptive System. They are the building blocks
which form hospitals.
Darunavir is an HIV
medication taken once a day. It is marketed in the US as Prezista.
Daily care review is a
process coordinated by case management to align care with
physician assessments and regulatory
Data exclusivity is a
regulatory protection extended to biologics
which protects their manufacturer's profits from attack from
Data visualization aims
to communicate information clearly and effectively via signals presented as
Day hospitals are based on the Royal
Bournemouth and Christchurch Hospital's Day
Hospital Program. This provides specialist
assessment, treatment and rehabilitation for older people
that aims to:
is dialectical behavioral therapy, a treatment for BPD. It was designed by Marsha
Linehan who added validation and dialectics to cognitive behavioral therapy.
- Maximize the health and independence of older people as
far as possible for that individual
- Assist primary care and social care services with the
treatment and management of people with complex conditions
that are associated with age
- Avoid preventable hospital admissions and facilitate
early supported discharge.
is ductal carcinoma in situ where abnormal cells have been
found piled up confined to the lining of the milk ducts of
the breast. They are detectable in a mammogram and can look like cancer cells to a pathologist.
The cells could be spread along the whole of the milk duct
suggesting a need for mastectomy rather than lumpectomy
analogous to cervical cancer treatments after a Pap
test. It is now known that the DCIS may disappear over
time, or stop growing and remain stable. Most women
diagnosed with early stage DCIS have surgical or
chemotherapy treatment, which does not alter their life
2015). No data is available detailing a
correlation with breast cancer.
But it is now understood that metastatic cancers are
different from localized cancers.
- Cognitive behavioral therapy - teaches how to change the
situation. The goal is to change behaviors to obtain
a life worth living.
- Validation - supports the BPD sufferer who finds change
- Dialectics - shows that everything is connected, change
is constant and inevitable and opposites can be integrated
to get closer to the truth.
is dilated cardiomyopathy.
It often starts in the left ventricle which stretches and
thins. Poor pumping can affect the: Lungs, Liver, and other organs;
is designated collaborating organization, an organization
that has established a formal relationship with a CCBHC to indirectly provide its
is a small protein fragment that is present in blood after
fibrinolysis of a clot. It
is a fibrin degradation
product. D-dimer can be measured with a blood
is the Drug Enforcement Administration.
Death with Dignity Act
of 1997 allows terminally-ill Oregonians to end their lives
with a voluntary self-administered of lethal drugs,
expressly prescribed by a physician for that purpose.
Debridement is the removal of damaged tissue
& foreign matter from a wound.
is death effector domain, a protein domain found in proteins
responsible for apoptosis.
has been used to treat:
Deep learning is an artificial intelligence
approach where engineers deploy data into deep neural networks.
- Parkinson's disease,
where the high-frequency impulses are used to block the
firing of neurons with abnormal signals causing the
symptoms of the disease.
- Depression with higher than
average activity anterior
insular. The stimulation is used to slow the
firing rate of neurons in area 25. The patients
recovered and were stabilized for the long term.
Deferred costs have already been incurred
but will not be expensed until a later reporting
period. Often they can compound while sitting on the
balance sheet as an asset or hidden off balance sheet.
Defined contribution plan
is a retirement plan (403(b), 457 or Thrift) in which the
employer, employee aor both make contributions on a regular
is Bis(2-ethylhexyl) pthalate is used as a
Delamanid is a drug treatment for MDR TB. It blocks the
synthesis of mycolic acids, resulting in the destabilizing
of the cell wall of Mycobacterium tuberculosis.
is a classification of memory impairment, constrained
feelings and enfeebled or extinct intellect. The most
common form for people under 60 is FTD.
Dementia has multiple causes including: vascular disease
(inducing VCI) including strokes, head trauma, syphilis and
mercury poisoning for treating syphilis, alcoholism, B12
2016), privation, Androgen
deprivation therapy (Oct
2016), stress, Parkinson's disease, Alzheimer's disease, and
prion infections such as CJD and kuru. The condition
is typically chronic and treatment long term (Laguna Honda
by Stanley Prusiner to become a major burden on the
health system. It may be possible to constrain the
development some forms of dementia by: physical activity, hypertension management, and
ongoing cognitive training. Dementia appears to develop
faster in women than men.
Dengue fever is a mosquito vectored virus that can cause high
temperature, intense joint and muscle pain,
hemorrhagic fever and hence
death. The number of cases has been growing sharply
and spreading out beyond its traditional base in the tropics
and subtropics to Hawaii, Japan and the Florida Keys.
Between 50 and 100 million people are estimated to be
sickened by dengue fever a year.
Denial management is an
aspect of case management
supporting the process of denial of claims.
Depression is a debilitating episodic state
of extreme sadness, typically
beginning in late teens or early twenties. This is
accompanied by a lack of energy and emotion,
which is facilitated by genetic predisposition - for example
genes coding for relatively low serotonin
levels, estrogen sensitive CREB-1 gene which increases
women's incidence of depression at puberty; and an
accumulation of traumatic events. There is a
significant risk of suicide:
depression is involved in 50% of the 43,000 suicides in the
US, and 15% of people with depression commit suicide.
Depression is the primary cause of disability with about 20
million Americans impacted by depression at any time. There is evidence of
shifts in the sleep/wake cycle in
affected individuals (Dec
2015). The affected person will experience a
pathological sense of loss of control, prolonged sadness
with feelings of hopelessness,
helplessness & worthlessness, irritability, sleep
disturbances, loss of appetite, and inability to experience
pleasure. Michael Pollan concludes depression is fear of the past. It affects 12%
of men and 20% of women. It appears to be associated
deprivation therapy treatment for prostate cancer (Apr
2016). Chronic stress
depletes the nucleus
accumbens of dopamine,
biasing humans towards depression. Depression easily
leads to following
unhealthy pathways: drinking, overeating; which
increase the risk of heart
disease. It has been associated with an aging
related B12 deficiency (Sep
2016). During depression, stress
mediates inhibition of dopamine
depression and stress activate the adrenal glands' release of cortisol, which will, over the
long term, impact the PFC.
There is an association between depression and additional
brain regions: Enlarged & more active amygdala, Hippocampal dendrite and spine
number reductions & in longer bouts hippocampal volume
reductions and memory problems,
Dorsal raphe nucleus linked to loneliness, Defective
functioning of the hypothalamus
undermining appetite and sex drive, Abnormalities of the ACC. Mayberg notes ACC area 25: serotonin transporters are
particularly active in depressed people and lower the
serotonin in area 25 impacting the emotion circuit it hubs,
inducing bodily sensations that patients can't place or
consciously do anything about; and right anterior insula: which
normally generates emotions from internal
feelings instead feel dead inside; are critical in
adversity can increase depression risk by linking
recollections of uncontrollable situations to
overgeneralizations that life will always be terrible and
uncontrollable. Sufferers of mild autism often develop
depression. Treatments include: CBT
which works well for cases with below average activity of
the right anterior insula
(mild and moderate depression), UMHS
depression management, deep-brain stimulation
of the anterior insula to slow firing of area 25. Drug
treatments are required for cases with above average
activity of the right anterior insula. As of 2010 drug
treatments: SSRIs (Prozac), MAO, monoamine reuptake inhibitors;
take weeks to facilitate a response & many patients do
not respond to the first drug applied, often prolonging the
agony. By 2018, Kandel
notes, Ketamine is being tested
as a short term treatment, as it acts much faster, reversing
the effect of cortisol in stimulating glutamate signalling,
and because it reverses the atrophy induced by chronic
predictions of which treatment will be effective have
not been possible because: Not all clinical depressions are
the same, a standard definition of drug response is
Dermatitis is inflammation of the
Dermatology is the branch of medicine
dealing with skin, hair, nails and their diseases. Dermatology
includes cosmetic and medical branches including
pathology. Mohs surgery
focuses on skin cancer. Tele
medicine is allowing non-dermatologists to send
details of a patient to an off-site
Desensitization is a two week long process
that stops rejection of a transplanted incompatible
organ. The process is performed before an organ
transplant. So there must be a living donor.
Often these are relatives or friends who have incompatible
organs. Desensitization involves:
Susan, is an oncologist by training. She was President
of product development (lead developer of Avastin and Herceptin) at Genentech,
chancellor of the University
of California, San Francisco and from May 2014 CEO
of the Gates
- First filtering the antibodies
out of a patient's blood.
- The patient is then given an infusion of other
antibodies to provide some protection while the immune
system regenerates its own antibodies. The person's
regenerated antibodies are less likely to attack the new
- If the person's regenerated natural antibodies are still
a concern, the patient is treated with drugs that destroy
any white blood cells that might make antibodies that
would attack the new organ.
is the Defense Health Agency established Oct 1st 2013.
It manages: TRICARE.
is the Maryland Department of Health and Mental Hygiene
is the disability insurance trust fund.
includes type 1 and type 2. Common side
effects include: increased heart
kidney disease, vision loss, nerve damage, and
occurs when diabetes sufferers
don't get enough insulin, at
which point the body converts fatty acids to ketones for
energy. It can cause death. It may be triggered
by infection, stroke, and
Diabetic neuropathy is
the damage of nerves associated with type 2 diabetes.
Diabetic retinopathy is
damage to the blood vessels of the retina due to high blood
sugar levels associated with type
can have many causes. Contaminated water supplies can
result in infection with:
is digital imaging and communications in Medicine a ACR-NEMA
standard for for distributing and viewing any kind of
medical image regardless of origin. As a
communications protocol it overlaps with HL7.
It is difficult to distinguish on what equipment type
(echocardiogram or coronary ultrasound for example) a
particular image was generated because of a lack of metadata
included in the standard.
is a WHO essential medicine for
treating heart conditions including: AF,
atrial flutter and CHF. It
typically makes the heart beat more strongly, slowly and
regularly. But in one patient in ten a gut bacterium, Eggerthella lenta
with two specific gene variants, inactivates the
digoxin. Digoxin was initially isolated from the
foxglove, Digitalis lanata.
is a compound of the form (NH)2.
Diphtheria is an acute infectious disease
with symptoms caused by toxins generated during an infection
by Corynebacterium diphtheriae. The bacterium is
spread by direct contact, contact with contaminated objects
or through the air. There is an effective vaccine and
infection can be treated with erythromycin or
Dipyridamole is a cAMP phosphodiesterase
inhibitor, increasing the volume of cellular cAMP and
blocking platelet aggregation response. It is used to
Direct messaging is a
secure messaging technology used by HIEs
(& Blue Button+) to
directly interoperate. It uses SMIME body in a SMTP
protocol and X.509 certification.
Direct Project at ONC
a simple, secure, scalable, standards-based way for
participants to send via email authenticated, encrypted
health information directly to known, trusted recipients
over the Internet. The email addresses are trusted
having been issued by ONC.
Directed evolution is
Dr. Frances Arnold's synthetic
biology iterative technique where DNA
for an enzyme is genetically
engineered into bacteria where rapid breeding then
introduces mutations. Dr. Arnold then selects the
bacteria which generate the enzyme with the most attractive
functional charactistics, and repeats the breeding/mutation
process with that starting sequence.
Disaster Relief Act Amendments
of 1974 signed by President Richard Nixon:
Discharge procedures -
have costly handoff problems reviewed by project BOOST. When
discharge takes too long it ties up acute bed space which
can result in adding up to 30% more (unnecessary) capacity
when improved discharge would translate into additional
revenue. Various interventions aim to improve the
execution of the process including: CTI,
TCN and RED for
discharge to outpatient; InterAct
for discharge to SNFs and BPIP to HHAs.
Discharge information can include:
- Established a process for presidential disaster
declarations. It focused the actions of the many
federal agencies that were participating in
- President Carter moved many of the disaster agencies
under a newly emergent FEMA in
Disease management uses
coordinated interventions and communications for populations
with conditions in which patient self-care efforts are
significant. It aims to minimize complications by
using evidence based practice
guidelines to enhance wellness.
It aims to stratify populations and use evidence and
education to drive beneficial behaviors.
Disintegrins are a family of small proteins
that functionally inhibit platelet aggregation and integrin-dependent cell
- Patient info
- Behavioral summary
- Treatment history
- Medical history
- Treatment objectives
- Insurance policy
- Discharge plans
Diuretics increase water excretion which
results in reduced blood volume and pressure. Many
work by making the kidneys
transport more sodium into the urine. The sodium pulls
water from the blood with it. The reduced fluid level
in the blood vessels reduces the pressure on the walls of
Drug-induced lupus is
induced by taking certain medications. Once the
patient stops taking the medications the lupus subsides.
Dry macular degeneration
is the slow destruction of foveal
vision. It is caused by a buildup of drusen pigments
due to a failure of the aging cellular infrastructure to
remove these metabolic waste products. The pigments
inhibit the flow of oxygen from the choroid blood supply
through Bruch's membrane to the RPE
and photo-receptor cells. The drusen damage the RPE
causing this layer of the macular to thin. Over a
decade this results in deterioration of perception in the
fovea. In about 20% of sufferers the reduced flows
across the RPE result in development
of more blood vessels which anomalously push through Bruch's
membrane causing the far more rapidly destructive wet macular
degeneration. Dry macular degeneration can be
detected using an Amsler
grid and confirmed with OCT.
Dual eligible is eligibility for both Medicare and Medicaid. With states
supplying Medicaid funding they may cost shift dual eligibles to
federally funded Medicare. Coordination was altered by
ACA title II. In some
states for beneficiaries with lower than a threshold income
Medicaid will pay the beneficiaries Medicare Part B premium
and some of their out of pocket expenses.
Dual eligible medical models
of care is a CMS CMMI/MMCO
initiative to investigate and develop new payment models for
dual eligibles. As
described by community catalyst since dual eligibles
are typically vulnerable, make more and costlier use of the
medical system, and are often unnecessarily admitted to
hospitals or placed in nursing homes the ACA
enables HHS to investigate how to
reduce their cost of care. Dual eligibles are typical
hot spots. The new payment
models are capitated and
managed FFS which are intended to
encourage better care coordination.
mellitus or disease
management in health care.
- Durable Medical Equipment describes any medical equipment
using in the home to aid in a better quality of
DNA colony sequencing is
Mayer and Farinelli's patented method of DNA
sequencing. It details methods of DNA sample
preparation and random surface-PCR arraying
DNA ligase joins DNA
strands together by forming a phospodiester bond, the ligase
reaction. DNA ligase is essential for repairing double
stranded DNA breaks.
DNA caretaker proteins, detect and repair
mutations of the DNA. Genes
coding for mismatch proteins include: MLH1, MSH2,
MLH3. Mutations in these genes are associated with
high risk of colon and
uterine cancer. The gene BRCA1
is also involved in DNA repair.
DNA nanoball sequencing
is a high throughput technology used to determine whole
genome sequences. It uses rolling circle replication,
where unidirectional base replication that rapidly
synthesizes multiple copies of circular molecules of DNA or
RNA, to amplify small fragments of DNA into nanoballs.
by ligation is then used to determine the
sequence. Lots of nanoballs can be sequenced per run
with low reagent costs. But only short sequences of
DNA are determined from each nanoball so the computerized
mapping of the sequences to the reference genome is
is DNA-dependent protein kinase
is domain name server.
is doctor of nursing science
- U.S. Department
Doctors Without Borders
is a French
medical charity that uses its French intials M.S.F.
- U.S. Department
- U.S. Department
is a birth coach, a non-medical person who supports the
mother and her family during childbirth and recovery.
is where a cheaper 'equivalent treatment' is payed for in
response to an insurers being charged for a provided
is diabetes prevention program,
a CMMI initiated and HHS Secretary instituted payment
program for innovative diabetes management.
is the deficit reduction act of 2005. It includes a
critical imperative to CMS to develop
a Medicare payment reform
demonstration, using standardized patient information to
examine consistency of payment incentives for various
Medicare populations, treated in various settings. As
the 2006 budget reconciliation
bill (S 1932) it included provisions expected to reduce Medicaid spending by $10 billion
over 10 years. Among the rules are:
is the disaster relief act amendments of 1974 which:
- Tighter restrictions on asset transfers. Aims to
reduce seniors transferring substantial amounts of their
money and other assetts to relatives to be eligible for
Medicaid funded long term care services. Those with
$500,000 or more in home equity would be automatically
disqualified from applying for Medicaid.
- Greater flexibility to impose premiums and cost-sharing
and to change benefit design for certain Medicaid
- Gives all states long-term care partnership programs
- Authorizes states to include home and community-based
services as an optional Medicaid benefit.
is a diagnosis-related group. It
transformed the health care operating model, when 467 DRGs
with standard payments were introduced by Medicare in the 1980s, enabling
for-profit business strategies to seek ways to cut expenses
and hence increase profits. The DRG is a
classification, designed by Yale's
Robert Fetter and John Thompson, intended to define the
products that a hospital provides. It assumes patients
within a grouping are clinically similar. Grouping is
based on ICDs adjusted for age, sex,
discharge status and comorbidities. For Medicare
hospital inpatient claims the DRG is used to select the fee
that will be reimbursed.
is deferred retirement option program, a common pension
format which allows one time withdrawls of accrued funds by
- .ind.include ('html/awffwglossary.html', 'gldraa1',
is disproportionate share hospital ACA
program providing federal government Medicare
compensation for a provider treating indigent
is the Dietary Supplement Health and Education Act of
1994. It prevents the FDA from
approving or evaluating most supplements before they are
sold. The agency must wait until consumers are harmed
before officials can remove them from stores.
is the diagnostic and statistical manual of mental
Duodenoscope is a long, flexible tube that
supports access to very small ducts that drain the liver and gallbladder. It
delivers a camera and instruments to the observation
site. The internal tubes are intricate and difficult
to clean. It is estimated as of Feb 2015 these can
harbor up to 10 billion bacteria. With the potential
for transfer of CRE from one patient
to another cleaning has to be perfect.
Dupilumab is a monoclonal antibody which
blocks two immune system
pathways: interleukin 4 and interleukin 13; that are over
produced in atopic
dermatitis, by binding to the alpha subunit of the
interleukin-4 receptor. It was developed by Regeneron and
marketed as Dupixent.
Durvalumab is a human immunoglobulin G1
kappa MAB that blocks apoptosis through interactions
with PD-L1 & PD-1. It was
developed by AstraZeneca's
marketed as Imfinzi.
is deep vein thrombosis.
After major peripheral joint surgery DVTs may form in the
legs and then fragment inducing PEs in
is diagnosis. It is described with an ICD code.
Earnings stripping is
where a company creates tax deductions in higher-tax
locations and income in lower-tax locations by making
intracompany loans to a foreign subsidiary. Until Apr
2016 the interest was tax-deductible for the U.S. operations and the income is taxed
at the lower rate in the foreign operations. In Apr
2016 Treasury and IRS rule
changes made earning stripping stock based instead of debt,
based on Section 385 of the tax code, eliminating the
interest deduction for the American subsidiary.
Eating disorders include
anorexia, bulimia & obesity.
is a US state department two-year visa
program and path to permanent residency in exchange for an
investment of $500,000. The GAO
has raised concerns about the programs limited background
checks and poor safeguards against illicit financing.
is a viral disease discovered in 1976. It is an
ancient virus branching 20 million
years ago. It mainly infects rodents and other
mammals. A West African epidemic
was probably hosted by bats and transferred to a boy.
The 1976 strain was able to infect man. The 2014
epidemic is seen as the result of a single infection.
Evolutionary biologists consider it unlikely that natural
selection will give the virus the ability to spread more
easily. The size of the 2014 epidemic gives more
potential for mutations but the current transmission
mechanism is working for the virus so there is little
obvious pressure for outcompetition by a new transmission
path. There are likely to be lots more viruses with
similar infection model to Ebola. Typically an
individual is not sick for three to five day after the onset
of symptoms which can fool care givers. Then around
day 5 to 7 they really crash. Their blood pressure
goes down, they become stuporous to unresponsive, and they
start to have renal and liver
failure. This correlates with the enormous viral load
(making it very contagious which is a significant risk to
care givers), which is just attacking every organ in the
body. Ebola patients lose enormous amounts of fluid
from diarrhea and vomiting, as
much as five to ten quarts a day during the worst phases of
the illness which lasts about a week. Doctors struggle
to rehydrate them, replace electrolytes and treat bleeding
Eric Duncan brought Ebola to Texas
Health Presbyterian hospital, where the ED failed
to identify his symptoms.
is evidence based medicine where explicit and judicious use
of current best practice evidence is used in making
decisions about the care of patients. There are
differences in the application to individuals and
populations. Still the goal was to replace subjective
use of basic and clinical research with:
is Epstein-Barr virus, also called HHV4, it is a human herpes virus
which causes mononuceosis
in some infected adolescents. EBV infects epithelial cells and B lymphocytes.
- Prioritization of clinical trial results to build
- Adoption of processes that translated epidemiological methods to
physician decision making.
- Widely used but innapropriate procedures were
- There is now explicit evaluation of evidence of
effectiveness before issuing practice guidelines. A
rational for adoption is required.
- HHS appointed USPSTF to develop evidence based
is eligible clinician, a CMS term for
a physician, nurse practitioner, physician assistant,
clinical nurse specialist and nurse anesthetist cooperating
in a practice. After 2018 under MACRA
EC will also include physical and occupational therapists,
nurse-midwifes, clinical social workers, clinical
is extended care facility providing long term rehabilitation
such as a SNF or a LTCH.
is equivalent case-mix-adjusted discharge
- Extracellular matrix.
- Enterprise content management which helps to organize
and store an enterprise's documents and other
content. It has involved image scanning of legal
documents, such as checks, to improve search, access and
to limit storage space.
is extracorporeal membrane
oxygenation where blood is drawn from the patient and passed
through an oxygenator and then back into the body.
Economic Growth, Regulatory
Relief, and Consumer Protection Act of 2018, which
amends the Dodd-Frank act,
signed by President Trump in May, reduces the regulatory
constraints on mid-size banks between $50 and $250 billion
Economic Stimulus Act of 2008
was developed in response to the 2007 collapse of the US
housing market. President Bush signed it into law with
bipartisan support. In 2008 the bill was projected to
cost $152 billion. It provided:
photopheresis apheratically removes white blood cells and
platelets from whole blood, treats them with a DNA crosslinking agent and ultraviolet
light before returning them to the patient. The goal
is apoptosis of nucleated
cells, subsequent induction of cytotoxic effects on T-cell
formation producing antitumor action.
- Tax rebates to low and middle income tax payers.
- Tax incentives to stimulate business
- Increases in limits on mortgages through Fannie Mae and Freddie
is electroconvulsive therapy
Ectopic fat is triglyceride stored in non
adipose tissue: liver, skeletal
muscle, heart, pancreas; where it can interfere with
cellular and organ function.
is atopic dermatitis.
department. Pain is the
main reason (75%) patients go to an E.D. It has
traditionally been part of an acute care hospital but
recently is being deployed standalone
as a catchment funnel to the owning hospital. The EMTALA legislation
requires E.D. treatment to stabilize every person seeking
treatment by most hospitals. Unreimbursed care is
supported from federal government funds. E. D.
profitability has been helped by hospitals contracting with
3rd party companies who are able to improve margins through
The standalone E.D. competes with the positioning and brand
power of lower cost urgent
care clinics. Commercial nature of care requires
walk-ins to register to gain access to care. With the
focus on treatment of pain, E.D.s are a major distributor of
opioids (5% of opioid prescriptions) and a major starting
point of addiction in patients
but are cutting back (Jun
is emergency department information system.
is the equal
employment opportunity commission. It is the
federal agency with oversight of employer actions and
develops the rules that implement employment legislation,
is the OPHG's evaluation of genomic
applications in practice and prevention
is early goal directed therapy, Henry
Ford Medical Center emergency and critical care
physician Dr. Emmanuel Rivers's 2001 New England Journal of
Medicine article recommending aggressive protocols for the
early detection and treatment of sepsis.
Pearl explains this
aggressive sepsis treatment is risky and potentially
fatal. The steps include:
is epidermal growth factor which signals,
via the Ras/Raf/MAP pathway, cell proliferation,
differentiation and growth. It stimulates DNA synthesis in target cells and cell
- Puncture the patient's neck with a large needle, and
deploy a central venous line down near the heart.
This carries the risk of damaging the underlying
- Administer powerful antibiotics with large amounts of
fluid. The fluid can flood the patient's lungs and
overwhelm the heart's ability to pump, drowning the
is epidermal growth factor receptor. It is the
cell-surface receptor for EGF family
is the economic growth and Tax
relief Reconciliation Act
of 2001. It was the third-largest tax cut in modern
history. Combined with an economic slowdown including
the 2000 Internet stocks' crash,
and increased military spending, these revenue cuts removed
the surplus by 2003.
eHealth Exchange is a
network ONC now facilitates together
with private foundations, to exchange health care
information. It focuses on web-services based
specifications designed to securely exchange health care
related data. It is implemented by the Connect Project. It
is related to the Direct
Project. Sponsoring private foundations include:
Markle foundation, Robert Wood Johnson foundation, and the
California healthcare foundation.
refers to electronic health records which are a synonym of EMR. EHR analysis suggests
strengths and weaknesses:
EHR module is a component of an EHR system that is fully compliant and
can be combined with other compliant modules to provide an
EHR system which is consequently compliant.
is electronic intensive care unit.
It allows centralized remote monitoring of intensive care
patients in distributed critical care units. eICU
deployment has resulted in a 27% reduction in mortality and
a 17% reduction in length of stay across multiple
studies. This is primarily because patients are being
watched more closely resulting in quicker
interventions. Its analogous to an air traffic control
system. Patients were also spending less time in
ventilators. Physicians and nurses use audio, video
and computers to provide effective remote monitoring.
Shorter stays in intensive care also free up these beds for
is Energy Independence and Security Act of 2007 was a
Democratic Party effort to make cars and trucks more CO2
efficient, while President Bush was keen to move the US
towards greater energy independence and security, based on a
requirement to develop and use more biofuels shifting
subsidies from petroleum. President George W. Bush
signed the act into law. It has catalyzed a global environmental
- The EHR provides an integrated record of the health
systems notes on a patient including: Diagnosis and
Treatment plans and protocols followed, Prescribed drugs
with doses, Adverse drug reactions;
- The EHR does not necessarily reflect the patient's
- The EHR often acts as a catch-all. There is often
little time for a doctor, newly attending the patient, to
review and validate the historic details.
- The meaningful use
requirements of HITECH and Medicare/Medicaid
specify compliance of an EHR system or EHR module for specific
environments such as an ambulatory
or hospital in-patient setting.
- As of 2016 interfacing with the EHR is cumbersome and
undermines face-to-face time between doctor and
patient. Doctors are allocated 12 minutes to
interact with a patient of which less than five minutes
was used for recording hand written notes. With the
EHR 12 minutes may be required to update the record!
or ECG is electrocardiogram which generates a record of the
Electroporation is the application of
electric fields to cells to increase the permeability of the
cell membrane to allow chemicals into the cell.
Elephantiasis is a form of lymphatic filariasis which induces huge
swellings of the lymphatic system. It is the result of
infection by Brugia malayi, Brugia timori or Wuchereria
bancrofti. It is vectored by mosquitos.
is electronic medication administration record. It is
the legal record of the drugs that were administered to a
patient at a facility by a health care professional.
is an employee assistance program.
is Explanation of Medicare
Benefits. It is a set of papers sent by CMS monthly to a patient detailing
charges for treatments performed and what will be paid by
CMS. It informs the patient and helps them to report
fraudulent billing to CMS.
is the partial or total blockage of a blood vessel by an
embolus: blood clot, fatty lump, gas bubble, or foregn
Emergency quota act of
1921, limited immigration flows into the US.
It placed a 3% immigration quota of current US residents
from a particular country. After World War 1, economic
collapse in Europe encouraged emigration. The
act was a response to the demobilization driven rise in
unemployment in the US. One effect of the limits was
to cut the number of foreign born midwifes who entered the
country encouraging the shift from home to hospital based
is electromyography, a diagnostic procedure to assess the
health of muscles and the motor
neurons that control them. EMG translates the
motor neurons electrical signals into graphs, sounds or
numerical values for interpretation.
is enterprise MPI. These are
being developed as part of the frameworks of the CommonWell
refers to electronic medical records which are a synonym of
EHR. EMRs have strengths and
Emphysema is the long term destruction of
the tissues that support the shape and function of the
is emergency medical services providing ambulance and
critical care transport.
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is emergency medical technician.
is the emergency medical treatment and active labor
act. It required that any hospital that accepted Medicare dollars should also treat
patients that have an "emergency medical condition" without
regard for the patient's ability to pay. Most
hospitals accept Medicare funded treatment. Prior to
the 1986 EMTALA law hospitals could refuse treatment to
patients facing life-threatening emergencies.
End of Life Option Act
of 2015 is California's aid in dying legislation.
It is based on Oregon's Death with Dignity
act. The law went into effect in June 2016. The
terminally ill patient must be capable of making medical
decisions and be prescribed an aid-in-dying
Endocarditis is an inflammation of the
inside lining of the heart chambers and valves.
is the inner most layer of the developing embryonic tube in
Endometrial cancer, is a
cancer that begins in the endometrium of the uterus. It is otherwise termed
a uterine cancer.
Endometrium is the lining of the uterus.
Endoscope is a tubular probe used to look
inside body cavities.
is electronic nicotine delivery systems
is electroneurogram a method to visualize directly recorded
electrical activity of neurons of
the CNS or peripheral nervous system. It is typically
recorded by placing an electrode in the neural
Enzalutamide is an androgen competitive
inhibitor with a very high binding affinity for the androgen
receptor and an androgen receptor signalling
inhibitor. It is a general purpose androgen inhibitor
and is used in androgen
deprivation therapy to treat prostate cancer in
men. It is fully synthetic and was developed by Medivation,
branded as Xtandi.
It can cross the blood-brain barrier and has mis-bound to GABA receptors
is explanation of benefits - sent by a health insurance
company to covered individuals explaining what was
is the Environmental
Protection Agency of the Federal government.
is the ensuring patient access and effective drug
enforcement act of 2016. It allows patients' access to
necessary medications including opioid painkillers
2015). And it constrains the powers of the DEA to intervene (May
2016). It establishes a process for federal
agencies to go through before a distribution center can be
shut down. Sponsors include Senators Orrin Hatch and
Sheldon Whitehouse and Representatives Tom Marino and Peter
is an early payment default.
is an ultrasound test to assess atherosclerosis of the
aorta (AAA). Evidence suggests
the incidence of stroke during
cardiac surgery is reduced with feedback from this
is the rapid spread of infectious disease: AIDS (Oct
2016), Cholera (2010),
2015), Ebola, Influenza, Polio,
2018), Malaria, Yellow fever, Zika; to large numbers of people in a
population within a short period of time -- two weeks or
less. Epidemics are studied and monitored by: NIAID, CDC, WHO; but are managed by states in the US. Infection control
escalation is supported by biocontainment units: Emory,
Once memes are included in the set
of infectious schematic materials, human
addictions can present as epidemics concludes Dr. Nora
Volkow of the NIDA.
aims to ensure public health
networks are effectively prepared for epidemics. PHCPI
aims to strengthen PCPs globally to
improve responsiveness to epidemics. GAVI helps
catalyze the development and
deployment of vaccines.
Sporadic investment in public health enables development of
conditions for vector development: Mosquitos. The
increasing demands of the global
population are altering the planet: Climate change is
shifting mosquito bases, Forests are being invaded bringing
wildlife and their diseases in contact with human
networks. Globalized travel acts as an infection amplifier: Ebola to Texas.
Health clinics have also acted as amplifiers: AIDS in Haiti,
C. diff & MRSA infections enabled &
amplified by hospitals. Haiti earthquake support from
the UN similarly introduced Cholera.
Epidemiology studies patterns, causes and
effects of health and disease in populations. It
identifies risk factors for disease and focuses on
preventative health care. Being observational it
suffers from a core limitation. It can only show
association, not causation. It can suggest hypothesis
but it can not disprove them.
Epithelium is a core cell type that lines
cavities and surfaces of blood vessels and organs. All
glands are constructed from epithelial cells.
Epithelial cells: secrete, absorb, protect, transport and
sense. They have no blood supply so they are nourished
via diffusion through the basement membrane from underlying
connective tissue. Epithelial cell differentiation
potency makes these significant cancer
is episode payment model, a CMS FFV episode
of care oriented payment model. CMS final rules
make cardiac EPMs mandatory for hospitals by July
2017. The cardiac EPM final rule increases cardiac
rehabilitation to gather feedback on the bundle. And
it provides a pathway to qualify for the QPP,
based on participation rate.
refers to a patient's copy of their EHR records. It
must be in both a human readable format and as a CCR or CCD.
It must include at a minimum diagnostic test results,
problem list, medication list and medication allergy list encoded in
standardized computer readable formats.
e-prescribing is sending prescriptions
electronically. It is constrained by a CMS rule to
communicate using NCPDP SCRIPT.
A code set must be adopted for the communication identifying
the medicine such as RxNorm.
Prescribing is complicated due to:
Episiotomy is an incision made in the
perineum and posterior vaginal wall to assist with
- The need to adjust drug strengths based on patient
weight. This is especially important in
- The prescribing of controlled substances is governed by
different rules and workflows.
Episode of care - An episode of care is the
treatment of a specific medical condition during a set
period of time. After MedPac
episode based payment
bundling for inpatient hospital care it has become a
key focus of Medicare incentive
is Erythropoietin a
glycoprotein hormone that
controls red blood cell production. It is available as
a biologic, which is used to
treat anemia, but Geisinger
found during their biologic
reengineering that 20% of their chronic renal failure
based anemia patients were being inappropriately treated
with costly EPO, putting the patients at risk of exacerbated
central and peripheral vascular disease, inplace of the
appropriate oral iron.
is earnings per share.
is a gene, often termed HER2, that encodes RTK erbB-2, a proto-oncogene.
is endoscopic retrograde cholangiopancreatography, a
procedure to diagnose diseases of the liver,
bile ducts, and pancreas. Through the endoscope
a physician can see the inside of the stomach and duodenum,
and inject radiographic contrast into the bile ducts and
pancreas so they can be seen on X-rays. With the
development of non-invasive MRCP and
endoscopic ultrasound ERCP is rarely used except
is the Employee Retirement Income Security Act of 1974
signed by President Ford. It regulated both pension
and health benefit plans once an employer had established
one. It setup the PBGC to
support voluntary private defined benefit pension
plans. Where self-funded health plans under ERISA are
exempt from a state's insurance regulation there will be no
solvency or consumer protection in place to support
providers that do business with ERISA plans. States
may consequently require provider networks that do business
with employer self-insured ERISA plans be licensed as an
insurance company (an HMO, medical
insurance plan, preferred provider arrangement or general
casualty insurer). ERISA section 404(a)(1)(B) defines
the prudent person rule associating prudence with portfolio
theory allowing pension funds to invest in stocks (index funds). The labor
department's interpretation of an ERISA employer has been
modified to support President Trump's executive order to
enable more use of AHPs (Jan
is the economic recovery tax
act (Kemp-Roth tax cut) of 1981 was President Reagan's huge
tax cut reducing the marginal tax rates on high-income tax
payers from 70 to 30%.
Erythropoiesis is the process which
generates red blood cells. When an oxygen
concentration decrease is detected by the kidneys it secretes erythropoietin to signal the bone marrow to
is a cytokine secreted by the kidney in response to hypoxia. It stimulates bone
marrow production of red blood
is the Elementary and Secondary Education Act of 1965 signed
by LBJ. It is the framework
later used to develop 'No child left behind'. ESEA's
original titles include:
Esomeprazole is a P.P.I.
used to reduce stomach acid. It inhibits a
transporter in parietal cells of the stomach. It is
branded as Nexium.
- Provides funding to local school districts to improve
the academic achievement of disadvantaged students.
The original authors worried that local and state
authorities might use the federal money to replace rather
than supplement their budgets to poor schools. When
this was found to be the case Congress amended the act in
1970 requiring districts to spend Title 1 dollars on
additional education for poor children (supplement), above
and beyond what they already received from other sources
- Preparing, training and recruiting high quality teachers
- Language instruction for limited English proficient and
- Educational research and training
- Grants to strengthen state departments of education
- Aid to handicapped children
Esophageal cancer is a
rare cancer (less than 200,000
cases per year in the US) that
typically starts in the cells that line the esophagus: flat cell squamous
cell carcinoma, and mucus secreting
It is associated with: Failure of TAD
borders, Obesity (adenocarcinoma Aug
2016), Alcohol consumption and smoking (Jul
2016). It appears to be inhibited by exercise (May
pylori and aspirin (ACS's
Eric Jacobs argues Sep
Esophagus is the tube that runs between the
throat and stomach.
is end-stage renal disease. This is the last stage of
CKD. It is associated with
adolescents who have hypertension.
There are more than 200,000 cases a year in the U.S.
Richard Nixon encouraged and signed Social Security
amendments that provided Medicare
for anyone suffering from ESRD. There are two main
Essential health benefits
are the minimum mandated set of benefits that insurers must
cover under the ACA. These
- Kidney transplants allow recovery from the disease but
are limited by the availability
of matching donated kidneys, enabled by UNOS, and the
patient's awareness of the option to have a
- Kidney dialysis performed at a dialysis
traded fund, which tracks stock and bond indexes, adhering to a set of
financial rules. These methods can be used to track
any financial market segment. They are transparent,
and low cost to operate, and invest in. ETFs are
priced during normal trading hours. But their
performance is impacted when they are forced by changing
conditions to sell assets at a loss. Selling of an ETF
by one investor to another does not redeem the ETF's
underlying investments, limiting the capital gains tax
- Mental health care,
- Emergency services,
- maternity and newborn care,
- prescription drugs;
Evergreening describes how drug companies
try to extend patent protection by introducing a new version
of a drug with minor variations without much clinical
benefit but that extends the patent. The new drug is
heavily advertised so that it replaces most of the still
patented, but old, drug on the market.
argues that the human genome and phenotypes
developed during the relatively long period when our
ancestors were hunter-gatherers. These biologists
argue we can best understand ourselves by observing the
remaining hunter-gatherer tribes including the Hadza.
is the environmental working group which researches and
advocates on the environment.
is an electrically neutral quasiparticle formed by the bound
state of an electron and an electron hole through
electrostatic Coulomb force.
is the 1 ot 2 percent of the genome which codes for the
Extracorporeal is a procedure performed
outside the body. Extracorporeal circuits include:
Cardiopulmonary bypass, Dialysis, ECMO,
ECP, Filtration, Plasmapheresis;
Ezetimibe reduces cholesterol by reducing
absorption in the small intestine. It is prescribed to
people who do not respond to treatment with statins.
is the US arbitration act of 1925. It provides for
judicial facilitation of private dispute resolution through
arbitration. It covers:
required by the ACA and enforced by CMS aim to ensure that orders and
certification for home health services are based on a
physician's current knowledge of the patient's clinical
- State and Federal courts (Southland Corp. v. Keating)
- Transactions that involve interstate commerce. It
is based on the commerce clause of the constitution.
Section two of the act allows invalidation of arbitration
provisions only for the same grounds as general
contractual provisions: unconscionability or duress.
Factor Xa catalyzes
prothrombin to convert to thrombin, inducing fibrin clot
is Food Allergen Labeling and Consumer Protection Act of
2004, defining a framework for F.D.A.
rules for food labeling by
manufacturers of prepackaged food containing specific
allergens: milk, eggs, fish, shellfish, peanuts, wheat,
soybeans, and tree nuts. Some major allergens are
missing from the constraints: Sesame; products packaged at
an in-store bakery, or deli, are not covered and cross contact rules are not
Fall assessments are
performed by nursing staff to determine a patient's risk of
falling. Falling results in 11,000 deaths
annually. The nurse gathers details from the patient:
medications, mobility issues and confusion. When
entered in the EMR these generate a
menu of appropriate interventions.
False Claims Act makes
someone liable who makes a false claim for payment or
approval, or makes a statement for a false claim. The
actions may be based on Anti-kickback
or Stark violations.
False positives are correlations between a
random variable and markers of some event of interest.
Over a statistically significant period the correlation of a
false positive will fail but in small sample sizes it may
hold. Identifying a statistically significant period
is non-trivial. As more data becomes available via the
web and it is applied in BI the
problem of false positives will become more
Fanconi anemia is a recessive disease where
the bone marrow fails to produce red and white cells.
PGD has been used to select for
embryos that do not have the Fanconi mutation and are a
transplantation match for a suffering sibling, and that
would result in a baby whose umbilical cord can be used to
generate stem cell bone marrow
for transplant to a sibling already born with the anemia.
Fannie Mae is the coloquial name for the FNMA which is:
is familial adenomatous polyposis. It is a relatively
rare dominant genetic condition in which the colon is filled
with hundreds or thousands of polyps, often in
childhood. Treatment requires colectomy.
Untreated FAP invariably leads to cancer.
- .ind.include ('html/awffwglossary.html', 'glfnma1',
Fast-food is defined by Nhanes as any item obtained from a fast-food/pizza
discusses the development of fast-food
restaurants in the US. Michael
Pollan compares the
industrial processed food supply chain with organic and
hunter gatherer equivalents.
is a gene which encodes fibrillin
and in white adipose tissue the hormone
is familial cerebral cavernous malformation syndrome, a
hereditary condition where blood-filled bubbles protrude
from veins in the brain and may leak blood or burst at any
of Pennsylvania's SOM professor
Mark Kahn identified a link to bacteria in the gut microbiome (May
is familial chylomicronemia syndrome, or LPLD, a very rare
hereditary condition where lipoprotein lipase (LPL) does not
clear triglycerides from plasma.
and Drug Administration.
FDA ACAADPC is the Advisory Committee on
Analgesics and Anesthetic Drug
Products to the F.D.A.
FDA drug accelerated approval
allows a drug treating serious conditions or unmet medical
needs be approved based on a surrogate endpoint.
FDA drug breakthrough approval
is used to speed the development and review of drugs that
may demonstrate substantial improvement compared to current
FDA drug fast track approval
is designed to speed the development and expedite the review
of drugs to treat serious conditions or fill unmet
FDA drug priority review
designation indicates the FDA aims to
act on the drug application within six months.
FDA DSRMAC is the Drug Safety and Risk
Management Advisory Committee to the F.D.A.
510k refers to section 510(k) of the FFDCA. It is a premarketing
submission made to the FDA to
demonstrate that a device to be marketed is as safe and
effective (substantially equivalent to) another device that
is not subject to PMA.
FDA amendments act
PMA is the F.D.A.'s
premarket approval process
FDA PMA Supplement is a
change or revision to an original F.D.A.
- The priority review voucher allowing companies that get
drugs approved for qualifying tropical diseases to be
awarded a voucher that entitles the holder to an expedited
(Priority) review by the F.D.A. of another drug, shaving four
months off the process. These vouchers are traded between
is the Food and Drug Administration Modernization Act of
1997 which added de novo classification option (Evaluation
of Automatic Class III designation) an alternative pathway
to classify novel devices of low to moderate risk.
Device so classified may be marketed and used as predicates
is the FDA Safety and Innovation Act
of 2012. It amends FFDCA to:
is the Federal Deposit Insurance Corporation which was
created by the Banking Act and designed as part of the New Deal to mitigate risk for
Americans by practically eliminating bank failures and loss
of depositors' savings.
- Reauthorize and establish new prescription drug user-fee
- The GDUFA requires industry
to pay user fees to supplement the cost of reviewing
generic drug applications and inspecting
facilities. It is modelled after the PDUFA.
- Revise and impose new requirements relating to:
- Prescription, pediatric and generic drugs
- Medical devices
- Biosimilar biological products
- New infectious disease drugs
- Drug manufacturer reporting.
- The FDA was given authority to designate a "breakthrough
therapy" to expedite development and review of new
drugs where preliminary clinical evidence indicates the
drug may offer a substantial improvement over other
therapies for life threatening or serious
- Patient focused drug development program to learn from
patients in their daily lives for five years.
- ONC/FCC/FDA public/private
working group on HCIT regulatory
- Global drug supply chain
- FDA has increased drug detention and destruction
powers, adulterated manufacture or distribution
penalties, and inspection identification
?is? financial decision support.
is a synthetic opioid pain
medication that acts on micro-opioid receptors in the
brain. It is 50 times more potent than morphine.
It was originally manufactured by Janssen Pharmaceutica in
1959 which was acquired by Johnson
& Johnson. It is branded as: Sublimaze,
with a variety of deployment formulations. It is often
used, in a transdermal patch such as durogesic, to treat
severe ongoing pain which can be induced by cancer. It has followed heroin
into the back-street opioid epidemic
is the federal food, drug and cosmetic act. In 1938 it
gave authority to the F.D.A. to
oversee the safety of food, drugs and cosmetics. It
provided physicians with power over pharmaceutical sale,
which had previously been uncontrolled and operated by
pharmacists. It replaced the pure
food and drug act of 1906. It includes
interstate constraints on medical devices and prescription
drugs. As of 2016 the act does not enforce testing of
cosmetic's components. While the EU
has banned or restricted over 1,300 chemicals & chemical
groups from use in cosmetics the F.D.A. has prohibited 11
is fee-for-service payment. For health care providers
the high profits were made in hospitalizations, imaging and
surgery. Due to its inducing
excessive treatment activity it may be replaced by FFV bundled
is fee-for-value payment. It may be a bundled payment for a set
of services provided by a group of doctors and facilities,
or full capitation. In
each case the risk has shifted from
the payer to the providers of
is a gene which encodes the fibroblast growth factor 21 hormone. It stimulates
uptake of glucose by adipocytes, by phosphorylation of FRS2
which links FGF receptors to the Ras/MAP kinase pathway.
is Familial Hypercholesterolemia,
which causes heart attacks
at a young age with symptoms of very high cholesterol
levels. A mutation in chromosome 19 inhibits removal
of low density lipoprotein.
is either the:
is fast healthcare interoperability resources (fire) an HL7 standard
defining a set of 'resources' that represent granular
clinical concepts. The items include:
FHIR CarePlan is an FHIR
that describes the intent to deliver care. In the
early proposal (v0.0.82) HL7 aims to capture basic details
about who is involved and what actions are intended without
dealing in discrete data about dependencies and
timing. If needed these can be represented via the
- General: AdverseReaction, AlergyIntolerance, CarePlan, Condition,
Family/History, Procedure, Questionnaire,
- Medications: Medication, MedicationPrescription,
- Diagnostics: Observation, DiagnosticReport,
DiagnosticOrder, ImagingStudy, Specimen
- Device Interactions: DeviceObservationreport
- Attribution: Patient, RelatedPerson, Practitioner,
- Entitites: Device, Location, Substance, Group
- Workflow Management: Encounter, Alert, Supply, Order,
- Support: List, Media, Other, Provenance,
- Document Handling: Composition, DocumentReference,
- Exchange: MessageHeader, OperationOutcome, Query
- Conformance: Conformance, Profile, ValueSet,
FHIR identity is one of the resources of the
FHIR specification such as CarePlan.
FHIR resources are entities with a URL, an FHIR identity, a set of
structured data items (XML or JSON), and a
is the Federal
home loan mortgage corporation more commonly called
Freddie Mac, a GSE which was created
to provide competition to the restructured Fannie Mae.
Fibrillin is a glycoprotein which is
secreted by fibroblasts into
the extracellular matrix to form the insoluble microfibrils
that provide the scaffold for elastin.
is a protein polymer, generated
by thrombin polymerization of fibrinogen. Fibrin with
platelets form clots over a
Fibrinolysis is the proteolytic degradation
of fibrin clots
by plamin. It results in fibrin degradation products
within the blood including D-dimer.
Fibroblasts are a cell type that synthesizes
the extracellular matrix and collagen. They are
powerful chemists synthesizing fibrillin.
are tumorous growths in the uterus
which can cause back pain and
bleeding. They occur in between 20 to 50% of women of
child bearing age.
is the Federal Insurance Contributions Act. It defines
a payroll tax on employers and employees used to fund Social Security and Medicare.
Filariasis is caused by infestation with
nematode worms. One produces River Blindness, another
three induce elephantiasis.
Filariasis is one of the most widespread infectious diseases
in the world. It infects 150 million people with 1.5
billion at risk in the tropics.
is the Federal Information Processing Standards.
Financial risk is composed of different
aspects of the hospital
systems overall risk. It
R. A. is an eminent geneticist who developed a statistical
method, Fisherian or
frequentist statistics, based on population samples and
- Patient accounting and collections
- Risk based reimbursement
Fisherian statistics is a branch of
statistics, promoted by R.A. Fisher
which avoids the possible bias of Bayesian
'priors' by replacing the use of priors with techniques to
remove the uncertainty from using a sample of a
population. Fisherian methods require a statistical
distribution to be selected to represent the attributes of
the population. This judgment can itself introduce a
form of bias however. While very popular during the
20th century application of Fisherian statistics can suffer
from false positives and
In medical trials based on Fisherian principles it is
therefore necessary to have a huge sample to build
confidence about the certainty of the trial findings.
Five caring processes is
Dr. Kristen Swanson's model for building caring
relationships. It maintains:
Fixed indemnity insurance
is a type of insurance that pays the policy holder a fixed
dollar amount for a specified service regardless of the
actual price. It is often less comprehensive than the
ACA's minimal essential
coverage. It differs from major medical coverage in
- Maintaining belief - holiding the patient in esteem and
maintaining hope on their behalf.
- Knowing - by avoiding assumptions, thoroughly assessing
the patient, getting to know them and centering care on
- Being with - by offering time and conveying a sense of
- Doing for - comforting, protecting and
- Enabling - by informing, explaining, advocating,
validating and generating alternatives.
Flow Chemistry performs reactions via
continuous flowing streams that react when they
intersect. It has been used for industrial scale
reactions but is now applicable to science and medical labs
- It does not have to provide the "essential health
benefits" required by the ACA.
- It does not have to pay any specific percentage of
- Some policies cover only specific diseases.
flow sheets extend EHR
to track clinical actions on patients
is the fair labor standards act of 1938 which introduced the
40 hour work week. Franklin Roosevelt considered it
the most important legislation
of the New Deal after the SSA.
is functional magnetic resonance imaging. Seiji Ogawa
leveraged the coupling of neuronal
circuit activity and blood flow through the associated
glial cells to build a 3
dimensional picture of brain cell activity. As
haemoglobin gives up its oxygen to support the neural
activity it becomes magnetic and acts as a signal detected
by the fMRI. fMRI easily visualizes the state of
activity in the living human brain at millimeter resolution,
up to several times a second but it cannot track the time
course of neural firing so it is augmented with EEG.
is fecal microbiota transplants, where human gut microbiome, fecal matter, is
transferred from a donor's bowel to another person.
is fluorescent nano-diamond. These are nano-scale
particles with long-lived electron spin properties and
indefinite photo-stability. With negatively charged NV centers they are superior imaging
probes. They can detect both magnetic and electric
fields. They are non-cytotoxic.
commonly known as Fannie Mae,
is fasting plasma glucose, a test of blood glucose level at
a point in time. It is most accurate after an 8 hour
- The federal
national mortgage association, a GSE.
It was made a publically traded company by the HUD act of 1968 to remove
its debt from the federal budget.
- In 1970 FNMA was authorized to purchase conventional
mortgages. FHLMC was setup
to ensure competition for FNMA in this task.
- In 1981 FNMA issued its first designated MBS.
- In 1992 the Democratic Congress and President Bush
established HCDA which gave FNMA affordable housing goals
set annually by HUD with
- In 1999 the Clinton administration put pressure on FNMA
to expand loans to low and moderate income
borrowers. FNMA took on additional subprime
- In 2000 HUD placed anti-predatory lending rules on the
affordable housing goals, but these constraints were
dropped in 2004. In effect they just pushed mortgage
originators to Wall
- Once mortgage
originators started to use warehouse loans, the GSEs
lost visibility and control of origination.
- The GSEs purchased AAA mortgages from commercial
banks. Many of these classifications were fraudulent
leaving the GSEs with bad debt. In 2008 to maintain
the stability of the global economy
the George W. Bush administration seized the GSEs and
placed them in conservatorship under the FHFA, ensuring
they could not collapse.
- In 2010 FNMA's stock was delisted from the NYSE.
They still trade over-the-counter.
is the Federal Public Housing Authority.
Framework region acts as
a scaffold for the CDRs of antibodies.
Fragile X syndrome is an
inactivation of a gene in the X chromosome which is the
second most common cause of mental retardation after Down
syndrome. It affects neuron's
Framingham Heart Study
is a large collection of health information collected since
1948 on study participants from Framingham Massachusetts and
Freddie Mac is the Federal
home loan mortgage corporation (FHLMC),
is the Food Safety Modernization Act of 2011 which provides
the F.D.A. with additional powers to
police food companies.
is the Federation
of State Medical Boards which is composed of the
agencies that license and discipline doctors.
- is either:
is frontotemporal degeneration, the most common form of dementia for people under age
60. It results from progressive loss of neurons from the frontal or temporal lobes. The
first neurons known to die are von Economo neurons.
Tau and TDP43 proteins both congregate in these areas.
People with FTD display behavioral disinhibition and
socially inappropriate behaviors. They appear
apathetic and don't make decisions because the PFC is being destroyed. FTD can
impact brain regions that help is relate to other
people. This makes the sufferers indifferent to those
around them. They may struggle with addictions: overeating, smoking, spending;
which can destroy the lives of the whole family. There
are three main types: Behavioral variant, primary
progressive aphasia, and disturbances of motor
function. FTD is associated with genetic risk factors:
mutated tau gene, mutated C90RF72 gene, and mutated
progranulin gene which does not make enough of the protein;
generating tau and TDP43 protein clumps in the brain which
lead to neuron death in the PFC. FTD provides insights
showing that the onset of FTD in the left hemisphere stops
it from inhibiting the creative and musical right
- Federal Trade Commission. Setup during the Wilson
administration. Its powers include blocking mergers
due to antitrust concerns using the powers of the Clayton act.
- Follicular thyroid cancer.
is farnesyl transferase inhibitor.
is the Federal Technology Transfer Act of 1986. It
amended the Stevenson-Wydler
Technology Innovation Act to allow Government-operated
laboratories to enter into cooperative research agreements
and by establishing the NSF's Federal
Laboratory Consortium for Technology Transfer.
is the foundation of research and education. It has
been contracted by HHS to identify
best practices for state-level RHIO
Formularies are lists of drugs that a health
plan will cover. The health plans control where and if
the drug is listed in the plan. A less expensive drug
can be assigned a lower copayment
to encourage patients to use it. To counter this
attack on their profits drug companies responded with
coupons to help patients pay copayments removing the
incentive to select the lower-priced drugs. Health
plans reacted to the copayment cards by dropping some drugs
from the formulary altogether. That encourages drug
companies to bid for their drug to be the only one listed
resulting in some downward price pressure.
is federally qualified health center
is full time equivalent workload of an employed
person. It allows workload comparisons.
is Fourier transform infrared spectroscopy.
Fund of funds is an asset management company
that invests in hedge funds.
G6PD deficiency is an inherited loss of
glucose-6-phosphate-dehydrogenase which can be advantageous
in Malarial regions.
is generally accepted accounting principles. These are
a framework of standards and procedures for compiling
internationally equivalent financial statements.
is generalized anxiety disorder, an anxiety disorder with
excessive, irrational worries about events and activities:
health, money, death, family, friends, relationships and
work, due to activity of the amygdala
and its reduced connectivity with the insula and cingulate. It
affects 4% of the population, most commonly the poor and
oppressed, is the most common cause of work place disability
and is twice as common in women due to greater poverty,
discrimination and abuse. It can be induced by
alcohol, benzodiazepines, smoking, caffeine, as well as stress.
is generating antibiotic
incentives now act of 2012 which grants manufacturers an
extended exclusive period to sell newly approved
antibiotics. It was an attempt by Congress to
companies to invest in antibiotics, which would be
likely to be held back from the market, as last resort
solutions for antibiotic
Gain modulation alters the responsiveness of
neurons based on factors
including: eye, head, body or
initial hand position. Gain modulation provides a
mechanism for coordinate transformations. While
certain neurons code their auditory targets in a
head-centered reference frame,
their level of responsiveness is modulated by eye
position. The neuron responded robustly when the eye
position was to the left but when the eye position was to
the right the neuron hardly responded. The neuron was
not affected by changes in hand position.
Gainsharing shares any cost saving gains
among the participants. In health care it is typically
focused on aligning economic
incentives between hospitals and physicians, but is also
found between payers and providers
and payers and patients. It carries a legal risk of anti-trust infringement.
accountability office. It is the authority on
the legality of federal spending. Its rulings are
usually followed by federal officials. Congress relies
on its modeling work when
writing laws and supervising federal agencies.
is Merck's HPV vaccine
designed to prevent infections with HPV types 6, 11, 16 and
18. Gardasil will not protect people from a virus type
they have already been exposed to, so it is recommended to
vaccinate young people. It protects against cervical, vulvar and
vaginal cancers caused by HPV types 16 & 18 and anal cancers caused by HPV
types 6, 11, 16 & 18. It protects against genital
warts caused by HPV 6 & 11. It protects against
some cancers of the penis and parts of the throat
(oropharyngeal cancers). Gardasil does not prevent
cervical cancer in women aged 27 to 45.
Garn-St. Germain Depository
Institutions Act of 1982 was signed by President
Reagan in response to the 1979 oil shock inflation driven
collapse of the US S&L
industry. The S&Ls had previously only been
allowed to offer depositors fixed rate loans on fixed length
mortgages which could not adapt to the rapid
inflation. The S&L depositors responded by
switching to higher interest bearing money market
funds. The 1982 act deregulated the savings and loan
associations and allowed banks to provide adjustable-rate
is a gene for a transcription factor regulating luminal
epithelial cell differentiation into mammary gland. In
mutations which up-regulate the differentiation, cancer can be induced.
is global budget revenue
is gas chromatography-mass spectrometry.
is granulocyte colony-stimulating factor (CSF-3) is a
glycoprotein: part cytokine and
part hormone; that stimulates
the bone marrow to produce granulocytes and stem cells and to release them
into the blood stream.
is the generic drug user fee amendment. It is enacted
as part of the FDASIA.
Gefitinib is an EGFR
inhibitor, interupting signalling.
It has been used to successfully treat cancer's
that are occuring because of uncontrolled EGFR
Gene drive is a biochemical technique to
turbo-charge a genetic chain reaction, forcing a mutation
across the gene pool. It leverages homing endonuclease
genes which generate an endonuclease that supports the
selects for their own gene sequence by cutting DNA sequences that do not include its
sequence. The Cas9 endonuclease is an example that has
been combined with CRISPR to drive
a desired gene edit throughout a gene pool.
Gene therapy is the deployment of genes into
patient's cells to treat or prevent diseases. It can
be performed outside the body (ex vivo) or in place (in
vivo). It requires a vector such as a: Virus, Ligandal style
nanoparticle, electric field (Jul
2018); to perform the deployment. But viruses
are: Difficult to sanitize (bringing in oncogenes etc.) and
hard to target as needed, Unable to target where the DNA is deployed into the target cell
chromosomes, Key targets of the immune
system. The process is disease specific:
induces a deep sleep that suppresses breathing and vigilance and often requires a
breathing tube. This is far more risky than sedation. Researchers are
actively looking at the impacts on children under three
years old including SmartTots
- Blood cancers: NHL; can be treated with ex vivo CAR-T (Jul
- Cystic fibrosis
requires a virus that infects the airways and then deploys
a non-cystic fibrosis allele into the nucleus of the
patient's cells. The obstacles to this process have
- The virus must not have any problematic effects.
In the case of cystic fibrosis one virus activated a cancer gene leaving several
trial subjects with leukemia.
- Efficiency of delivery has to be very high and this
has not proved possible as of 2015.
- The newly delivered DNA must
remain intact and be replicated and transcribed.
This has not proved to be the case.
- The process has not been able to avoid an immune
response. Gene therapy has consequently been of
limited value for cystic fibrosis.
- Hemophilia A and B; virus delivered in vivo
therapies enter final stage trials (Aug
- ADA based SCID
was the first human treatment with gene therapy. A
normal ADA gene was inserted ex vivo into immune system cells.
Initially the updated cells did not live as long as
- Sickle-cell anemia
requires a non-sickle-cell
trait allele of the hemoglobin gene to be vectored
into the bone marrow of the affected person.
- T-lymphocyte DNA updates
for: mutation induced autoimmune diseases, melanoma treatment; using gene
editing delivered with an electric field.
Genetic risk factors for
diseases have been found for type 1 and 2 diabetes, heart disease, common cancers, asthma,
hypertension, atrial fibrillation and
gallstones. Mostly the individual risk
changes are small (10 to 40%) except for AMD.
In some instances, however, they interact synergistically
making the total relative risk much higher. The
genetic variants often affect whether a response is
[de]activated at the right time and in the right
amount. Variations in a single gene were implicated in
type 1 diabetes, rheumatoid arthritis,
and Crohn's disease.
And variations in one small region of chromosome 9
independently affects risk in type
2 diabetes and coronary heart disease. Rare
variants of the PCSK9 gene
significantly alter the risk of cardivascular disease.
It is important to include family medical history in the
assessment of risk.
Genetically engineered food
right-to-know act of 2016 specifies what foods must
declare on a label as genetically modified. It
replaces all state labeling laws.
is gastroesophageal reflux disease where the acids from the
stomach come into contact with the esophagus
- Studies of children have found an association between
learning problems and multiple exposures to anesthesia
early in life.
- Experiments in young monkeys have shown that commonly
used anesthetics and sedatives can kill brain cells,
diminish learning and memory and cause behavior
is the glomerular filtration rate of the kidneys. It is a measure of
how effectively the kidneys are filtering waste from the
blood. Healthy young people typically have a GFR of
120. A GFR of less than 60 is considered a marker of chronic kidney disease.
But the value of 60 should be viewed skeptically as the
patient's age increases.
health security agenda, a partnership of nation
states, international organizations and NGOs
working to strengthen the world's capacity to prevent,
detect, and respond to human and higher animal infectious
Bill is the Serviceman's Readjustment Act of 1944
(G.I. Bill) which provided benefits to soldiers returning
from the Second World War: tuition payments and living
expenses, low-cost mortgages, low-interest loans to start
businesses and one year of unemployment compensation; acting
as a major catalyst in
generating human capital.
is the genetic information nondiscrimination act. The
act prohibits group health plans and health insurers from
denying coverage to a healthy individual or charging that
person higher premiums due to their genetic predisposition
to develop a disease in the future. It also bars
employers from using individuals' genetic information when
making hiring, firing, job placement or promotion
decisions. The act amends the ERISA
and the Internal Revenue Code. It does not apply to
three types of insurance -- life, disabilities and long-term
is gastrointestinal stromal
tumor occuring in the stomach (70%) small intestine (20%)
and esophogus (10%): not all cells classified visually as
stromal fit with GIST while genetic markers can tightly
define GIST. GIST is often induced by mutations in CD117 gene's exon 11 which codes for
a tyrosine kinase.
The binding site of the mutated tyrosine kinase fits Gleevec.
combines recombinant DNA editing with
CRISPR; DNA next generation
sequencing and bioinformatics
to sequence, assemble and analyse
Genomic testing uses genomic
analysis to diagnose genetic disorders - for example Genomic
Health's Oncotype DX
The desire to see the genetic
risk factors identified by such tests should depend on
the risk * burden
* Possibility of
intervention. Early tests look at only single
gene mutations, but big data
research tools are showing promise with large gene
2018). Genomic testing can be performed direct-to-consumer.
Data is being collated on the genetic components of most
diseases to enable more sophisticated diagnosis in the
future such as the OPHG (EGAPP initiative), USPSTF recommendations and NCBI (Genetic test registry).
While there is only limited identification of the
significant mutations and limited patient bases misdiagnosis
is a problem (Aug
is damage to the optic nerve from high pressure within the eye.
Gleason score grades prostate cancers based on
their aggressiveness, an indication of metastasis and early
death, based on the appearance of cells from a biopsy. The score
ranges from 1 (no apparent cancer)
to 10 (aggressive).
is the Novartis
trade name for Imatinib. It is a tyrosine-kinase inhibitor
that was designed to treat CML
through a partnership between Dr. Brian Druker and Novartis
who selected and productized it from a long list of
potential small molecule inhibitors. Due to the
binding site that Gleevec targets being present in a variety
of related cancer inducing proteins Gleevec is being used to
successfully treat other types of cancers.
Glioblastomas are a fast growing form of glioma which usually strike older
people and have an average survival time of 18 months in
2015. The reason for the aggressive growth of
glioblastomas is due to collapse of the barriers between two
DNA islands which integrates a highly
active loop with a low activation loop containing a growth
2015). Researched by the TCGA
are the most common type of malignant brain tumors of
adults. The most aggressive form are glioblastomas.
is NR3C1 a receptor deployed in several forms, to which cortisol and other glucocorticoids bind.
It regulates transcription
of genes controlling development,
metabolism and immune response. The unbound receptor
resides in the cytosol. Gene/environment interactions
have been identified:
Glucocorticoids are corticosteroids which
bind the glucocorticoid
receptor. They decrease excitability of prefrontal cortical neurons. They have adverse
effects in fetal/infant development having organizational
effects on fetal brain construction and decreasing levels
of: growth factors, neurons, synapses;
resulting in an adult brain that is more sensitive to
environmental triggers of depression
Glucocorticoids affect gene control
structures and induce epi-genetic
changes. They have been found associated with high
sodium chloride consumption (May
- One variant of the gene for the MR receptor in the
presence of childhood
abuse produces an amydala
that is hyperactive to threat.
- The GR receptor's activity is modified by FKBP5.
Once FKBP5 variant in the presence of childhood abuse is
associated with: aggression, hostility, PTSD, hyperreactivity of the
amygdala to threat.
Glatiramer acetate is an
immunomodulator. It is a random polymer of four amino
acids: glutamic acid, lysine, alanine, tyrosine; found in myelin. It is used to treat multiple sclerosis.
is General Motors.
is General Motors Acceptance Corporation, established by GM in 1919 to finance consumer credit installment
plans for GM cars.
is graduate medical education
is genetically modified organism.
is a GOP training 527 organization, founded by Pierre du
Pont, Governor of Delaware in 1979. It was leveraged
by radical Republican Newt Gingrich to educate a new set of
is generally recognized as safe, an FDA
food substance classification. Most substances added
to a food are classed as food additives which are subject to
premarket review and approval by the FDA but some substances
are excepted when they are recognized by qualified experts
as having been shown to be safe under conditions of intended
Greenhouse Nursing homes
Greenhouse nursing homes offer personal service and private
rooms. This reduces the opportunities for cross
infections reducing cost of errors.
Group practice is an integrated health care
organization with salaried physicians and bundled
pricing. Early examples included Kaiser
Permanente and the Mayo Clinic.
- Most nursing homes are designed like hospitals.
They are designed around the nursing station. They
are institutions and aim to limit risk and serve the
patient's childrens' interest in the safety of their
parents. But they actually undermine will to
- Greenhouses are smaller and designed around the
kitchen. They allow knives. Patients keep
their own shoes - even though they may increase the
likelihood of falling. Patients bring in their own
furniture. Greenhouse nursing home developers had to
educate the regulators and health officials about the goal
of improved purpose of life rather than patients being
destroyed by 'safety' (really boredom, loneliness and
is a global organization
that agrees common standards and naming for shared
information to solve supply chain problems through adoption
of GS1 standards. It is supporting a common language
and trusted network. It leverages RFID, bar coding
etc. A Global GS1 Healthcare Conference shared best
practices for implementing GS1 Standards in health
care. These included:
is gross state product
provide the federal government's interpretation of
laws. They are typically written by federal agencies:
CMS, F.D.A.; to
describe how legislation should be used. The D.O.J. prosecutors watch for violation
of the guidance documents as breaking the rules developed
and enforced by agencies and regulators to implement
- Unique device identification including the FDA Global
Unique Device Identification Database.
- Hospital implementation of GS1 standards
- Customs and Pharmacists presented.
- Bedside scanning for drug dispensing with barcode
(GBS) is a condition where peripheral neurons
are attacked by the immune
system. Zika virus attacks the Glial cells protecting neurons
and can be associated with GBS symptoms.
is genome-wide association study which examines common
genetic variants (mostly SNPs) of
different individuals to find those common variants that are
associated with a trait. Sample size has been made
manageable by the HapMap SNP
clustering strategy. To detect the uncommon variants
with GWAS would be exponentially more costly and time
consuming. So it can't be used to detect schizophrenia or autism SNPs which are associated
with a significant reduction in reproductive
fitness and will thus never become common in the
is highly active ARV therapy using a
combination of at least three drugs that supress HIV
is Hospital-Acquired Condition.
is CMS's HAC
reduction program, authorized by section 3008 of the ACA, it is a part of pay-for-performance.
is a Tanzanian hunter gatherer tribe that subsists by
hunting and foraging. They forage for berries, honey,
baobab fruit and tubers.
hereditary angioedema - is an autosomal dominant genetic
disorder. it induces symptoms including swelling,
edema, in the hands, feet, face and airways. While
relatively rare it can be life threatening.
Heamolytic anaemia is a
condition where red blood cells are destroyed and removed
from the blood stream faster than the bone marrow is
replenishing them. Treatment can involve splenectomy for extravascular
or hereditary heamolytic anaemia.
is health care-associated infection.
Hantaviruses are RNA
viruses that can kill humans and are
hosted by rodents. People can be infected if they
inhale dried mouse urine infected with hantavirus.
is Hospital acquired pneumonia.
Haplotypes are the limited number of human
chromosomal types due to the recent origin of our species
from a relatively small group of founders. Differences
occur clustered into local neighborhoods. Sampling one
or two variations in a neighborhood allows prediction of
what will be the variations. On average 30 to 40 SNPs travel together in one of the
is a genomics project of 2000
scientists in six countries project managed by Francis
Collins, which mapped the various haplotypes. By leveraging
the clustering of SNPs in
neighborhoods of the genes and knowledge of the boundaries
of the neighborhoods you can identify all the SNPs without
spending huge amounts of money or laboratory time to test
for every one. HapMap was designed to define the
boundaries of the neighborhoods to allow these shortcuts in
genome analysis reducing the amount of work by a factor of
Hardiness is a psychological factor
correlated with high relative health under stress. It is associated with
individuals who assume they are in control of their
and enjoy commitment and challenge.
is hospital consumer assessment of health care providers and
systems, also known as CAHPS.
It introduces a common metric allowing comparison of
hospital care across the US. CMS partnered with AHRQ
to setup a scientific process including a public call for
measures, a literature review, cognitive interviews,
consumer focus groups, stakeholder input, pilot testing,
consumer testing and field trials. The survey is endorsed
by NQF. It is used as an
incentive mechanism by DRA and ACA.
HCBS Waiver is a congressionally authorized
Medicaid home- and
community-based services waiver program specified in section
1915(c) of the SSA. This
allowed states to create community-based services covered
under the same financial and clinical requirements as
nursing-home benefits. Most Medicaid long-term care
beneficiaries are dual eligible,
linking Medicare into the
HCFA 1500 is a paper Medicare
or Medicaid reimbursement claim
submission form used by a health care provider to integrate
the provider activities with the seperate EMB
papers from CMS so the patient can associate the two and
send them on to any supplemental insurance company as an
insurance claim. The provider billing department
includes on the form:
- Hepatocellular carcinoma, a cancer
of the hepatocytes or
- Hierarchical condition category - a BBA
mandated and CMS implemented
payment model, required for Medicare Advantage reimbursement. It
utilizes diagnoses from all hospital and physician
encounters to produce a health-based measure of future
medical need or
- Hospital condition category - an AHA
guideline for describing a patient's condition to the
media in just one word.
is health care incentives
- Claim number for this billing.
- Supplemental insurance company name and address
- Insured persons identification number
- Insured persons policy group number
- Verification that the patient has allowed the
information to be released (signature on
- Verification that the patient has allowed the provider
to assign payment of medical benefits.
- Dates of any hospital stay.
- Itemized list of services (description and charge)
performed by the provider. Patient is expected to
match each service via its description to a payment for a
charge listed on the EMB.
is health care information technology. The AHRQ argues HCIT consists of a complex
set of technologies, policies, standards and user
sets. Technically they represent it as a set of
layers: Application: CPOE, CDS, e-prescribing, eMAR, Results reporting, Electronic
engines, etc.; Communication: Messaging standards (HL7, ADT, NCPDP, X12,
DICOM, ASTM, etc,) Coding standards
CPT, NDC, RxNorm, SNOMED
CT, etc.), Process: HIE, MPI, HIPAA
security & privacy, etc.; Device: Tablet and PC, ASP,
PDAs, Bar Coding, etc.;
is hypertrophic cardiomyopathy,
a condition where the heart muscle (myocardium) becomes
abnormally thick. HCM can result in abnormal heart
rhythms and sudden death. It is a common disease at
all ages. It can be caused by over a 1000 mutations
that can occur in one of 10 to 20 genes.
is health care common procedure coding system a set of
procedure codes based on the AMA's CPT
is huntingdon's disease (formerly chorea). It is a
rare dominantly inherited adult-onset neurodegenerative
disorder. Each child of a sufferer has a 50% chance of
developing the disease with the onset occuring on average at
37. While the mutation that causes the disease is
known no effective treatment has been identified.
is a high-deductible health plan which has lower premiums
and a higher deductable than traditional health insurance
plan such as a HMO plan or PPO plan.
is NCQA's Healthcare Effectiveness
Data and Information Set. It is significant because
90% of health plans use the tool to collect metrics on 75
measures across 8 domains of care. Its ubiquity allows
apples for apples comparisons. It provides mappings
for ICD-9 and ICD-10 but will
phase out ICD-9 support in 2016.
Health Navigator is:
Heart attack is an AMI.
can induce cardiac arrest.
Blocking the formation of clots
aggregation inhibitors, can help with treating and
avoiding AMI. Risk factors include: taking NSAID pain
2017). There is uncertainty about why AMI
occur. Alternative hypotheses include:
- A nurse case manager (TCN) at Geisinger
focused on the patient's transition of care from the
health system to their home or nursing home.
- An advisor who helps people obtain insurance on the ACA individual
Heart disease is cardiovascular disease
which refers to:
- Plaques started to gather in the coronary arteries and
grew until no blood flow was possible. If this is
true it makes sense to preventatively treat the buildup
- Plaques form anywhere in the body due to atherosclerosis and then
break up and get lodged in the coronary artery and start
to clot. If this is true it makes sense to
preventatively limit the buildup of plaques with drugs
like statins or PCSK9 inhibitors.
Heartland virus is a Lone Star Tick vectored
phlebovirus infection in humans. The host is not
- .ind.include ('html/awffwglossary.html', 'glcardiovas1',
Helicobacter pylori is a
gram-negative bacteria, found in the stomach microbiome. Having been
identified as the causative agent of stomach ulcers and
stomach cancer it has been a focus
of eradication campaigns. However, it has been
subsequently realized that it limits acid reflux and esophageal cancer, and
may be a necessary component of the infant microbiome.
Helicopter money was a
thought experiment by Milton Friedman to apply when
conventional policy tools no longer work. Central
banks could print money and toss it out of helicopters to
eager citizens who would spend the money and stimulate the economy.
Hematopoiesis is the process of generating
blood cells. All blood cells start as hematopoietic stem cells, that differentiate
into erythrocytes, megakaryocytes, monocytes,
neutrophils, basophils, eosinophils, T-lymphocytes and
Hemochromatosis is caused by the build up of
excess iron within the body, extracted from the food we
eat. It is often genetic in origin. There are
multiple genes that can cause iron overload: HFE, HJV, HAMP,
BCS1L. When untreated the iron can poison the liver leading to cirrhosis. Iron chelating
drugs can provide treatment.
Hemophilia is the inability to form blood clots. There are multiple
forms: A, B; with mutations of different
clotting factor genes. Traditional treatment: Advate;
is expensive for the hemophiliacs (Jan
2016). Gene therapy
holds the promise of replacing the defective somatic genes in the liver of the
Hemophilia A is due to problems with clotting factor VIII.
Hemophilia B is due to problems with clotting factor IX.
Hemorrhage is the rupturing of a weakened
Hemorrhagic stroke is
the hemorrhage of a weakened
blood vessel causing blood to leak into and around the brain
creating swelling and pressure, damaging cells and tissue in
the brain. There are two main types:
Hepatitis C is a virus
which destroys the liver during
infection. In 2016 it affects 185 million people
worldwide. Once the virus genome was sequenced in 1989
Dr. Bartenschlager and Dr. Rice worked to replicate the
virus in the laboratory. Rice realized the genome
sequence was missing details that stopped the lab
replication. Bartenschlager was then successful at
replicating the virus in cells in his laboratory. The
replication technique allowed Pharmasset's Dr. Sofia to
develop a new hepatitis C drug, by enhancing an RNA-polymerase inhibitor with a coat
that allowed the drug to enter the liver, where the coat was
destroyed and the polymerase inhibitor was activated.
With high concentrations of the drug, sofosbuvir, in the
liver it could eradicate the hepatitis C virus.
Sovaldi was the first sofosbuvir
approved by the F.D.A.
- Intracerebral - where the hemorrhage is in small
arteries or arterioles within the brain.
- Subarachnoid - where the hemorrhage is in a blood vessel
just outside the brain leading to the skull filling with
Hepatoblastoma is a liver cancer seen mainly in
infants and children composed on immature hepatocytes,
mature hepatocytes or bile duct cells. It is
Hepatocytes are the major cell type in the liver. They have an unusually
high level of endoplasmic reticulum. They derive from
Hepatocytes are a main processor of proteins, carbohydrates,
lipids, and perform detoxification. They can enfold up
to eight sets of chromosomes, which may allow the liver to
regenerate effectively. Hepatocytes are covered in
microvilli that expand their surface area enhancing their
ability to take up substances from the blood.
is a gene encoding the protein 'human epidermal growth
factor receptor 2', which is similar in structure to the
native receptor HER1.
is a bulging of tissue or an organ through an abnormal hole
in the musculature. Hernias include: inguinal, umbilical. It the
protruding tissue or organ becomes trapped (incarceration)
the situation can deteriorate and may become life
threatening. Treatment of babies over three months of
age with hernias requires a checkup (blood tests, urine
analysis, medicine checks, and possibly an ultrasound) and
straight forward outpatient surgery with general anesthesia.
is a family of viruses including: CMV, EBV,
varicella zoster (chicken pox), Roseolovirus;
is the US federal government health
care financing administration
is the human genome project an international research
project to determine
the sequence of DNA base pairs
of humans and identify and map physically and
functionally all the genes in the human genome. The HapMap project proved very helpful
for discovering the SNPs.
is home health agency.
is the U.S. Department
of Health and Human Services.
Tags are home
health survey tags which are used in OBRA 87 mandated outcome oriented
home health surveys. HHAs are
considered unique in the act. Survey assumed patient
rights. Evaluated training and competency. OASIS data gathering started in
2000. Patient focused. Home falls and wound
infections raise alarms. But other outcomes that are
statistically outside thresholds for a patient or agency are
signals for further
study. Also data must be flowing from the HHA at rates
within OASIS thresholds. Survey protocols are
data-driven. Level 1 tags most related to patient care
processes. A condition will be cited if expected
outcomes are not met for three of the eight high-priority
tags listed, or HHA is out of compliance with one of the
high-priority tags plus two additional tags. That
initiates evaluation of the level 2 tags.
is a double stranded DNA Roseolovirus. It infects
all tested humans and is neuroinflammatory, being seen in
diseases such as MS.
is a double stranded DNA Roseolovirus.
a Health Information Exchange is responsible for the
transmission of health care-related data among facilities,
health information organizations and government agencies
according to national standards. They are designed to
address legal, organizational and technical challenges that
would otherwise impede the sustainability of health
information interchange. An HIE is a component of the
HIT. It must enable reliable and
secure transfer of data among diverse systems and facilitate
access and retrieval. The two main types are private
and public exchanges. Private exchanges may be able to
leverage homogeneous IT infrastructure to facilitate data
sharing. Public exchanges are likely to be
heterogeneous. RHIO provide
the regional organizations to support such HIE. They
are there to ensure that infrastructure
amplification initiates. The government will
ensure that low healthcare density areas are served by
public HIE infrastructure. Both centralized and
federated technical solutions were initially considered for
implementation by the RHIOs for deploying HIE as specified
in the Markle
Foundation's NHIN common framework.
Common framework clients such as appropriately architected
HIE use SOAP messaging to interact
with their local SNO's ISB and RLS.
The HIE SOAP query transactions follow the HL7 Query
Model. Alternatively some HIE's are now using direct messaging to
support interoperation. HIE deployment goals have been
phased (1 - supporting care transitions, 2 - Quality and
care management, 3 - Population
health). Some HIEs will support "EHR-lite" as part of their
functionality. HIE does not yet solve some difficult
are hypoxia-inducible factors, transcription factors
that respond to changes in oxygen levels by promoting gene
expression. HIF-1 is a master regulator of cellular
and homeostatic response to
hypoxia by activating: energy metabolism, angiogenesis, apoptosis; to increase oxygen
delivery or adjust metabolism to adapt to hypoxia.
Hypoxia promotes vascular system formation in embryos and cancers. That makes HIFs
important targets for anemia, cardiovascular disease
and cancer therapies.
High risk pools offer a separate insurance
program for people with potentially expensive medical
conditions. Low risk customers pay a low premium while
those constrained to the high risk pools pay more if they
can get coverage at all. Prior to the ACA high risk pools were operated in
many US states. Many states
turned applicants away from the high risk pools and some of
those states turned away the majority, and refused to cover
conditions with high costs: HIV,
Kidney disease. California's program was a first come
first served pool which left people to die on a wait
list. California law makers had to allocate funds in
the state budget for the pools. The California high
risk pool had only 6,300 people enrolled by
Hill-Burton Free and Reduced-Cost Health
Care act of 1946 gave health facilities including:
Hospitals: General, Long-term care, Mental; Nursing homes,
Outpatient facilities, Public health centers; grants and
loans for construction and modernization. It specified
administration through the HRSA.
It was amended by Congress in 1954 to cover development of
- Safeguarding the security of health information.
Currently HIEs conforming to the common framework only
provide locations of clinical data held
- Providing effective life cycle management. The HIE
is dependent on the local set of entities to provide
updates that match the current state of the entity
is Healthcare Information and Management Systems
Society. It includes an annual conference and
exhibition. It defined an EHR
is a gene encoding the protein, huntingtin interacting
protein 1 (Hip-1), a membrane-associated protein which
operates within clathrin-mediated
endocytosis and protein
trafficing. Hip-1 interacts with huntingtin
protein. It has sub-domains homologous to apoptosis protein's DEDs. The accumulation of the
free form of Hip-1 is suspected to contribute to caspase-3 based neuron cell death during
- Stage 7 - Medical record fully electronic; CDO able to contribute to ICEHR as byproduct of SEHR
- Stage 6 - Physician documentation (structured
templates), full CDSS (variance
and compliance), full PACS.
- Stage 5 - Closed loop medication administration
- Stage 4 - CPOE, CDSS (clinical
- Stage 3 - Clinical documentation (flow sheets), CDSS
(error checking), PACS available outside
- Stage 2 - CDR, CMV,
CDSS inference engine, may have document
- Stage 1 - Ancillaries--laboratory, Radiology, Pharmacy
- Stage 0 - All three Ancillaries not
is the Health Insurance Portability and Accountability Act
of 1996. It added part C (administrative
simplifications) to the SSA.
HIPAA Operating Rules
define the rights and responsibilities of all parties,
security requirements, transmission formats, response times,
liabilities, exception processing, error resolution etc. in
the form of business rules and guidelines to encourage
uniform use and hence facilitate ACA
mandated administrative simplification and successful HIPAA transaction interoperability
between data systems of different entities.
Health care information systems. There were
traditionally four backbone services:
- CFR 45CFR 160.103 is the general
provisions section of the regulations. HIPAA
Transactions and Code Sets Standards regulations 45CFR
162.923(a) Covered entities must use adopted transaction
standards for inter and intra covered entity
- HIPAA only applies to health care providers, health
insurers, clearinghouses of health care data, and their BAs.
- Initially HIPAA was designed to specify a secure
standardized MPI. Late in the
development of the legislation
the MPI was viewed as too risky and was removed from the
- The law does not prohibit health care providers from
sharing information with family, friends or caregivers
unless the patient specifically objects. Providers
can use 'professional judgement' to disclose information
to a relative or friend if it is in the best interest of
an incapacitated patient.
- It is also allowed to share general information about a
patient's condition and location in a facility.
- Family members can provide information.
- Caregivers who are a patient's personal representative,
such as: a health care proxy or guardian or with power of
attorney; or who have had the patient authorize the
release of information must be provided with
- HHS office of Civil Rights
enforces HIPAA but typically they try to fix problems
rather than applying penalties.
is a health information service provider.
- Acuity (EDIS);
is a project of the AHRQ to address
privacy and security policy issues affecting interoperable HIE. It is managed by RTI, the NGA, AHRQ, and HHS
Office of the National Coordinator for
health IT. It aims to identify
variation among states on privacy and security practices and
laws, to propose solutions to address challenges, and to
increase expertise about health information privacy and
security protection. Phase I of the project resulted
in the identification of four key public policy concerns:
patient consent to the use of HIE networks, use and
disclosure of sensitive medical information, implementation
of access controls, and application of community
the health information technology infrastructure.
is the HIT Adoption Initiative.
HHS contracted and financed the
development of HITAI to develop consistent measures of EHR adoption rates to track progress of
achieving the President's 10 year goal of widespread
adoption of interoperable EHRs.
- Achieve adoption and Information Exchange through Meaningful Use of health
IT. ONC and AHRQ identified best practices
will be distributed by HITRC
and REC to providers in
the community. HITECH Beacon community
grants have created 17 demonstration communities using
HIT. CMMI will test
innovative payment and service delivery models.
There are 3 objectives:
- Accelerate adoption of EHRs.
Incentives for Meaningful use. Provide
implementation help. Train an implementation
workforce. Add meaningful use to professional
certification. Certify EHR technology that
supports meaningful use. Promote the
benefits. Align federal programs.
Encourage private payers to
- Facilitate information exchange to support
meaningful use of electronic health records.
Support exchange based business models. Fill
gaps in provider options. Develop
- Support heath IT adoption and information exchange
for public health and
populations with unique needs. Ensure public
health agencies can exchange EHRs. Track health
disparities and promote HIT that reduces them.
Support HIT adoption in post-acute, behavioral health
- Improve Care, Improve Population Health, and Reduce
Health Care Costs through the Use of Health IT.
There are 4 objectives:
- Support more sophisticated uses of EHRs (viewed as a
necessary step to the three aims) and other health IT
to improve health system performance. ICD-10 migration is viewed as
necessary to obtain fine granularity of health care
treatments, outcomes and costs. Enrollment in
federal health programs will be improved by
development of interoperable and secure standards and
protocols for enrollment.
- Better manage care, efficiency, and population
health through EHR-generated reporting measures.
HHS National Quality Strategy has 6 priorities which
will be the focus of measures. These will then
be incorporated in EHR.
- Demonstrate health IT-enabled reform of payment
structures, clinical practices, and population health
management. Beacon demonstrator best practices
will be replicated into the community. Payment
reforms were also piloted (bundled payments, medical home).
CMS will translate the best
practices into policy.
- Support new approaches to the use of health IT in
research, public and population health, and national
health security. CDC is
encouraging deployment of Health IT and communications
infrastructure at public health departments.
- Inspire Confidence and Trust in Health IT. There
are 3 objectives:
- Protect confidentiality, integrity, and availability
of health information. HIPAA
is being strengthened by the OCR
to match HITECH. EHRs
must be encrypted, with access controls, audit logs,
and login timeouts. EHRs will be made granular
so certain aspects can be withheld from sharing
(substance abuse notes for example). Assess
security vulnerabilities of EHR systems.
Identify privacy/security requirements and best
practices and communicate them.
- Inform individuals of their rights and increase
transparency regarding the uses of protected health
information. Transparent policy making and
explanations of rights.
- Improve safety and effectiveness of health IT.
Safety concerns of patients researched and
- Empower Individuals with Health IT to Improve their
Health and the Health Care System. There are 3
- Engage individuals with health IT. Most
individuals don't use EHR.
HIT argues if they did their health data could become
centered on them and enable Tele-health
including local sensors reporting back to the HIT
infrastructure and applications providing [social]
support and advice. It is also presumed it would
enable new classes of health care market. HIT
hopes that involving individuals in the policy making
through participation via HITPC
and HITSC will increase
confidence in EHR. Ensuring individuals are
aware of the benefits of HIPAA
privacy and that EHR supports HIPAA may build
confidence and use of EHR. HIT also promotes
generating AIDA via social
networks and social media.
- Accelerate individual and caregiver access to their
electronic health information in a format they can use
and reuse. HIT is using Medicare
and Medicaid EHR
incentives to encourage providers to give individuals
and caregivers access to EHRs as PHRs
and secure m-Health
Button presents a use case.
- Integrate patient-generated health information and
consumer health IT with clinical applications to
support patient-centered care. ONC will use device certification
to enable the integration of consumer health device
data with the individuals EHRs.
HHS is studying how to enable
the integration of patient generated insights from
blog entries, health journals etc. Diabetes management is being
used to identify tools for benefiting from EHR
- Achieve Rapid Learning and Technological
Advancement. There are 2 objectives:
- Lead the creation of a learning health system to
support quality, research, and public and population
health. HIT conjectures that electronic records
will provide a foundation for learning about the
population's health. Examples include tracking
and managing epidemics (CDC) and improving quality and
efficiency of prevention and care (FDA
sentinel). New standards (spearheaded by IOM) will be developed for
technologies supporting de-identification,
aggregation, querying and analysis of population
health data. Individuals and providers will be
encouraged to share information with the learning
health infrastructure users.
- Broaden the capacity of health IT through innovation
and research. CHDI is
making many large data sets and tools to analyze them
available. The best practices from SHARP funded (NIH
and AHRQ) research programs
will be promoted into the practice of medicine.
The focus topics are: usability of EHRs,
clinical decision support, consumer health IT, HIEs and Tele-health. NITRD is developing the
programs and strategic plans that HITECH requires to coordinate
research and development relating to Heath IT. VA, DOD and
CMS are acting as test beds for
the Health Information Technology and Economic and Clinical Health Act 2009.
Central to the act is the establishment of the Medicare and Medicaid EHR
incentive programs which make available $27 Billion over 10
years to encourage eligible professionals and hospitals to
adopt and meaningfully use
certified EHR technology. It is assumed that over time
use of the new infrastructure
will grow exponentially. HITECH established a formal
mechanism for public input into HIT
policy - the HITPC and HITSC. Hitech is a key evolved
amplifier driving the migration to and installation of
Epic and Cerner EHR
is the HIT Policy Committee.
is the Health Information Technology Research Council which
supports the RECs by
gathering information on effective practices and helping the
RECs collaborate with one another and share best
is the HIT Standards
is the healthcare
information technology standards panel, a cooperative
partnership sponsored by HHS.
HITSP is charged with developing outline HIT
standards and developing a synchronization process to allow
dissemination of those standards to enable interoperable HIE. AHIC
issues the use cases that create the focus for HITSP.
It has developed an HL7 CCD summary document component C 32 which is referenced as an
acceptable transfer document type for certified EHR
is human immunodeficiency virus, an
which causes AIDS. It infects
T-lymphocytes destroying the
host's immune system.
Some HIV's enter the lymphocytes by leveraging the T cells
CCR5 protein. The HIV X4 variant leverages
HIV undetectable viral load
indicates that treatment for HIV has
resulted in no detectable HIV viral RNA in a patient's blood
tested with a standard assay. It is used as a quality
metric for internists
managing patients with HIV.
is health level 7 (name implying focused on application
level protocols in health care). It includes a variety
of standards: Arden Syntax,
RIM, CDA, CCOW, claims attachments, FHIR, SPL and
messaging and has developed a EHR
system functional model providing a standardized description
of the functions provided. The formation of HL7
messaging communications streams has a relatively high
overhead. HL7 version 2 is generally deployed.
The version 2 messaging standardizes health care data
interchange with messages originally based on character
delimited '|' segments (containing character delimited '^'
composite fields (containing character delimited '&'
subcomponents) in a non XML structure interchanged widely
over a secure network stack. The first field in a
message segment is the 3 character segment name. HL7
is generally transmitted over MLLP.
HL7 v2 has been extended with an XML encoding. HL7 v2
messages have to be augmented to transmit over TCP/IP.
The US Government mandate that
licenced recipients of HL7 messages understand all aspects
of the information transferred. That is point-to-point
specific since each sender has their own interpretation of
what information goes in what HL7 fields. The usual
solution to this situation and rule is (1) an interface
engine placed between the two points which maps the sender's
information from the fields it uses for transmission to the
recipients interpretation of HL7 field usage and (2) a lot
of testing to show the mappings are correct and
reliable. Because of the impact of changing the
interpretation of use of HL7 (on all the interface engines
of point connected partners) operational adjustments to HL7
are difficult. Version 3 of HL7 adopts a different
strategy. It introduces a Meta model (RIM) of the data and so when adopted
changes the strategies available for interconnection.
It is XML based. But the operational difficulty of
switching to version 3 has left most systems tied to version
IG is an HL7 implementation
HL7 Query is a logical query transaction
between a client and server. It can be immediate or
deferred, in which case the response is returned in a
separate asynchronous communication. HL7 version 2.4
and 3 can both use XML to represent the encoded query and
response. HL7 queries are supported by a conformance
is human leucocyte antigen, a gene complex that encodes the
MHC proteins in humans.
is a health
maintenance organization. Originally HMOs were
fashioned after Dr. Paul Ellwood's admiration for group practices such as: Kaiser
Permanente, Mayo Clinic;
which employed salaried physicians and charged fixed fees
rather than FFS. Ellwood argued
that this architecture helped keep subscribers healthy which
he termed a health maintenance organization. President
Nixon was convinced by Ellwood signing the HMO Act. But the legislated
HMO did not have to conform to Ellwood's group practice
architecture. Instead by 1997 for-profit commercial
insurance companies operated two-thirds of the HMO
business. The legislated HMO:
Act is the Health Maintenance Organization Act of
1973 which amended the PHSA to
provide assistance for the creation of HMOs
- Provides or arranges managed
- Health insurance
- Self-funded health care benefit plans
- Acts as a liaison with health care providers
- Covers care rendered by those doctors and others who
have agreed by contract to treat patients in accordance
with the HMO's guidelines and restrictions in return for
access to patients. Treatment choices were often
driven by insurance company rules. Financial
incentives often based the contracted physician income on
success in reducing expenses rather than health
outcomes. There are a variety of contracts with
- Covers emergency care regardless of the providers
plan is a Health Maintenance
organization managed care
plan as opposed to a PPO plan.
It uses the allocated PCP as a
gatekeeper who must refer a patient to any health specialist
for the patient to gain access.
- Money for development
- An override of specific restrictive state laws
- A mandate offered to specific employers to offer an
optional HMO plan as part of
their employee benefits package.
is hereditary nonpolyposis colon
cancer, also called Lynch syndrome. It is a
common inherited dominant trait, although it accounts for
only 5 to 10 percent of colon cancers. It leads to a
60% risk of colon cancer and a 30% chance of uterine
cancer. It is caused by mutations in genome spell checker genes:
MLH1, MSH2 or MLH3.
is Hutchinson-Gilford progeria syndrome, a very rare disease
that appears to result in very rapid aging. It is
caused by a germ-line mutation of the LMNA
gene, typically occuring in the father's sperm.
is human papillomavirus which causes
cancer of the cervix in
women and is also associated with anal
is the California hospital quality assurance fee which is
used to secure billions of dollars each year in federal
matching funds for Medi-Cal.
Funding and Accountability Act, aims to make the fee
is health risk assessment. It is a survey that
estimates adverse outcomes for individuals using responses
that are weighted and mathematically transformed into
numerical expressions of global or condition-specific risk.
is the home ownership and equity protection act. It
was developed by the Republican led Congress and signed ito
law by President Clinton in 1994.
is Hodgkin lymphoma which is
characterized by an orderly spread of the cancerous lymphocytes
from one lymph group to the next. It has a 95%
survival rate. Treatments can include:
is the product of the Homer1 gene short form splice.
The HomeriA has an EVH1 domain which competes with the long
splice forms such as Homer1B and Homer1C,
uncoupling mGluR signalling
and shrinking dendritic spline structures. Homer1a is
expressed by neuronal activity.
is a product of the Homer1 gene long form splice.
Homer1C plays a role in synaptic plasticity and the
stabilization of synaptic changes during long-term
has the key goal of helping people with a fatal illness to
have the fullest possible life right now. There are
chains focused on providing palliative care.
Hospital at home is a Johns Hopkins
initiated program which deploys hospital services at home
such as intravenous antibiotics,
oxygen, breathing treatments, and diagnostic tests to treat
patients with urinary and skin infections, pneumonia and heart
failure. Doctors visit daily and nurse
practitioners visit once or twice a day and remotely monitor
the patients. Cost savings vary between 19 and 44
Hospital system is the owner
of a set of hospitals and other owned infrastructure
and employer of direct staff.
Hospitalists are internists
based at a hospital, where they handle the care of all the
patients on site. It's a recently created role
developed in response to the economic
pressure of managed care in
the mid-1990s. Formerly doctors saw patients at the
hospital in the morning before heading to the office for the
next eight hours. Internists would go to a hospital if
one of their patients needed them. Dr. Diane Craig
argued it would be better for dedicated physicians to be
available to care for hospital patients throughout the
day. And hospitalists were initially very profitable
for hospitals. Even though the hospitals had the
additional cost of their salaries the hospitalists were able
to discharge patients as soon as possible emptying beds that
could be used to get more revenue. But hospitalists' Medicare treatment reimbursements are typically
less than the hospital must pay them. This is the
opposite of the situation with surgeons. Hospitalists
are responsible for maintaining accurate metrics on their
patients: readmission rates,
HAI. As of 2015 there are 50,000
Spot is a highly connected agent with an outsize
influence. In medicine these are very high cost
patients often with very poor personal health care
2017). The logic of hot spots is reviewed
by Atul Gawande. Glenn
Steele & David Feinberg describe
has successfully identified
and reduced the cost impact of its hot spot
Pearl argues the strategy
applicability in the current health care network.
He asserts a revolution
can/must happen that will help this strategy to become
broadly applicable. Ezekiel
Emanuel asserts practice
transformations have allowed chronic care operations:
to identify and support hotspot patients in the
Housing Act of 1949
vastly expanded the federal involvement in public housing
programs, initiating urban
renewal, as part of President Truman's Fair
Deal. The act included:
is a health professional shortage area, an HRSA designation that an area or
population group is experiencing a shortage of health
- Title I financed slum clearance programs to support
- Title II increased mortgage insurance authorization
through the FHA
- Title III increased federal funds for public housing
- Title IV financed research on housing and building
- Title V financed farm buildings
is the Hospital Readmissions
Reduction Program of the ACA.
It imposes payment penalties on high readmitting IPPS hospitals. Such hospitals
with higher than expected readmissions rates will receive
reduced Medicare payments for
all Medicare discharges relating to three medical
conditions: heart failure, acute myocardial infarction, and pneumonia. The reductions
will be driven by an adjustment factor of 1% in 2013, 2% in
2014, and 3% subsequently. The incentives/penalties
induce complex adaptive responses (Dec
is the Health
Resources & Services Administration, the primary
federal agency for improving access to healthcare service
for people who are uninsured, isolated or medically
vulnerable. It was defined by Congress through the Hill-Burton act.
is the Maryland health services cost review commission, an
independent state agency with responsibility to set rates
and drive down costs of hospital care.
- An employee health savings account which uses a person's
health score to calculate the costs of reimbursement and insurance
coverage necessary to cope with expected medical
costs. HSAs are an expansion of MSAs
that existed in 20 states since the 1990s. HSAs were
enacted as part of MPDIMA.
Each HSA has an insurance policy to handle the risk of catastrophic illness.
Policy holders can withdraw funds untaxed when they are
used for paying eligible medical costs including:
long-term-care insurance premiums and medical care during
retirement. Employer contributions can be diverted
to increased insurance payments if the employee's actions
result in a low health score. HSAs are federally
tied to HDHPs and can't be used
with Medicare. It is
argued that HSAs are very useful to the wealthy as a tax shield. The
poor would depend on the catastrophic insurance limiting
the financial impact of cancer
treatment or major surgery. Or it is a
- Hospital service area - a local health care market for
hospital care as used in the Dartmouth Atlas.
is human T-cell leukemia virus type
1, a human retrovirus, which
causes adult T-cell leukemia/lymphoma and a demyelinating disease. It
infects millions of people in: Japan, Africa, South America,
Caribbean, Australia; but only 5% of those infected develop
the cancer. It is
transmitted between humans by: sex, breast-feeding,
needle-sharing, transfusions, and transplants.
- Helical tomotherapy:
- .ind.include ('html/awffwglossary.html',
'gltomotherapy1', 'gltomotherapy1', '1')
- Hormone Therapy, previously called hormone replacement
is the US department
of housing and urban development.
HUD act of 1965 is part of LBJ's Great Society program, an act of
Congress revising federal housing policy and setting up HUD.
HUD act of 1968
Human readable format is
defined in 45
CFR Part 170 final rule as a format that enables a
human to read and easily comprehend the information
presented to him or her regardless of the method of
presentation (e.g., computer screen, handheld device,
Huntington's disease is
caused by a mutation, the CAG expansion, in a single gene of
chromosome 4, causing
involuntary movements, changes in personality and
cognition. A person with the mutation, where more than
39 CAG repeats are included in the gene, will have the
disease, which results in protein clumping and death of the
effected neuron. 30,000
people in the US have the disease
which impacts both sexes. It leads to cognitive and
motor defects, including sleep
disorders and dementia. It
damages the basal ganglia,
cerebral cortex, hippocampus, hypothalamus, thalamus and occasionally the cerebellum.
- Split out Ginnie Mae from Fannie
Mae placing it under the FHA.
- Made Fannie Mae a publically traded company to remove
its debt from the federal budget.
Hybridoma is Cesar
Milstein's technique to generate monoclonal
antibodies. The process:
argues that to avoid hyper-reactive tendencies in the immune response that underlie
autoimmune and allergic diseases need
stimulation early in life. Lifestyle is assumed to be
a major aspect:
- Injects a mouse with the antigen to generate an immune
- B lymphocytes that bind
to the antigen are harvested.
- The isolated B cells are fused with myeloma cells to generate a
hybridoma cell line, which has the antibody
producing capability and the extended longevity. The
myeloma cell line is selected for its ability to grow in
tissue culture and not produce antibodies.
a hereditary condition (FH) that causes
the body to generate a high density of cholesterol. It
can result in coronary artery
disease. Hypercholesterolemia can be identified by genomic testing.
- How the way you live guarantees exposure to a rich
variety of microbes that favorably impact the immune
Hypertension is high blood pressure.
It is directly associated with death rate due to pressure
induced damage to the left ventricle and in general to cardiovascular diseases.
Treated with antihypertensives:
Diuretics, Calcium channel
receptor blockers or Beta
Hypothyroidism is under production of thyroxine by the thyroid.
is oxygen deprivation, which induces the body to generate HIF-1 to improve the oxygen
is the international
anesthesia research society. It sponsored SmartTots.
is inflammatory bowel disease, which is a chronic
inflammation of part of the digestive tract. It
includes Crohn's disease
and Ulcerative colitis. Johns
Hopkins's Bayless noted it differs from irritable
bowel syndrome - they require different treatments.
Symptoms include: Severe diarrhea,
Pain, Fatigue & weight
loss. It typically begins in the teens or
twenties. Incidence has increased exponentially since
1945 in developed countries. 160 genes have been
associated with IBD. These genes all relate to:
Producing mucus, solidifying the
lining of the gut, or regulating the immune system. The
rapid increase in the incidence of IBD can be explained by
societal impacts on the gut microbiome
which interacts with these genes and their products.
No particular culprit has been found. It is probably
an ecological shift away from symbiosis.
There is a shift from fibre-fermenters: Faecalibaterium
prausnitzii, Bacteroides fragilis; to: Fusobacterium
nucleatum, Escherichia coli; which are more
inflammatory. The trigger for disease appears complex:
Less early infections with tapeworms, bacteria & viruses, Smaller families - which are
typically cleaner, More
urban environments - resulting in less contact with
higher animals, Less pets, Antibiotics,
Endocrine disrupters, Caeserean births, Formula fed babies -
rather than breast milk; all
potentially contributing to the altered setup and operation
of the immune system and microbiome.
is intern-to-bed ratio
is the Interstate Commerce Commission, which was created by
Commerce Act to regulate railroad transit. By
1915 the ICC controlled almost all aspects of railroad
is the state wide Indiana Health Information Exchange which
leverages the IT and informatics team at the INPC. It includes clinical and
administrative claims data to support electronic delivery of
test reports to physician offices. It also maintains a
report card and incentives on established quality measures
to physicians, practice groups, payers
Inguinal hernia is a protrusion of tissue
through the abdominal muscle. Inguinal hernias affect
3 to 5% of children born full term and up to 30% of children
born premature. Most of those affected are boys.
During fetal development the
testes have to pass from the abdominal cavity through the
inguinal canal to reach the scrotum. Before birth, the
opening to the canal is supposed to close. When it
doesn't, a hernia may result.
is the Indianapolis
Network for Patient Care a federated RHIO connecting all five major hospital systems in greater
Indianapolis. It has been operational since
1994. All participants now deliver registration
records, all laboratory tests, text reports, medication
history and all UB92 records for hospital admission and E.D. to separate medical record vaults
in a central INPC server using a federated data store
model. The messages are exchanged using HL7.
Information is mapped to LOINC
codes before storing in the vaults. Patients with
multiple medical record numbers are linked.
is the International Classification of Diseases diagnosis
codes which doctors must specify and associate with a
correct CPT procedure code to have
treatment accepted and reimbursed.
ICD is mainly focused on billing. Methodological
2018) are driving a shift to precision medicine.
is the 2009 iteration of the ICD.
ICD is mainly focused on billing. ICD-10 allows for
greater specificity which is assumed to translate into lower
rejection rates, easier audit compliance, and better data
mining. ICD is seen as less rich as a representation
for clinical record keeping than SNOMED-CT
which becomes a concern if the EHR
standards force ICD-9 codes to be the required but
insufficient representation of a medical
is integrated care EHR. This is
a sharable EHR repository.
is the international
consortium for health outcomes measurement. It
gathers patient oriented outcome data for specific diseases
and treatments. It was founded by Michael Porter,
Stefen Larsson and Martin Ingvar.
is immunochromatographic strip, otherwise termed LFS, a technology used in IVD, which:
is intensive care unit. It is now being realized that
the procedures and environment of the ICU is highly stressful for the patients. In
particular sedation with
benzodiazepines is suspected to enhance the risk of inducing
and catheterization are
also traumatic. Sometimes seperated into MICU and SICU.
eICU skill centralization may bring
- .ind.include ('html/awffwglossary.html', 'lfstech1',
ICU delierium is also called ICU
ICU psychosis is also called ICU
- Is an acute brain failure.
- Can be due to: Dehydration, Hypoxia, Heart
failure, Drug induced, including
- May be minimized by limiting sedatives, and encouraging
activity as soon as is possible.
is the inter-American development bank, established by the
Organization of American States, as a source of financing to
member governments within the Latin American and Caribbean
- .ind.include ('html/awffwglossary.html', 'glicudel1',
is a mitochondrial isocitrate dehydrogenase involved in cell
metabolism. Certain mutations of the genes encoding
IDH-2 result in the production of 2-hydroxyglutarate
inhibiting multiple dioxygenases and causing abnormal
histone and DNA methylation producing
a molecular inhibition of nuclear gene operations that
control cell differentiation. The result can be A.M.L.
is an integrated delivery network. It is a network of
health care providers that use ownership or formal
agreements to deliver integrated care.
is infective (bacterial) endocarditis.
The infection of the endocardium -- heart inner lining -- or
the heart valves causes inflammation and can be fatal.
is the HHS Indian Health Service
is a tyrosine-kinase
inhibitor that treats a set of cancers
-- particularly CML -- where a
tyrosine kinase becomes stuck turned on. It is an
early and well known targeted therapy. It is marketed
by Novartis as Gleevec. It
is taken orally and metabolised in the liver.
It has a benign side effect set allowing users to live a
relatively normal life.
Immigration act of 1924
aimed to extend the emergency
quota act in limiting immigration of Southern and
Eastern Europeans into the US.
It also severely restricted the immigration of Africans, and
banned Arabs and Asians. It divided the implementation
of immigration controls between the state department and the
immigration and naturalization service. It established
consular control by mandating that no alien be allowed to
enter the US without a valid visa issued by an American
consular officer abroad.
Immuno-oncology uses the immune system to
treat cancer. Cancer cells
often have different molecules on their cell surface.
Studies have shown that genetic signatures of tumors can
help predict which patients will benefit from treatment with
PD-1 checkpoint inhibitors.
Checkpoint inhibitor based treatments aim to make the immune
system target these antigens. Clinical trial results
indicate they are prolonging lives - even if only by a few
months. They have reduced side effects relative to
generic chemo therapy. There are three main
strategies: cellular, antibody
Immunotherapy is indirect
treatment of disease by altering the immune system. Targeted
diseases include: cancers -- immuno-oncology, organ
- Antibody therapies target receptors including CD20,
CD274, CD279 and CTLA-4.
These therapies include MABs:
Alemtuzumab, Ofatumumab, Rituximab;
and may induce checkpoint
- Cellular therapies have
typically involved removing the immune cells from the
blood or a tumor, activating, culturing and then returning
them to the patient. Trials of these CAR and TCR
therapies are proceeding, with some significant problems (Jul
- Cytokine therapies enhance anti-tumor activity through
the cytokine's regulation and coordination of the immune
- Vaccines, including Sipuleucel-T for prostate cancer and BCG, classically a vaccine for tuberculosis, which is used
for treating bladder cancer.
IMPaCT Model is individualized management
for patient-centered targets, a standardized, exportable
tool kit that supports community health
worker (CHW) recruitment, training, and care,
developed by the Penn Center for community health workers.
The ACA makes health systems
responsible for outcomes: primary
care access, patient-reported quality of care,
hospital readmissions; which
have a dependency on socioeconomic and behavioral risk
factors. CHWs using IMPaCT can relate to the patients'
needs and values, and support them, improving intervention
success, and quality. The keys to CHW success are
is intensity modulated radiation therapy which allows
accurate targeting of radiation to tumors of complicated
- Hiring: listening skills, human connectedness,
compassion, empathy, engagement
- Training: train at all levels including: directors,
managers, CHW; Train using adult learning theory, and
- Standardized interviewing: Semi-structured interviewing
- Safety: Meet patients in public places, or at their
homes in a team. Report issues at safety huddle
- Data: Systematically tracking outcomes, and provide
- Supervision & management: Weekly meetings with
management to ensure realistic goals, progress achieved,
obstacles overcome, stress reduced
is an IT information management system used to manage core
IT infrastructure including availability, capacity,
security, continuity, service levels etc.
Index funds use simple rules to decide what
assets to include in an investment fund: mutual fund or ETF. John
Bogle leveraged the low cost and predictability of the
approach to build Vanguard's
index funds for consumer investors, explaining "My ideas are
very simple. In investing, you get what you don't pay
for. Costs matter, so intelligent investors will use
low-cost index funds to build a diversified portfolio of
stocks and bonds, and they will stay the course. And
be foolish enough to think they can consistently outsmart
the market." University
of Chicago economists:
Renshaw, Feldstein, Samuelson;
initially developed the indexing idea to obtain a
diversified open-ended vehicle aligned
with the assumed random operation of the market.
Complexity economics undermines
these ideas, suggesting index funds are an evolved amplifier leveraging
captive 401K funds. Index funds are not guaranteed to
be transparent and the selection process involves lightly
regulated companies which can be open to conflict of
interest - their selections will alter the demand for and
price of the stocks (Feb
Infection control works
to prevent healthcare-associated infections. It
monitors & supports associated hospital processes:
Anti-microbial surfaces, Barrier clothing, Cleaning,
Disinfection, Hand washing: North
shore; Patient access during epidemics,
Sterilization; to contain cross infection. The CDC provides support: Ebola process;
and works closely with the primary biocontainment unit at Emory
Influenza is a virus,
normally hosted in birds, which jumps to humans causing
pandemics of flu
infection and deaths. There are various types
including: H1N1, H3N2 which mutates more causing vaccination strategies to have
problems, B/Victoria, B/Yamagata; strains. The
"Spanish flu" epidemic of
1918-1919 killed between 50 and 100 million
people. The 2017 winter flu killed 80,000 people in
the US. 95% of US winter flu
occurs in mid-December. The US has vaccines that
target three and four types of flu at once. It also
adds the adjuvant MF59 and
increases the dose for people over 65. Vaccine
effectiveness drops from 60% by 20% a month so November is
the most effective month. Infection in people appears
to depend on host genetics but no mechanism has been
identified. Flu is spread by droplets in the
air. Being within 3 to 6 feet of someone who is
affected means likely breathing in their exhaled
virus. In the initial one to four day phase of
infection the virus latches onto the mucous membranes that
line the back of the nose, throat, and bronchial
tubes. The viruses then leverage the metabolic and
replication systems of the epithelial
cells that make up the mucous membranes. People
typically don't know they are infected in this first
phase. In the next phase the immune system mounts an
attack on the virus which is concentrated in the respiratory
tract: releasing interferon and cytokines
generating the classic symptoms: aches, fever, dehydration;
of flu. Drinking lots of fluids compensates for the
dehydration and helps the immune system agents to circulate. The
respiratory tract epithelial cells are typically inflamed
and damaged and release their contents which are experienced
as a runny nose and cough. Stay upright and get fresh
air to support the coughing. Medications that suppress
this are not helping with recovery. If enough cells in
the bronchial tubes are destroyed to create holes then
secondary bacterial infections can occur including pneumonia.
Information commons is a
dynamic network supported by a data repository that includes
layers of captured data:
Integrins are transmembrane receptors that
act as bridges for cell-cell and cell-ECM
is a medical graduate in their first year of residency.
InterQual is an evidence-based
clinical decision support criteria that helps answer
critical questions about the appropriate levels of care and
resource use. Over 30 years these criteria have helped
and care management.
Prior to InterQual the length of time a patient would stay
in a hospital was highly variable. Common accepted
practices and physician judgment were used to decide stay
length. But with the Medicare
and Medicaid acts of 1965
hospitals were required to have processes available to
control spending. It mandated a review of medical necessity, length
of stay, discharge
practice, necessity of ordered services, and
utilization reviews. Joan Lamprey argued that the
length of stay should depend on how sick the patient is and
the type of treatment deployed. With Charles Jacobs of
JC she formed InterQual to develop
quality assurance solutions for Medicare. The company
reviewed clinical norms and assessed sickness by body
system: respiratory, cardiac, orthopedic, reproductive,
etc. They published severity of illness/intensity of
service criteria in 1978 for evaluating appropriateness of
admissions and levels of service. Later discharge
screens were added. Many hospitals adopted the
methodology. InterQual is now part of McKesson but the
criteria it develops are reviewed by 800 independent
practicing clinicians and academics.
Innovation Center is the
CMS Innovation Center.
It was created by the ACA to test new
models of health care delivery and payment including the Pioneer ACO and the Advance Payment ACO.
It also offers technical support to providers to improve the
coordination of care and share lessons learned and best
practices. In 2016
Slavitt proposed testing a new Medicare
part B drug pricing
rule, which was furiously resisted by PhRMA
and blocked by Representative Skimkus collection of 242
is international normalized ratio. It is a blood clotting time IVD
test. It is also called a PT.
regulates the metabolism of carbohydrates, fats and protein by signalling the absorption of
glucose by fat, liver and skeletal
muscle cells. It is a peptide hormone
generated in the islets of Langerhans beta cells of the
it was an early drug therapy success. As manufacturers
have shifted from products developed by extraction to biologics: Humulin,
safety has improved. But the US list price has risen
Insulin Glargine is a
long-acting, man-made version of human insulin.
Intensivists are specialist physicians
focused on ICU medicine. They
learn about the specific problems of ICUs and help to reduce
errors. There are higher death rates in hospitals
where ICU patients are not cared for by intensivists.
Interact model is a discharge intervention
for reducing early readmissions
for patients discharged to SNFs.
Interventions to Reduce
Acute Care Transfers focus on early identification,
assessment documentation and communication about changes in
the status of residents in SNFs.
Interface engines are
middleware infrastructure which:
Internists are physicians who specialize in
internal medicine - the diagnosis and treatment of
- Translates data between alternative supported message
- Links with various systems within a clinical network to
transfer data to and from them.
- Verifies the accuracy and conformance of messages to
standards supported by the end nodes of a transfer.
scientific understanding and technology that shows how
'neurons' in a deep
neural network arrive at their decisions
Interstate Commerce Act
of 1887 granted the power to regulate the railroads to the ICC.
Intraparietal sulcus is
a part of the parietal lobe
associated with: Perceptual motor coordination and visual
attention, Symbolic numerical information, Visiospatial
working memory and interpreting intent.
Possibility of intervention
is an indication of the possibility, and likely impact, of
effectively treating a disease. Francis
Intubation is the insertion of a tube into
the trachea to support breathing. It often results in
feelings of suffocation and will result in inhibition of
- Preventing a serious disease is not associated with a
simple, one-time-only, inexpensive, and easily
- Type 2 diabetes is
highly preventable with the opportunity to change diet,
exercise and hence limit obesity.
This has been demonstrated by the diabetes
prevention program. The possibility of
intervention for diabetes is high.
Inversion allows a U.S.
company to move its tax domicile overseas by purchasing a
foreign company. In 2015 the U.S. Treasury department adjusted the
inversion rules to require 40% of the combined company is
owned by the shareholders of the purchased foreign
entity. In Apr
2016 they clamped down on the option to serially
acquire American companies. In section 7874 of the tax
code, Congress defined statutory hurdles that must be
cleared to gain tax benefits: Shareholders of foreign
acquirers owning less than 20% of the combined entity the
inversion fails, If less than 40% and the acquirer does
substantial business in the foreign jurisdiction the
inversion works but with some pain,
If they own more than 40% there are few negative
consequences. Companies purchased serially within
three years would be disregarded by the new rules.
Companies invert because of lower foreign tax rates and earnings stripping.
Once foreign, the parent loans the US subsidiary
money. The loan repayments offset the US income and
the US tax bill is vastly reduced.
Investment company act
was developed by Congress and signed into law in 1940 to
regulate new investments, such as mutual funds
which gave the general public more ability to indirectly
purchase securities. Hedge
funds are not regulated by the act. The act
required public disclosure of the financial health of these
investment companies. The act was updated by
provisions of Dodd-Frank.
Settlement is a process bound in by the trade
agreement which gives companies the right to sue governments
directly. A small panel of lawyers decides the matter,
not a country's courts. It is an aspect of
international trade agreements which ensures foreign
of Medicine which was renamed National
and Medicine Division in May 2016.
is interoperability. ONC offers
a vision. Interoperability
providers aim to integrate all the HCIT.
- That they have some recourse if a country nationalizes
or expropriates company assets.
- Some financial security.
is an independent practice association, a pharmacy or
laboratory with the legal authority to contract with other
pharmacies or laboratories to arrange for or provide
services to enrollees of a state MCO.
is the independent payment advisory board, with 15 members
which the ACA (III) section 3403 and 10320
is tasked with achieving, CMS
determined per capita growth rate goal, focused savings in Medicare without affecting
coverage or quality. (But the BBA of Feb
2018 removed the IPAB.) It has authority to make
the CMS goal driven changes which Congress can only overrule
with a supermajority vote. Prior to the ACA, MedPAC could recommend changes to
payment rates and program rules but Congress had to enact
Ipilimumab is a monoclonal antibody (MAB),
marketed as the checkpoint
that targets CTLA-4 an immune
system down regulator receptor.
is Inpatient Prospective Payment System for
is induced pluripotent stem cell a technique which generates
stem cells from adult
cells. It uses the genes that generate the signals present in SCNT egg cell cytoplasm, rather than
the whole egg cell, to induce the stem cell lines from adult
cells by adding these genes to the adult cells. Such
iPS cells have been generated from adult cells of
individuals with inherited diseases providing a research platform for studying the
diseases. Since iPS cells can be generated from a
patient's skin cells they could be used therapeutically
without generating an immune system response. But
before iPS cells could be used in therapies it must be clear
that they would obey the local environmental signals
appropriately. Indeed Dr. Yamanaki has since found
that iPS cell lines must be carefully selected. With
the ability to proliferate rapidly and infinitely some lines
could cause cancer. So his
partners are selecting allogenic differentiated cell lines
(direct cellular reprogramming which does not build a
pluripotent stem cell) from particular donors whose DNA has been exhaustively checked for oncogenes.
is Medicare's Inpatient Quality
is interventional radiology.
is the Internal Revenue Code Congressional statute codifying
the tax laws in one place. The IRC was setup in 1939
but restructured in 1954. Subsequent updates have kept
the 1954 structure.
is inpatient rehabilitation facility.
is the CMS IRF
assessment Instrument including database, software,
is a hormone which stimulates
white adipose (fat) tissue to turn brown. Irisin is
created in working muscles in mice. After entering the
bloodstream it migrates to other tissues, in particular
adipose cells where it signals
a pathway that promotes UCP1
generation and causes some of the white adipose cells to
turn brown. Brown adipose: Burns calories, Controls
insulin and blood sugar; and reduces the risk of type-2-diabetes.
Irisin signals white adipose stem cells to become bone
cells. Irisin has no apparent effect on brown adipose
cells. When irisin was injected into mice being fed a
high fat, high calorie diet it inhibited them becoming obese.
is Income Related Monthly Adjustment Amount.
is anemia caused by lack of
iron. It is generally caused by loss of blood,
insufficient dietary iron, poor absorption of iron.
is the Internal Revenue Service.
I-SPY 2 TRIAL is the investigation of serial
studies to predict your therapeutic response with imaging
and molecular analysis 2. It aims to significantly
reduce the cost, time and number of patients required for
efficiently bringing new drug therapies to breast cancer patients who
need them urgently.
By using the cellular signalling
pathways as targets of 'targeted' therapies. In
I-SPY 2 the pathway information forms the basis of
rationalized therapeutic guidance for patient selection,
stratification and further exploration to find
response-predictive biomarkers. From an overview of
gene mutations, gene copy number, gene expression as mRNA
and protein and protein phosphorylation of both tumor and
background tissue and blood a patient and tumor sub-group
specific set of diagnostics and therapies. The
- Uses tissue and imaging markers from individual cancer patients' tumors to
determine eligibility, guide/screen promising new
treatments and identify which treatments are most
effective in specific tumor subtypes.
- The trial's adaptive design allow the I-SPY 2 team to
'learn as we go,' enabling researchers to use data from
patients early in the trial to guide decisions about
which treatments might be more useful for patient who
enter the trial later. I-SPY 2 provides a
scientific basis for researchers to eliminate
ineffective treatments and graduate effective treatments
- The I-SPY 2 neoadjuvant treatment approach, where chemotherapy is applied
prior to surgery, allows the team to evaluate tumor
response with MRI before removing the 'evidence'.
This approach is as safe as treating after surgery,
allowing tumors to shrink, and most importantly, it
enables critical learning early on about how well
- Key to the trial's distinctive design, the team will
screen multiple drug candidates developed by multiple
companies--up to 12 different investigational drugs over
the course of the trial. New drug agents will be
selected and added as those used initially either
graduate to Phase III or are dropped for futility, based
on their Bayesian predicted
efficacy in targeted patient subgroups. Not only
does this enable an enormous improvement in efficiency
but, by using only one standard arm for comparison
throughout the trial, it also immediately saves 35% of
the costs of standard Phase III trials.
- The trial incorporates a robust informatics system
that allows data to be collected, verified and shared
real-time and to be accessed early and in an integrated
fashion--enhancing and encouraging pre-competitive
I-SPY 2 adaptively randomizes its iterative allocation
of the initial/current patient population to either:
- Standard, FDA approved,
biomarkers to determine patient eligibility and allow
- CLIA biomarkers to aid
- Exploratory biomarkers to aid hypothesis
I-SPY 2 collects data from each patient:
- Existing standard of care or
- Various experimental arms which eventually should
graduate to phase III, or be abandoned, for some patient
subgroup. Abandoned arms are replaced by
alternative experimental regimes in a new randomized
arm. Deciding to graduate or abandon uses Bayesian modeling. That
requires (1) a reasonable model that allows simulation
to assess behavior and (2) a simulation. Want to
favor treatments that, on average, have superior interim
results for specific biomarkers (patient
segments). Aim to graduate experimental treatments
with the largest signature that is likely to
benefit. Graduate small signatures if it is
unlikely that a larger signature benefits. Want to
evaluate many drugs and combinations.
I-SPY 2 benefits:
- Biomarkers (HR+/-, HER2+/-,
MP1/2) -> 2(8) combinations but treated as 10
subgroups (1. All, 2. HR+, 3. HR-, 4. HER2+, 5. HER2-,
6. MP2, 7. HR-HER2-, 8. HR-HER2+, 9. HR+HER2+, 10.
- MRI volume at baseline, 2, 4 & 6 months;
- pCR at 6 months;
is the common framework's
inter SNO bridge. It is the
required way to flow medical information from one SNO to
another bridged over the Internet. But it is only for
patient-centered queries! Aggregate queries must be
resolved by other facilities? Due to the hierarchic
nature of the NHIN the ISB must be
able to support different types of architecture
(centralized, federated, proxy ...) based requests for its
entities. Inter ISB communication is all
asynchronous. The receiving ISB will immediately ACK
the SOAP request. The ISB must
support two patterns of request: a one pass structure where
the request is made to the ISB and it passes back the
aggregate result; a two pass request where the ISB acts like
a RLS returning locators to the
remote information. The requesting SNO can select a
method for delivering the response to the requesting entity
including email, fax, leave the request call active or ask
for the requestor's procedure to call back
periodically. In line with the policies of the common
framework the addressing scheme is WS-Addressing. Query
user identity is included. It is specified in HL7 2.4 XCN data types in line with HIPAA requirements. Assertions
about the identity of requesting individuals are required to
be specified in SAML.
- Reduce the cost of bringing a drug from discovery to
- Reduce the time to conclusive results.
- Reduce the number of patients needed to enroll in the
trial. There is a tenfold reduction for Phase
- Improve the pace of innovation.
- Improve the success rate of Phase III trials (85% vs.
- Improve pre-competitive collaboration for applying
molecular and protein pathway profiling and imaging in
- Improve the efficiency of drug evaluation and approval
in concert with the FDA, and provide support for
innovation in regulatory decision-making.
is a restriction in blood supply to an organ such as the
Ischemic stroke is a clot
that occurs as a result of an Ischemia
within a blood vessel supplying blood to the brain.
They account for 87% of all strokes. There are two
Swaps and Derivatives Association. The trade
association for over-the-counter
- Thrombotic - where cerebral arteries become diseased or
damaged and then blocked by a blood clot within the
- Embolic - where a blood clot or plaque fragment forms
outside the brain (usually the heart) and travels to the
brain where it blocks a blood vessel.
Itraconazole is an antifungal medication,
classified by the WHO as an essential
medicine. It is a triazole which stops fungal growth
by undermining metabolism and cell membrane integrity.
Effectiveness is being undermined by global agricultural
deployment of equivalent azole fungicides on crops.
is the international union against tuberculosis and lung
Ivacaftor is a drug treatment for the G551D
variant. The CFTR protein
regulates fluid flow into cells but with the G551D mutation,
while the transporter is migrated to the cell surface as
normal, it cannot transport chloride through the
channel. Ivacaftor binds directly to the channel
increasing the probability that the channel is open and
increasing chloride flow.
is in vitro
is in vitro fertilization. In the US,
in 2018, multiple eggs are deployed during the IVF procedure
to maximize the chance of pregnancy. This practice is
driven by the metrics promoted by the CDC.
However, multiple eggs increase the likelihood of multiple
births, significantly raising the risk
of problems for newborn and mother. In other advanced
economies single egg IVF is
encouraged. More women are delaying having children
for education and career goals, with the assumption that
they can use IVF if necessary to ensure pregnancy. But
the failure rate becomes 70% to 80% for women over 40 (Oct
is the journal of the American medical association.
is the Joint Commission
John Henryism is the effect of using
high-effort coping in a system which undermines the
strategy. John Henry Martin was from a family of North
Carolina sharecroppers who worked tirelessly to escape from
the situation. He did so but developed hypertension, arthritis and a
peptic ulcer. The effect is true of poor blacks in the
US and poor white Fins who had heart attacks.
High-effort coping correlated with increased disease in both
John Pierpoint Morgan
was an American financier who founded J.P. Morgan and
Company which merged in 2000 with Chase Manhattan Bank to
Chase & Co.
is an independent group of scientists that advise the US government on matters of science and
technology. It is administered through the Mitre
Corporation. It has proposed
an architecture for improved IOP
in the HIT.
Joint Commission, JC or
JCAHO is a nonprofit that accredits
more than 19,000 health care organizations and programs in
the United States.
is the Joint Commission
on Accreditation of Healthcare Organizations.
is the jobs and growth tax relief reconciliation act of
2003. It was an evolved
amplifier for the Republican author's and their wealthy backers.
Congressional legislators were constrained by the ATR and the Club for Growth.
- Home health care: The JC is one of three groups (JC, CHAP, ACHC)
recognized by the federal government as accreditors of HHAs. The JC requires its
accredited HHAs receive payment from Medicare. To become
accredited an HHA must undergo detailed reviews and onsite
visits, including direct observation of patient
caregiving, every three years.
- Hospitals: In 1965 the federal government decided that a
hospital that met joint commission accreditation met the Medicare conditions of
removed the joint commission's accreditation authority
requiring it to submit accreditations to CMS which subsequently determines the
granting of accreditation.
- Rehabilitation: Joint Commission accreditation is an
alternative to CARF certification
Johnson Act of 1934 prohibited American
citizens from lending money to foreign countries that had
not paid their past war debts. It is still on the
- Lowered the tax on capital gains to a maximum of 15%
- Lowered th tax on dividends to a maximum of 15%
- Accelerated parts of EGTRRA.
It was argued to cost $350 billion if the proposed early
phase-outs were implemented. They were not.
Instead the cuts were extended by the TIPRA.
data-interchange format (RFC 7159). It is easy for
humans to read and write.
is a veterinary anesthetic.
It also treats depression,
altering the patients mood within hours. It targets
the mediating neurotransmitter glutamate, by blocking a receptor on the signal's target
cell. It is not a long term treatment since it has
side effects including nausea, vomiting and disorientation,
but can be used to limit suicides in the two weeks before SSRIs take effect.
Key opinion leaders are
highly influential physicians who, according to Dr. Marcia
Angell, write textbooks and medical journal articles, issue
practice guidelines, sit on the F.D.A.
advisory panels, head physician
specialty societies and speak at events where
clinicians are taught about prescription drugs.
provides multiple vital functions. It: Produces renin
which supports negative feedback, Removes excess organic
molecules from the blood, Regulates electrolytes in the
blood, Maintains pH homeostasis,
Regulates fluid balance, Regulates blood pressure, monitors
blood oxygen concentration and signals
erythropoiesis with EPO, Reabsorbs water, glucose (SGLT2) and amino acids. Kidney
function is monitored with the GFR.
Kidneys can fail acutely or chronically.
Kidneys are affected by a variety of cancers
kidney cancer, von Hippel Landau;
some of which are induced by PFAS.
myeloma, type 2
diabetes, TB and drug
treatments for MDR TB place a
strain on the kidneys and can induce failure.
Kidney cancer includes any cancer initiated in the kidney. In adults the most
common form is an RCC. In
children Wilms tumors are
most common. Transitional cell cancer is the other
common form. It develops in the renal pelvis and
ureter in adults. It is associated with obesity.
is the gene CD117.
is a healthcare technology rating
Know the Lowest Price
act of 2018 bans gag clauses from outpatient Medicare drug coverage: both Medicare Advantage and
traditional FFS plans. It was
sponsored by Senator Stabenow and signed into law by
includes the technical, scientific and social strategies
required to build, maintain and use knowledge-based
computing systems. The technical infrastructure
includes a set of rules about the domain, a user interface
& an inference engine.
is key opinion leader: Francis
Kocher (ACA), Tom Scully
(Medicare part D); a
medical or pharmaceutical subject matter expert who drives
original research, writes text books and articles, and
expands the adjacent
possible to increase the profitable space for
medications and medical devices.
is key performance indicator
is a gene that encodes the GTPase KRas, which is part of
many signal transduction pathways that propagate growth factors.
Mutations in KRAS are essential for the development of many cancers.
Kupffer cells are specialized macrophages located in the liver. They form part of the
system. They develop from the embryonic mesoderm cell layer.
Kwashiorkor is a form of malnutrition where
under-nourished children develop blood-vessel leaks leading
to swollen limbs, stomachs and damaged skin. The gut microbiome of kwashiorkor
sufferers includes microbes that interfere with energy
generation within the host's cells.
aims to improve the processes in laboratories. Robots
and lab-on-a-chip are a key aspect. High-throughput
screening and combinatorial chemistry, automated clinical
and analytic testing, diagnostics, and biorepositories
depend on automation.
is left anterior descending coronary
artery is a branch of the left coronary artery.
A is a fibrous structural protein which supports
the shape of the eucaryotic cell's nuclear envelope.
It contributes to the reshaping of the nuclear envelope
during cell division. To operate correctly its NLS is modified during
deployment. Certain sperm based germ-line mutations of LMNA alter the NLS resulting in HPGS.
is loop-mediated isothermal DNA
amplification. It allows sequence amplification at a
constant temperature via multiple primers and a DNA polymerase with high replication
and chain displacement activity. It removes the need
in PCR for
expensive and power hungry thermocyclers in moldecular
Laparoscopy uses small incisions, endoscopes and surgical
instruments to perform MIS.
is long-acting reversible contraception
virus is a hemorrhagic fever carried
by rodents and transmitted through urine and feces.
is a licensed clinical social worker performs mental health
screenings, assessments, diagnoses and interventions.
They may develop and implement treatment plans to assist
patients and families to build social, emotional, financial
and environmental strength. Manage ASWs.
is a laboratory data sharing and interoperability
application which the VA and DoD are developing to facilitate
sharing of chemistry and hematology laboratory
is a lab-developed test, which as of Nov 2015 does not need
to be cleared by the F.D.A. But
the F.D.A. is concerned at the increasing complexity and
higher volumes of LDTs so it is considering revisions to its
Lean Management is the application of the
Toyota quality improvement process. This focuses on:
- Removing the seven critical wastes:
The result should be improved processes and outcomes,
reduced cost and increasing patient and staff
- Excessive motion
- Waiting time
- Over production
- Unnecessary processing time
- Excessive resources
- Unnecessary/ineffective handoffs
It is typical to use metric collection and analysis to
understand where the issues are and if they are being
Legacy chemicals are
present in the US environment but are
no longer sold in the market.
is a hormone that is released by
adipose cells into the blood stream, which targets receptors
in the brain where it is used to guage fat levels.
When the level of leptin is low the brain induces hunger,
encouraging eating. When the person has limited
numbers of fat cells, as in lipodystrophy,
the leptin levels are always low inducing over eating which
often leads to type-2-diabetes,
hypertension and heart disease.
is a group of cancers of blood
forming tissues: bone marrow, lymphatic network; where
abnormal white blood cells are generated. One type of
leukemia is induced when TAD
boundaries near the TAL1 gene fail
allowing promotors from across the TAD border to distort the
operation of the TAL transcription
factor. Mutation clusters common in leukemia
have been identified in CHIP.
Level 1 trauma center
criteria and has passed a site review of requirements of
state law. A level 1 trauma
center typically has access to specialist medical and
nursing care for: emergency, trauma surgery, critical care,
neurosurgery, orthopedic surgery, anesthesiology, &
radiology. In Texas level 1 designation requires a
trauma surgeon to be on premise 24 by 7, and surgical
specialists to be readily available.
Level 3 assets are securities that trade so
infrequently that their prices can only be estimated.
Leverage ratios are used by financial
regulators to assess that a bank has adequate capital.
The ratios are computed by dividing the bank's tangible
common equity by its total assets.
Levothyroxine is a manufactured form of thyroxine (thyroid
hormone) to treat hypothyroidism.
Lewy bodies are protein clumps that are a
pathological mark of Parkinson's
disease and Lewy
body dementia. A major component of the clumps
Lewy body dementia
progresses rapidly and has no cure as of 2015. It is
often mistaken for Alzheimer's
disease. There is an Alzheimer's-like memory
slippage. There are movement problems like in
Parkinson's. Eventually the chronic symptoms
establish: sleep problems, 'fluctuations" in thinking, depression, visual
hallucinations. The psychotic aspects can mistakenly
lead to invalid treatment with psychiatric drugs. The
experience of the symptoms and especially the depression can
lead sufferers to suicide.
is lateral flow strip, otherwise termed ICS,
a technology used in IVD, which:
describes the brain's unconscious operation of a balance of
virtuous and less honorable actions. The key insight
first described by Uzma Khan and Ravi Dhar is that our
choices are contingent. We use a self-concept to
adjust as we judge our actions to be swinging away from our
reference image of how: good/bad, healthy/unhealthy,
selfish/altruistic; we are.
is laboratory information management system (also LIS). Initially laboratory
automation reduced laboratory test transcription
errors. It now supports a modern laboratory with
- Carry out immunoassays, to detect the presence or
absence of a target analyte, adapted to operate along a
single axis provided by the test strip.
- The test strip includes in series and integrated by
- Sample pad - An adsorbent sponge to which the test
sample is deployed.
- Conjugate pad - contains antibodies, conjugated to
colored particles (gold nanoparticles, or fluorescent
labels), specific to the target analyte.
- Reaction membrane - often a hydrophobic nitrocellulose
or cellulose acetate membrane onto which antibodies are
immobilized in a line to provide:
- Antibody test line - which will highlight the
particles now bound to the target analyte.
- Control line - which uses an antibody to pick up
free latex/gold to show the test strip is operating
- Waste reservoir - an absorbent pad which uses
capillary action to draw the sample and collect
it. The wick acts as a waste bin.
- Many patents apply in this area, for example by Unipath,
acquired by Alere.
- Limitations include:
- Hard to multiplex lots of tests from one sample.
- Limited sensitivity making it difficult to use LFS in
infectious disease testing.
is laboratory information system (also called LIMS in environmental, research and
commercial labs) deployed in a reference laboratory.
- Data tracking
- Data exchange interfaces that support the requirements
of regulated environments.
- Clinical functionality
- Electronic lab notebook
- Support for SaaS distribution.
is either the
Lipodystrophy is a rare genetic disorder,
characterized by an abnormal lack of fatty tissue but the
symptoms of obesity. It
results in reduced production of leptin.
- Medicaid supplemental
'low-income pool' hospital funding program which reimburses hospitals for
the cost of care for the uninsured. LIP is being
wound down as the ACA Medicaid
expansion occurs. Or it is the
- Lateral intraparietal area is involved in saccades of the eyes. Some neurons in the LIP code the
location of visual and auditary targets in an eye-centered
Others code the location of a sound in reference frame
intermediate between head-centered and eye-centered.
For many cells the magnitude of response is 'gain' modulated by eye,
head, body or initial hand position.
Liquid biopsy uses a tiny blood sample used
for diagnostic testing. Often the testing is based on
using DNA sequencing to
detect DNA in the blood from cancer
cells. By identifying the mutations in a patient's
tumor accurate treatments can be selected, and recurrence
can be detected. But aging generates many similar
mutations which could lead to false positives in a broad
screening test. Research and development is ongoing (Jun
is an emergent cellular system providing metabolic: Dietary
compound metabolism and signalling:
After gorging on sugar-rich foods the liver releases FGF21 hormone
to dampen further eating activity; Detoxification,
Regulation of glucose through glycogen storage (asprosin signalling
from white adipose tissue); clotting, immune, exocrine and
endocrine functions. It is supplied with oxygen-rich
blood via the hepatic artery and blood rich in
semi-processed foodstuffs from the intestines & spleen
via the hepatic portal vein. It is constructed from: Hepatocytes which swim in the
blood to process it, BECs, Stromal cells, Hepatic stellate cells, Kupffer cells, and blood
vessels. The embryonic endoderm cells invade the
mesoderm to form the liver bud. Subsequently the liver
bud vascularizes and is colonized by hematopoietic cells.
The liver operates on a daily
2018) allowing it time to recover from the stress of
processing toxic substances. In a healthy adult liver
cells do not divide significantly. But in a damaged
liver, the liver cells shift back to a neonatal state to
re-enter the cell cycle and rebuild the liver. There
are over 100 disorders of the liver. Obesity and diabetes
are associated with increased prevalence of these liver
Liver cancer is the sixth most frequent cancer globally, and the second
leading cause of cancer based death. It is mainly
associated with cirrhosis from
hepatitis B, C, or
alcohol, but there is also a correlation with obesity (Aug
2016). The most common liver
cancer is HCC. Immature hepatocytes can produce hepatoblastomas. Some
types of the fungus Aspergillus produce aflatoxins, which can be
dangerous to children when ingested or to adults in chronic
exposure causing cirrhosis and carcinoma of the liver.
Aflatoxin metabolites intercalate into DNA
and alkylate the bases. This
causes mutations in p53.
is a gene encoding the lamin A
protein. Mutations that fail to produce the mature
lamin A protein result in HPGS.
salts, a second generation tau aggregation inhibitor
manufactured by TauRx
is lab-on-a-chip a device that integrates one or several
laboratory functions on a single chip. LOCs allow the
use of extreemly small fluid volumes. It uses microfluidics via a microarray.
is ordering based on Logical Observation Identifiers Names
Loneliness is an aversive signal like thirst, hunger or pain. It has been associated
with the dorsal raphe nucleus (Sep
2016). Loneliness affects several important
bodily functions through overstimulation of the stress response. Chronic
loneliness is associated with increased cortisol levels, hypertension and impaired
production of white blood cells undermining the immune system.
Long-short strategy is
used primarily by hedge funds
when they take a long position in stocks expected to
increase in value and short
positions in stocks that are expected to decrease in
Long transactions assume
that ACID properties
can be applied to a group of actions that together make up a
transaction. It is assumed that if any of the actions
fail the complete transaction is undone. Since these
'long' transactions can be executed over a number of days
the strategy for undoing parts that have been completed is
to provide a compensating
is length of stay
is licensed practical nurses provide basic and routine care
under the direction of a RN, APRN or doctor.
is a leucine-rich repeat kinase
gene. It has mutational variants that associate with Parkinson's disease (74%
likelihood by age 80) and Crohn's
is long-term acute care. These 400+- hospitals in the
US were setup by Congress in 1983 to
cope with acute treatments requiring stays of greater than
25 days. Typical stay lengths in acute care hospitals
are 5-6 days. Typical patients are severely-ill with
medically-complex comorbidities. Many have respiratory
issues and often require ventilation.
is a long-term care hospital. The formal designation
began as a congressional strategy to protect the 40 chronic
disease hospitals from the impact of the original PPS being deployed to constrain costs
in acute care hospitals in the 1980s. A historic
example San Francisco's Laguna Honda
Hospital is discussed in Victoria Sweet's God's
Hotel. LTCH PPS reimburses at far higher rates
than the PPSs for other PAC
providers. Most of the more than 400
LTCHs are now operated by large for-profit health care
Medical. LTCH's trade group is the NALTH.
Capital Management, a hedge
fund that used Black-Scholes
quantitative models to trade in derivatives. The hedge fund's bets failed during
the Asian and Russian debt crisis of 1998 and it had to be
rescued by the Federal Reserve.
Lung cancer affects 200,000 Americans each
year. Inflammation is a driver of lung cancer spread (Aug
2017). All these cancers
are carcinomas. There
are two main hystological types:
is a chronic autoimmune
disease, in which many parts of the body can be
attacked: joints, skin, kidneys, blood cells, brain, heart,
lungs. Its cause is unknown, there is little linkage
within families, but women are affected 4 to 12 times as
often as men - especially those of childbearing age.
There are various types: SLE,
cutaneous lupus, drug-induced
lupus, Neonatal lupus. It is treated with Belimumab, prednisone
- Non-small-cell carcinomas are of three sub-types:
- Adenocarcinomas (40% of lung cancers) are typically
peripherally situated and mostly induced by smoking.
- Squamous-cell carcinomas (30% of lung cancers) arise
in the large bronchi an are highly correlated with
- Large-cell carcinomas (5 to 10% of lung cancers).
- Small-cell carcinomas.
Lyme disease is an Ixodes tick vectored
borrelia bacterial infection.
Lymphedema is a permanent pooling of
lymphatic fluid. This is a serious condition that can
result in massive swelling. It can be induced
surgically when lymph nodes are removed for
biopsy. Prophylactic switching to nano-sensors
to detect cancer metastasis in the
nodes and sensing of high risk situations is
developing. Until 2016 there were no recognized
structures deployed by surgeons may encourage cells to
rebuild the lymphatic network.
is when lymphocytes continue
reproducing, and do not die - a blood cancer.
as a terminator in medication names indicates the drug is a
monoclonal antibody biologic.
is the Medicaid CHIP payment and access
commission, a federal level body of 17 commissioners,
chartered, as part of CHIPRA, to
is Medicare Access and CHIP Reauthorization Act of 2015 is
designed to encourage physicians to move to FFV and to link Medicare payment to
quality & value. It alters the way Medicare pays
for part B physician services
encouraging physicians and other ECs
to conform to one of two value based payment schemes: Advanced APMs (where the EC
can become a QP) or MIPS. MACRA does not apply to
hospitals which have their own meaningful
use. MACRA is designed to promote transformation
and includes: Data reporting by ECs, New practice models,
Changing clinical standards, and Physician evaluations; with
hundreds of millions of dollars in penalties and
bonuses. It authorizes CMS to
develop and deploy new rules. It provides for PCPs in PCMHs to
qualify as advanced APMs via
a special lower risk pathway. It replaced the
problematic physician SGR
Macro funds is a hedge
fund strategy where bets are made on the direction of
Macrolides are large macrocyclic lactone
rings including deoxy sugars produced by microbes.
Maine Rx Plus extends the Medicaid prices for drugs to
people above the poverty line.
The program was initially contested by pharmaceutical
manufacturers to SCOTUS.
Malnutrition is unbalanced nourishment that
causes health problems. Cystic
Fibrosis can result in failure to deploy the enzymes necessary to effectively
digest food inducing malnutrition. Starvation can take
different forms: Kwashiorkor,
Marasmus; even in identical
differences have been implicated in some of these starvation
cases in research by Jeff Gordon's lab carried out in
Malawi. Gordon found that a Malawian starvation diet
and specific set of gut bacteria caused weight loss in
mice. The poor diet induces changes in susceptible gut
flora and undermine the host's immune
system. Harmful infections then further disrupt
the flora and absorption by the gut wall. A cascade
occurs resulting in collapse of the prior microbiome and
stabilization with one that repeatedly results in
is a managed
behavioral health care company
Managed behavioral heath care
company conducts for a payer:
Managed care contracts together its
subscribing patients with particular groups of doctors and
hospitals who agree to provide contracted care for a
particular price which the managed care
It was based on the group
practice organizations: Kaiser,
operations. The initial HMOs,
supported by the HMO act and PPOs
has subsequently been joined by other forms of managed
care. Original capitation
based implementations were problematic with only Kaiser
succeeding. Managed care is now enhanced by inclusion
of upside measures as in alternative
is an extreme form of elation and hyperactivity. Kandel
explains, it is characterized by an elated, expansive or
irritable mood, together with several other symptoms,
including heightened activity, racing thoughts,
impulsiveness, and decreased need for sleep. There may
be high-risk behaviors: substance abuse, sexual
promiscurity, excessive spending, and violence.
- Utilization reviews
was most delivered service
- Case management
- Risk based contacting is
growing rapidly with the mbhcc taking some of the claims
risk and being responsible for providing and managing the
services. Often the strategy used by the mbhcc is to
divert hospital admissions to outpatient care and by
negotiating substantial price reductions with
hospitals. It has been researched
by Frank et al.
is monoamine oxidase, an enzyme
which breaks down monamine neurotransmitters. First
MAO based drug was iproniazid.
March-in rights lets the N.I.H.
take back control of a patent on an invention made from
federal funding if the drug is not being made available to
the public on reasonable terms.
Marfan syndrome is a recessive single gene
mutation of the gene that encodes fibrillin
which is essential to connective tissue in the aorta, spine
and the fibers holding the eye's
lens in place. Marfan also results in enlargement of
the aorta. Johns Hopkins's
Dr. Hal Deitz proposed the enlargement is due to mutated
fibrillin's failure to bind to TGF-beta.
His team showed the TGF-beta antagonist Losartan
reduced the enlargement.
Market Baskets are used by CMS to update payment and cost limits
in the various CMS payment systems. They measure pure
price changes by representing a fixed-weight index.
The market baskets aim to reflect the input price inflation
facing providers in the provision of medical services.
The market baskets are setup by OACT.
is the Medicare administrative
contractor program created by MMA.
It is intended to improve service to providers, physicians
and practitioners, and administrative efficiency and
effectiveness for FFS Medicare.
Under MAC CMS is able to move claims
processing to the contractors.
Macular degeneration is
a disease that results in progressive and complete
blindness. It includes: AMD
which has two forms dry
is an American
Nurses Credentialing Center award for excellence in
nursing. It requires the demonstration of platforms
that ensure nursing empowerment through:
- Written documentation verifying the implementation of
key nursing procedures.
- Site visits
- Ongoing monitoring
- The Magnet model has five elements:
is now called UniPaaS (Uni
Platform as a Service)
is matrix-assisted laser desorption/ionization mass
spectrometry. It generates ions in the gas phase from
large molecules. The sample (a protein,
DNA, sugar) is: 1. Mixed with an
appropriate matrix material and is deployed to a metal
plate. 2. Irradiated with a pulsed laser. 3.
Ionized with an ablated gas; and then flowed to an
appropriate mass spectrometer. MALDI is low cost and
rapid to perform but it is hard to make quantitatively
- Tranformational leadership
- Structural empowerment
- Exemplary professional practice
- New knowledge, innovation & improvements
- Empirical quality outcomes
Mammogram is an X-ray record of the breast
used for screening and diagnosis of breast cancer.
Mammograms have become progressively more sensitive allowing
detection of smaller tumors. This has allowed
aggressive treatment practices which may be
2015). Mammography policies are defined by: ACOG, ACS,
organization which provides practice management and
administrative support to individual physicians. It
may provide services like malpractice discounts, discounted
equipment leasing, shared staffing and benefits, electronic
billing and EMR. It is typically an
organization owned by a group of physicians, a physician
hospital joint venture or investors in conjunction with
MAP kinase is mitogen-activated protein kinase. It is the start point
of a key cellular signalling
cascade the Ras/MAP kinase
phosphorylation cascade. This is the main signalling
route for growth factors:
EGF. It drives cell-cycle progression,
proliferation and differentiation, and apoptosis.
is a form of malnutrition
where mal-nourished children become emaciated.
Maryland All-Payer Model
is an annual, global hospital budget that includes inpatient
and outpatient hospital services. It operates under an
agreement between Maryland and CMS
that exempts Maryland hospitals from IPPS
and OPPS. The agreement
is a research study of Mediators of Atherosclerosis in South
Asians Living in America. Researchers at UCSF
University followed 900 South Asians in Chicago and
the San Francisco Bay Area for 9 years, noting a tendency to
develop hypertension, high
cholesterol and triglycerides and type 2 diabetes at lower
body weights than other groups. South Asians have four
times more risk of heart disease. The
research suggests this is partly due to the increased
amounts of ectopic fats in
Asian bodies, relative to Europeans, but diet also plays a
role with consumption of fried snacks, sweetened beverages,
& high-fat dairy products.
Mastectomy is removal of the whole
breast. Surgeons perform total, modified radical,
radical, partial and subcutaneous variants. Typically
performed as part of breast
- Limit all-payer per capita inpatient and outpatient
hospital cost growth to the previous 10-year growth in
gross state product.
- Generate $330 million in savings to Medicare over 5 years comparing
Maryland to the US overall.
- Reduce 30-day readmission
rate to the unadjusted national Medicare
- Reduce the rate of admissions for potentially
preventable conditions by nearly 30% over 5 years.
- Submit an annual report (Oct
2016) demonstrating performance over various population health
Master limited partnership
is a limited partnership which is publicly traded. Tax
code section 7704 limited MLPs to businesses generating 90%
of gross income from transportation, processing, storage
& production of natural resources and minerals.
includes a variety of tests during pregnancy to assess the
status of the fetus. There is a degree of uncertainty
with the tests facilitating counciling and implying a
prospective mother should be given the choice not to have
the tests. Tests include:
is mindfulness-based stress reduction. Jon Kabat-Zinn
developed the stress reduction
clinic where techniques are taught to develop mindfulness and integrate it
and a personal vision of success into every day
experience. In Kabat-Zinn's book Full
Catastrophe Living a model of stress is described that
allows stressful events to be coped with effectively.
Strategies are described for a wide variety of specific
situations including medical symptoms, physical and
emotional pain, anxiety and panic, time pressures,
relationships, work, food, and external events.
is mother and baby unit.
- Ultrasound to check for anatomical abnormalities
including congenital heart defects.
- Maternal blood tests for chromosomal disorders such as
Down syndrome and neural tube defects. The
development of liquid biopsys
will allow assessment of fetal DNA
and RNA in maternal blood.
is management by wondering around.
Medical Staff Organizations
(MSO) allows the integration of an autonomous group of
physicians and a hospital's management hierarchy.
Physicians argued that they must remain autonomous to avoid
conflicts of interest and their complex life-and-death
decisions could only be judged by other physicians.
MSOs should hold physicians collectively accountable for
patient safety and clinical performance. But often
they are used to champion physician's interests with the
hospital's administration and board of trustees. So
they can become a barrier to clinical improvement.
Hospital boards have split responsibility with the
administration overseeing: plant, employees and finances;
and MSO overseeing: patient safety, clinical performance
& admitting privileges. With physician's fixed
costs increasing and price increases constrained by payers, MSOs have become more
interested in increasing service volume and value.
Some physicians assume patient-safety and clinical
performance are administration responsibilities.
Hospitals wanting to increase pay-for-performance responded
by increasing the workload placed on hospitalists. In such an
environment ad-hoc groups must form to improve clinical
Melanocytes are melanin-producing
cells. They are found in the bottom layer of the
skin's epidermis, the middle layer of the eye, the inner ear, meninges, bones
leverages the randomized splitting up and assignment of
sister chromatids - when meiosis generates haploid sex
cells, to enhance epidemiological
studies by finding unbiased estimates of the effects of
causal variables without a randomized trial. It
depends on genetic association studies to have identified
genes that deploy randomly across the population being
studied. Alleles at different loci must be
independent, not exhibit pleiotropy,
and non-random mating within the population. Mendelian
randomization is designed to control for reverse causation,
where correlated variables are invalidly assumed to be
causally related & confounding variables that alter the
dependent and independent variables. It requires that
there is no direct relationship to the dependent variable,
or to potential cofounders.
Methotrexate is a chemotherapy drug
developed in 1947 and used to treat cancer:
breast, leukemia, lung, lymphoma,
osteosarcoma; suppress the immune
system, and as a treatment for ectopic
pregnancy. It is a W.H.O.
is molecular imaging and contrast agent database, a database
of in vivo molecular imaging agents setup as a key part of
the NIH Roadmap Molecular Libraries
and Imaging program. MICAD represents agents for key
imaging modalities: PET, SPECT, MRI, ultrasound, CT, optical, planar gamma;
Microchimerism is the escape of cells from a
baby in the uterus and their
spreading around the mother's body. The fetal cells
then differentiate into cells of the organ type in which
they end up. This process occurs when ever women
become pregnant. This means that sons will leave cells
with 'y' chromosomes in the mother. There are some
Million-person research cohort
is a precision medicine
activity funded through the NIH with
$130 million in December
2015 by Congress (Jul
- There is the opportunity for the fetus to take advantage
of the situation to obtain more resources than the mother
- Tumors can be loaded with fetal cells suggesting that
they may help drive cancer.
But other studies suggest microchimerism helps protect
- Mother's immune systems increase activity after giving
birth which may help clear fetal cells.
Mindfulness is an active meditative state of
non-doing, attentively seeking each 'present moment' with
ones body and mind 'being' at rest and so cultivating
awareness. The thinking mind usually spends a lot of
time relating to the future and past which Kabat-Zinn argues
limits its ability to become fully aware of the
present. In times of stress
those thoughts are so overpowering that they crowd out
awareness and appreciation of the present. Mindfulness
shifts attention to calming internal feelings. It
allows review and prioritization of thoughts as they are
recognized. Major attitude based pillars of successful
mindfullness are: impartial to judging, patience, a
beginner's mind, trust,
non-striving, acceptance of seeing things the way they are,
and letting go. An awareness of the body's state can
be built from attention to:
is merit based incentive payment system, a MACRA legislated, CMS
regulated, patient outcome based Medicare
part B payment
system for ECs. It is an
alternative value based payment scheme when physicians
aren't setup to work in an advanced APM,
such as an ACO. It is seen as a
training route to the EC becoming a QP
in an advanced APM. It
includes a new reporting category: clinical practice
improvement activities - which can be selected from an
approved list. Doctors are scored in four areas: cost
of care, quality of care, activities that improve clinical
practice, and how they use EHR in
exchanging clinical information. Small medical
practices may struggle to resource, & gain expertise
necessary for, the quality reporting to registries and
compliance requirements. MIPS repurposes current CMS
- Breathing - which is a proxy for the environmental
situation and through its rhythms is a model of our
emotional state. Attention to breathing reminds
people to feel their bodies too. Belly breathing is
- Sitting - erect with head, neck and back aligned
vertically. Then attend to breathing moving back to
it each time you observe the mind has wandered. When
the body becomes uncomfortable direct attention to the
discomfort and observe and welcome it.
- Experience our body - rather than model, judge or hate
it relative to an ideal - with a body
- Hatha yoga - very slow stretching and strengthening
exercises with moment-to-moment awareness supports being
in your body.
- Walking meditation - Intentionally attend to the
immediate experience of walking.
Institute of Technology.
is methicillin-resistant Staphylococcus aureus
- MU becomes MIPS ACI.
- PQRS will become MIPS quality
- VBPM becomes MIPS resource
Sans Frontieres which means Doctors Without Borders.
is either a physician's management
services organization or a hospital's medical staff
is the Michigan care improvement registry which collects and
distributes immunization information.
is Markov Chain Monte Carlo sampling. It is a method
for sampling from the distributions of random
quantities. It can be applied in Bayesian
is a managed care
organization contractually allowed by state governments to
contract with IPAs to provide state
care with risk based reimbursement. An MCO
is doctor of medicine and is either a physician or a
- Traditional health maintenance organizations certified
with respect to public health
- Special purpose prepaid health service plans;
- HIV special needs plans;
- Managed long term care plans.
is multidistrict litigation, where many legal cases are
consolidated to improve efficiency & reduce costs.
TB is multidrug-resistant Tuberculosis (Vank's
Disease). It is difficult to treat. Some
of the medicines are intravenous, must be taken for two
years (potentially just 9 months - Oct
2017) and can cause deafness, psychosis
and kidney failure. Patients
must be hospitalized and their movements restricted to one
or two corridors, for months until they stop coughing live
is myelodysplastic syndrome formerly prelukemia a disorder
of the hematopoietic stem cells in the bone
marrow. It typically worsens into AML.
MDS process is the minimum data set process
a tool used in nursing homes for resident assessment and
care planning. It is a process for indicating facility
quality and the extent of residents care needs. The
process by which the MDS is completed by facilities has not
been empirically studied. Understanding common
strategies and practices for completing the MDS helps
further comprehend the validity of the MDS and its relevance
for focusing on residents and implementing clinical nursing
provides an instantaneous snapshot of the physiology of a
cell in terms of its metabolites. GC-MS,
and NMR can illuminate the profile. The Scripps
institute has developed the METLIN web database of human
metabolites including 10,000 metabolites and associated
spectra. It can be used to determine the phenotypic
change due to a gene insertion or deletion.
Microbeads are tiny plastic orbs. They
are used as abrasives in toothpastes and anti-acne
Microreactor is a device in which flow based chemical reactions
take place in a confinement of less than one
is minimal lower layer protocol. It is supported by
Microsoft and Oracle.
Meaningful use is the set
of standards defined by CMS
Incentive Programs that governs the use of electronic health records and allows
eligible providers and hospitals to earn incentive payments
by meeting specific criteria. It aims to ensure that ARRA subsidies for HIS
are used to generate health improvements. It is
2016 Improved outcomes - Improving quality, safety, and
efficiency, leading to improved health outcomes.
Decision support for national high-priority
conditions. Patient access to self-managed
tools. Access to comprehensive patient data through
Improving population health.
or rubeola, is a highly contagious respiratory viral
infection that can be dangerous in young children. It
is easily avoided by M.M.R. vaccination.
- 2011-2012 Data capture and sharing - Criteria focus on
electronically capturing health information in a
standardized format. Using that information to track
key clinical conditions. Communicating that
information for care coordination processes.
Initiating the reporting of clinical quality measures and
information. Using information to engage patients
and their families in their care. Achieving
meaningful use stage 1 requires meeting all core and
selected menu objectives.
- 2014 Advance clinical processes - More rigorous health information exchange requirements.
Increased requirements for e-prescribing
and incorporating lab results. Electronic
transmission of patient care summaries across multiple
settings. More patient-controlled data. A patient portal is
hospital core measures, CMS hospital menu set
measures, NPRMs of stage 2 meaningful use and
certification criteria have been announced
Medication adherence is
focused on improving how effectively patients take their
medicines. In the US in 2017 the
problem is huge and costly (Apr
2017). Chronic diseases such as Malaria illustrate
the complexity of the task. A coherent medical
network with shared access to EHR
should help. So do blister packs with the days of the
week marked. M-health glow
caps with a wireless transmitter that lights up if
medication has not been taken as expected. An improved
prescription label is less open to confusion. Codes on
drugs can be scanned by smartphones to initiate download of
an informational video. Smart pillboxes control when
pills are dispensed. Measuring the contents of a
medication bottle can alert for intervention if too much or
too little is in the bottle. Drug manufacturers see
ways to get closer to the patient: Sanofi Toujeo deployment;
Pharmacies are implementing VDS to
support medication adherence: Connected
includes product selection, product administration and
monitoring for side effects. Baxter,
facilitating products and services. Scriptrx
provides IT solutions.
Medical home models are
primary care architectures which deliver: patient-centered,
accessible, coordinated, comprehensive care of high quality
and safety (Dec
2015). The models have been made more
significant due to Affordable Care Act payment reform
requirements. The goal is to reduce treatment costs
and improve population health by reengineering of the
traditional silo'd provider network. See PCMH.
Medical necessity is a
legal doctrine where activities may be justified as
reasonable and necessary based on evidence-based
clinical standards of care.
Medical neighborhood is
an extension to the PCMH which
supports coordination of care across providers connecting
with specialty and subspecialties that are essential to the
treatment of chronic illnesses. The PCMH
hospital-based specialists and community practitioner team
located near where the patients live, must have an effective
relationship with ambulatory care, pharmacists, SNF, HHA, and
Merkle tree is a form of tree structure
where every non-leaf node is labelled with a hash of the
labels (values for leaf children) of its child nodes.
This tree is used by: Git, BitTorrent
Messenger model network
A messenger model network attempts to legally facilitate
contracting for its members even though it does not meet the
financial and/or clinical
integration standards for joint pricing of a rule of reason clinically
integrated network. Each participating agent
acts independently in assessing proposed contract
pricing. The participants typically give the network a
limited opportunity to arrange for a contract with payers. A 'pure' messenger
communicates offers from the payers to the network agents
and then communicates back the responses. Once
agreement is reached network agents either opt in or out of
the contract. In a 'modified' messenger model the
network agents pre-specify their price point without
collusion. The modified messenger's negotiators then
act as a black box in discussions with the payers. If
the payer's offer is within an agent's proposed bounds they
are contractually bound. Payers can undermine the
goals of the messenger network by contracting with each
agent separately and refusing to deal with the network
Metallosis is where metal debris deposits
and builds up in the soft tissues of the body. It is
suspected to occur when metal device components, such as
artificial joints, wear against one another. The metal
build up can damage: muscle, tendon, ligaments, heart and
is the mental health parity and addiction
equity act of 2008 aimed to ensure that group health plans
and health insurers could not require less favorable benefit
limitations on mental health or substance abuse disorder
benefits. The ACA title 1 extended the mandated
equity to individual health insurance and specified broadly
health benefits which included mental health.
The PACE Act extended this coverage
requirement down to small employers of 1 - 50 people.
Microarray is a 2D array on a solid
substrate that assays large amounts of biological material
using high-throughput screening. It is the central
technology of Bio-MEMS, LOC and MTAS.
They are used with tissues, cells, antibodies,
DNA, RNA, protein, peptides and
carbohydrates. Once fed magnetic nanoparticles
individual cells can be moved independently and
simultaneously on a microarray of magnetic cells. A
microarray of NMR microcells is being developed.
Microcephaly is a condition in which a
baby's head is significantly smaller than expected.
Often it is due to abnormal brain development.
Infection with Zika virus is known to induce the
is a medical ICU. It
specializes in serious medical illnesses -- often with
patients presenting complex, comorbid conditions from sepsis to pneumonia,
acute respiratory distress and multiple organ failure.
Will require a multi-disciplinary team including:
is either the:
- Pulmonary intensivists
- Respiratory therapists
- Clinical pharmacists
- Clinical nutritionists
- Physical, occupational and speech therapists
- Socual workers
- Case managers
- Medicare Integrity
Program. It is tasked by CMS
to pay benefit claims correctly in a system designed to
leverage partners. To do this it uses four
- Preventing fraud through effective enrollment and
through education of providers and beneficiaries.
- Early detection of error through medical review and
- Close coordination with partners, including PSCs, ZPICs
and law enforcement.
- Fair and firm enforcement policies.
is the Medicare Improvements for
Patients and Providers Act of 2008. Section 125
removed the joint commission's
hospital accreditation statutory-guarantee. Subsequently
these accreditations had to be submitted to CMS for acceptance.
Mohs surgery, involves slicing off a skin
cancer in layers under local anesthesia with microscopic
pathology performed between each "stage" until the growth
has been removed. It is useful when the removal of a skin
cancer is complicated or in a sensitive area since it allows
the dermatologist to be confident that all the cancerous cells have been removed
while it takes less tissue and leaves less scars. It
is not typically used for melanomas,
which require more extensive cutting.
- The Medicare Modernization
Act of 2003. It includes Medicare part D, the Medicare
prescription drug benefit, which constrains Medicare from
negotiation of its drug prices and created MAC and RAC.
It was sponsored by Senator Bill Tauzin and implemented by
- Mammalian meat allergy
which is induced by a month prior tick bite that
introduced the allergen alpha-gal.
About 1% of bitten humans develop the allergy &
prevalence is increasing. Humans & old world
primates & monkeys don't make alpha-gal (Jul
2018). Symptoms can include: hives,
anaphylactic shock, low blood pressure.
is master patient index used by a health care organization
to correlate all activity across departments with one
patient demographic and medical data for a patient.
The US still lacks a standardized MPI
resulting in difficulties with matching patient identities
from different systems.
is the state-federal
program for the poor. Originally part of Lyndon
Johnson's 1965 Bill, eligibility and services vary by
state. Medicaid currently pays less for care than Medicare, resulting in many care
providers refusing to participate in the program. Less
than 10 percent of Medicaid recipients, those in long-term
care including nursing homes where 64% are dependent on
Medicaid, use one-third of all Medicaid spending which
is a problem. The ACA's
Medicaid expansion program, made state optional by the SCOTUS
decision, was initially taken up by fifty percent of
states. As of 2016 it covers 70 million Americans at a
federal cost of $350 billion a year. In 2017 it pays
for 40% of new US births.
is the California Medical Assistance Program the state Medicaid welfare. It
Medi-Cal Funding &
Accountability Act of 2014/16 is known as the
Hospital Fee Initiative. The 2016 act sustains Medi-Cal federal matching funding
via the HQAF by making the HQAF
permanent, removing the sunset date and requiring a 2/3
legislative vote to make further changes. It will
generate $4 billion in Medi-Cal payments to hospitals, and
$1 billion to the state.
is a social insurance program that guarantees
access to health insurance for Americans aged 65 and
over, and younger people with disabilities and end stage renal disease or ALS. Medicare
is currently missing a cap on out-of-pocket costs and direct
prescription drug coverage. It includes:
Medicare 340B drug discount
program requires pharmaceutical manufacturers to
provide outpatient drugs at significant price discounts to
eligible health care providers and other covered
entities. 340B was legislated by Congress as a section
of the PHSA, as a strategy to drive
federal resources to more eligible patients and to provide
more comprehensive services. The eligible set of
hospitals was expanded by the ACA.
It is not clear that all eligible hospitals have used the
discounts to extend and improve services to the poor (Aug
- Part A: Hospital inpatient insurance. As of Dec
2013 Medicare pays for home care in only limited
circumstances, such as when a person needs temporary
nursing care after a hospitalization. Part A
covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient
care at a hospital.
- Part B: Medical
insurance for non-hospital services including:
doctor visits, tests, injectable drugs, ambulances,
- Part C: Medicare
- Part D: indirect
prescription drug coverage The MMA
prohibits Medicare from directly negotiating drug
- All persons 65 years of age or older who are legal
residents for at least 5 years. If they or a
spouse have paid Medicare taxes for 10 years the
Medicare part A payments are waived. Medicare is
legislated to become the primary health plan.
- Persons under 65 with disabilities who receive
- Persons with specific medical conditions:
- Some beneficiaries are dual
- Part A requires the person has been admitted as an
inpatient at a hospital. This is constrained by a
rule that they stay for three days after admission.
- Part A has automatic sign-up if the person is drawing
social security. Otherwise the person must sign-up
for Part A and Part B.
- Should sign-up for Part B during the Initial
Enrollment Period, of seven months centered around 65th
or at a social security office. But if still
covered by spouse's insurance or not yet retired then
may only join during the 3 month general enrollment
period (January to March) each year, with coverage
initiated the following July. Incremental yearly
10% penalties apply for not signing up at 65.
These penalties apply to all subsequent premiums.
- Part A premium
- Part B insurance
- Part C & D premiums are set by the commercial
Medicare Advantage (MA)
is a private provider administered health insurance plan
providing access to Medicare
benefits. It was originally enacted as part of BBA Medicare + Choice or Part C
plans. The government funded the plan with an annual
fee, based on age and severity of the subscriber's medical
conditions, rather than FFS.
When a Medicare eligible person enrolls in a MA plan the
government pays the private provider a set amount each
month. The participant pays the Medicare part B
premium and if required a part C premium each month.
The MA plans offer a PCP who coordinates care. And the
plans have an annual limit on out-of-pocket expenses unlike
traditional Medicare. When they obtain treatment they
will have to pay a copayment
which may be quite high for some specialists. It is
the health plan's responsibility to contract the physician
network that will provide the care, leaving the risk with the insurer. About 36%
of Medicare beneficiaries are enrolled with Medicare
Advantage by 2019. The ACA
introduced quality outcome and patient satisfaction based
differential payments into MA. To measure the
performance it added a five-star
quality rating scheme. MA plans report their
quality and patient satisfaction data to CMS
annually and based on the results are awarded one to five
stars. The highest rated plans are provided with large additional payments. It was
assumed that subscribers would shift to the highest rated
plans and the other plans would improve or drop out of
MA. And the ACA eliminated subsidies which the federal
government used to establish Medicare Advantage.
However, the Obama administration has used a $8.5 Billion
demonstration project to maintain this funding. It is
intended that it will eventually taper off so that the cost
of Medicare Advantage coverage will be equivalent to
Medicare anti-kickback safe
harbor is a 1987 congressional act which exempts
hospital group purchasing organizations from prosecution for
accepting vendor kickbacks.
is Medicare care management
demonstration project. It rewards physician practices
for EHR adoption, use and improvement impact on continuity
of care, health outcomes, quality of care, patient
satisfaction, physician satisfaction, and Medicare
Medicare Part B benefits
provides coverage for the elderly including: clinical
services, DME, Mental health,
second opinions before surgery, and limited outpatient
prescription drugs to treat: cancer,
AMD and other conditions. Part B
covers two types of services:
Medicare Part B costs
There is a monthy premium for Part B. It may be paid
directly from Social Security. Higher earners may have
to pay IRMAA. Medicare
payments to doctors and hospitals for Part B drugs have been
based on the average sale price of the drug plus 6%. MedPac advised Congress that this
may encourage prescribers to select the highest priced
alternative to maximize the 6% payment. Increasingly
prescribed high priced biologics
increase the impact of the nudge.
- Medically necessary services and supplies that are
accepted standards of medical practice and are needed to
diagnose or treat a medical condition. Hospital
based services are outpatient based. These do not
include the 20 days of SNF costs
for hospital inpatient rehabilitation.
- Preventative services that use treatment to help in
early detection or prevention of a disease such as flu.
Medicare Part D is a federal program to
subsidize the costs of outpatient prescription drugs for Medicare beneficiaries enacted as
part of the MMA and delivered
entirely by private companies. It is an evolved amplifier with MMA schematic rules ensuring catalytic tax subsidies: reinsurance; flow to a broad
group of elderly voters and a small but influential group of
Humana, CVS Health; while
pharmaceutical companies also benefited from increased sales
of reimbursed drugs.
Merger arbitrage is a hedge fund strategy where for
stock mergers of companies, the hedge fund will
simultaneously purchase the target and short sell the acquirers stock,
while for cash mergers the hedge fund purchases the target
stock; to speculate on the successful completion of the
deal, when the target's stock should reach the offer price,
leveraging pricing inefficiencies awaiting the event.
is a natural dark pigment that can be found in human skin
and eyes. It serves as a
useful biomarker for melanoma.
regulations. Health care providers that
electronically prescribe Part D drugs for Part D eligible
individuals under 42 CFR 423.160(a)(3)(iii) may use HL7 or NCPDP
SCRIPT standard to transmit prescriptions &
related information internally but must use NCPDP SCRIPT
(or other adopted standard) to transmit information to
another legal entity.
- Premium subsidy set by a market average. Medicare
collects bids from all plans that reflect their costs of
providing the minimum required level of drug coverage. It
then sets the subsidy at 74.5% of the average
- Premium coverage gap (doughnut hole) between the 74.5%
premium subsidy and the catastrophic-coverage
threshold. The BBA of
2018 required Part D insurers cover 5% of the
beneficiaries coverage gap and drug companies provide
discounts that reduce federal spending by a total of $7.7
billion through 2027.
is a cancer of the melanocytes. It is a less
common form of skin cancer but is the most deadly once it
has invaded deeply into layers of skin. It is
primarily caused by UV light. It is tied to mutations
in the signalling pathway (BRAF) and regulatory genes (P53) with a key dependency on crestin reactivation (Jan
Mesenchymal stem cells
are stem cells that
differentiate into osteoblasts, chondrocytes, myocytes and
is the middle layer of cells in the developing bilateral
- Middle east respiratory syndrome. It is a
coronavirus illness that can be fatal, inducing an acute pneumonia. It originates
in bats and circulates in camels.
- Mortgage Electronic Registration Systems Inc a
corporation that serves as a nominee on mortgages and
provides an automated registry of mortgage deeds of
has been studied in hibernation, where the process of
hibernation includes rapid inhibition of mitochondrial
respiration. Otherwise it seems poorly defined.
Fast and slow weight loss appear equally effective at
inducing metabolic suppression.
Metabolic syndrome is an
inadequate ability to store fat. The body aims to
store excess energy in the form of fats in adipose
tissue. It there is not enough the fat is stored in
other organs: liver, heart, muscles
and pancreas where it poisons the organs resulting in
metabolic syndrome. Obese
people do not have enough adipose tissue to cope and so
develop metabolic syndrome. Ceramide and
diacylglycerol buildup in tissues appear to inhibit insulin
signalling. They are
suspected to be the poisons in metabolic syndrome.
Modified dinitrophenol may safely inhibit diacylglycerol
buildup, stopping type-2-diabetes
and fatty liver development.
is a multiple-employer welfare arrangement which is state
is the Medicare Prescription Drug Improvement and
Modernization Act. It established HSAs
is the Medicare prescription
drug plan finder.
is Massively parallel signature sequencing incorporating
bead based sequencing
is additional private insurance purchased to cover health
care costs not covered by Medicare:
copayments, deductibles and
foreign travel insurance.
is the Medicare Payment
Advisory Commission. It was established by the BBA. The mandate is to advise the
U.S. Congress on payments to private
health plans participating in Medicare and health providers
with Medicare beneficiaries. It produces two major
reports each year for Congress.
is the major histocompatibility complex, the variable cell
surface proteins that bind to foreign molecules as part of
the acquired immune system.
It is encoded by the gene complex HLA
which includes complement component gene C4.
is Medicare Volume Performance
Standard a mechanism CMS used to
control spending. It was replaced through the BBA of 1997 with SGR.
Med Works is an Indiana Medicaid buy-in program that
protects Medicaid payments for patients who attempt to
return to work.
Microbiome, the trillions of bacteria and viruses that live inside higher
animals' guts, on their skin etc. These bacteria and
viruses seem to play a role in: immune responses, digesting
food, making nutrients, controlling mental health and
maintaining a healthy weight. The signals from the gut
microbiota are relayed by major nerve fibers: vagus; to the central nervous
system. The symbiotic
relationship must be actively managed. Human armpits
include glands which provide food favoring certain symbionts
who build a defensive shield above the skin. In the
human gut: Barriers are setup: Mucus
secretions form a physical constraint and provide sites for
bacteriophages to anchor and attack pathogenic bacteria;
Symbiont tailored nourishment: Plant-heavy food creates
opportunities for fibre specialists like Bacteroides
thetaiotaomicron; is provided, Selective binding sites are
provided, Poisons are deployed against the unwelcome, and
Temperature, acidity and oxygenation are managed.
throughput sequencing allows the characterization of
bacterial populations inside guts. Beginning at birth,
as they pass down the birth canal infants are supplied with
a microbiome from their mothers. If they are borne via
cesarean they never receive some of the key bacteria: Bifidobaterium
infantis which is also dependent on oligosaccharides
in breast milk; from their
mothers. A variety of diseases may be caused by
changes in the microbiome:
is mild cognitive impairment, a sense of memory loss despite
normal performance on memory tests. It is often
associated with Alzheimer's
is micro total analysis system meaning a flow chemistry chip
integrating the total sequence the lab processes (LOCs) to perform a chemical
is mild behavioral impairment, a proposed early diagnosis
for dementia. It
recognizes and measures something that some experts say is
often overlooked: Sharp changes in mood and behavior can
precede the memory and thinking problems of dementia.
But there is a risk of over diagnosis which could leave many
people unnecessarily fearful about
their futures and seeking more tests. And the
diagnosis could affect insurance premiums. To imply
MBI the symptoms must last for more than six months and be a
fundamental change in behavior.
- mobile health applications running on smart phones and
other mobile devices. It is viewed as key to improving
clinical efficiency, access and cost effectiveness of
treatments. Applications will be integrated into
bidirectional flows, enhancing team collaboration, as well
as providing clinical information. Both should improve
decision making and reduce
errors. Hope for access at inpatient bed side, exam
room. As usual with mobility the light weight devices,
extended access to confidential data and wireless
connectivity work in opposition to the desire for zero
latency, video streaming and conferencing, large image
access, offline operation with synchronization, and strong
security. Privacy has been a major drag on
search the bitcoin blockchain for nonces. Any new nonces they
identify they can trade for the current market value of a
bitcoin. In performing the search they will also
verify the integrity of the current blockchain. To
perform the computationally costly search miners build
optimized computing networks.
is minimally invasive surgery, which aims to replace open
surgery with techniques that reduce pain
and recovery time by use robots or laparoscopes.
Mitral valve allows blood to flow from the
heart's left atrium to the left ventricle. If it fails
the heart will have trouble pumping blood around the body
resulting in CHF.
is Medicare learning network (website).
is medical loss ratio, the percentage of an insurer's
premium spent on direct patient care and quality
improvement. The ACA requires
an MLR of greater than 80 percent for small group policies
and 85 percent of the premiums collected from medium and
large businesses for direct medical care, Medicare part D, and Medicare Advantage
Mobile Point of Care is
Molecular imaging allows
the visualization of cellular function and molecular
processes, allowing more precise and earlier diagnosis of
disease. It extends traditional imaging by:
Mononucleosis, or: mono, kissing disease,
glandular fever; results from infection with EBV in 35 to 50% of adolescents.
By midlife, over 90% of adults have been exposed.
Mononucleosis is transmitted in saliva, which may be
infectious months or years after any symptoms
disappear. Symptoms include: sore throat, laryngitis,
swollen lymph nodes, fever, head and body aches, enlarged
tonsils; and some people become severely fatigued, and or
have a swollen spleen or liver. It is treated with bed
rest and by drinking fluids.
- Using biomarkers, including Nano
sensors, which interact chemically with their
surroundings, to image particular targets and pathways
- Leveraging deep learning
to reduce the required imaging, and target it more
- Providing quantitative data on the imaged process or
function enabling Nano
- Extending mass spectrometry with MALDI
to allow rapid (relative to sequencing or
x-ray crystallography), low cost analysis of proteins,
bacteria and viruses.
is master of public health.
is the Minnesota Premium Security Plan. It provides reinsurance to support the ACA individual
markets. The program pays 80% of a claim from
$50,000 to $250,000. The insurer is responsible for
claims over $250,000. It is funded based on the
assumption that lower premiums will allow the federal
government to provide half the cost via the ACA's risk adjustment. It
is expected the lower premiums will reduce the federal
payments for high premium tax credits.
is magnetic resonance cholangiopancreatography, a medical
imaging technique used to visualize the bile and pancreatic
is magnetic resonance imaging where the nucleus of any atom
with a net spin will produce a response to the signal.
The variety of molecules that can be detected has generated
a variety of specialized medical applications.
is monthly recurring revenue.
Moral hazard involves responding to a
generalized problem by rewarding those who caused the
Morcellator, a tool to shred tissue via
spinning blades, used for example in the removal of uterine
fibroids, so that the tissue can be easily removed using MIS techniques. It has been found
to spread cancerous cells around the surgery site reducing
long-time survival rates and worsening the disease (Feb
- In health care it includes the over use of subsidized
treatments and medicines.
- For the US economy
it includes using tax revenue to underwrite the losses
induced by the reckless behavior of financiers and the
politicians and regulators who enabled them.
Morning sickness is
pregnancy sickness, a universal part of
Morrill Act of 1862 was a powerful evolved amplifier that supported
land-grants by federal and state governments to develop
agricultural experimentation stations and state colleges and
universities in every state and territory of the US. It allowed the agricultural
research findings of the Agricultural Extension Service to
be distributed to the local farms, via demonstrations of
improved farming methods in 56,000 rural communities.
And the mission of the stations, colleges and universities
was extended to provide college education for the children
- It as a beneficial response to toxins that would harm a
developing fetus. Margie Profet developed this
hypothesis and collated hundreds of studies that supported
- It is protecting a differentiating embryo from teratogens. Women with
more extreme pregnancy sickness are less likely to bear
babies with birth defects.
- Women with pregnancy sickness avoid bitter, pungent,
highly flavored and novel foods which are likely to
contain toxins. Their sense of smell becomes
hypersensitive during the period of pregnancy
- Hunter gatherers are particularly at risk from
teratogens since much of their diet is from wild plants
gathered as they travel.
- Differentiating embryos, while laying down organ systems
are growing slowly with limited need for
- Once organ systems are nearly complete pregnancy
- Pregnancy sickness treatments include: Duchesnay's
is multiple sclerosis.
is master of science in nursing.
- Medical savings account a program in over 20 states for
self-employed individuals, in which medical expenses can
be paid with tax-deferred deposits. The model was
leveraged for HSAs.
- Multiple sequence alignment, a sequence alignment of
three or more biological sequences of either: proteins, DNA,
RNA; looking to infer homology,
since they share a common ancestor.
is Medicare shared savings
is mild traumatic brain injury (TBI)
is medullary thyroid cancer.
is medullary thymic epithelial cells, a set of thymus cells
that ensure immune system
tolerance. They can express 80% of the genome.
Their expression is controlled by AIRE
driven by the NF-kappa B signalling
pathway, or Fezf2 another AIRE independent regulator.
is mechanistic target of rapamycin,
a PIKK regulator of cellular
metabolism, growth and proliferation. Many human
tumors occur because of dysregulation of mTOR signalling.
is Meaningful use.
are polypeptides with suger side chains. The sugers
bind resulting in an impenitrable web.
is used to cover tissues that are exposed. It is made
from mucins. Mucous membranes may secrete mucus to
generate a robust barrier.
Multiple endocrine neoplasia
is a highly heritable tumor of the endocrine
Multiple myeloma is a cancer of B lymphocytes. The cause is
unknown, but alcohol and obesity
are risk factors. Abnormal antibodies are generated
which cause kidney problems and
overly thick blood. If the abnormal lymphocytes form a
single mass the diagnosis is plasmacytoma. If there
are multiple masses the diagnosis is multple myeloma.
Treatments include: Revlimid,
Multiple sclerosis is
caused by collapse of the protective covering of certain neurons. It is the most
common disabling neurologic disease of young adults.
It may be due to problems with the Schwann cells that
generate the myelin sheath or an autoimmune response
where the myelin sheath covering of certain neurons are attacked. Somatic
DNA editing provides one direction for
treatment adding surface signals
which will tell the immune system cells to ignore the
neurons. Multipe sclerosis has been linked to
Epstein-Barr virus which establishes a lifelong, mostly
asymptomatic, infection in the majority of adults. Harvard's
Alberto Ascherio argues analogous to the
late Polio infection induced paralysis model, that
early infection with Epstein-Barr virus
protects against M.S. while if infected in adolescence or
adulthood the risk of M.S. doubles. M.S. has been
treated with Glatiramer
is an ACID database
access language where the built in database M is accessed
via MUMPS variables. It was developed at Massachusetts
is the licensed vaccine
is a regulator gene
family: c-myc, l-myc, n-myc; coding for transcription factors.
When mutations lock Myc on, they act as cancer oncogenes.
c-Myc upregulates cyclins causing
cell proliferation, ribosomal RNA causing cell growth,
downregulates Bcl-2 causing apoptosis.
Myc over expression is associated with Burkitt's lymphoma, epithelial ovarian cancers, breast cancer, colorectal cancer, pancreatic cancer,
gastric cancer and uterine cancer.
Myoblasts are embryonic cells that become
myocytes which form muscles via myogenesis.
is a cancer of the plasma cells (B
lymphocytes). The cancer
results in the generation of abnormal antibodies. Diagnosis: with
blood or urine test finding abnormal antibodies, bone marrow
biopsy finding cancerous plasma cells and medical imaging
finding bone lesions. Untreated survival time is seven
months. With treatment survival can extend 4-5
Myocarditis is an inflammation of the
myocardium, the middle layer of the heart wall.
is the National Ambulatory Medical Care Survey conducted
annually by the CDC.
is the national association for home care and hospice an industry
is the National
Association of Manufacturers.
is a gene which encodes the NANOG homeodomain protein, a transcription factor
involved in self-renewal of undifferentiated embryonic stem cells.
Nanomedicine is the application of
nanotechnology to medicine (May
2019). Commercial applications are focused on
research and clinical tools for drug delivery, therapies,
safer and more effective in vivo imaging, neuro-electronic
interfaces, other Nano-sensors, and eventually cell repair
machines!! There are issues with determining
Nanopore sequencing is
Daniel Branton's DNA sequencing
method. It uses a tunneling electron microscope to
view the nucleotides. The DNA is forced to flow
through a nanopore, using a nanotube to orient the bases and
encourage the DNA to flow, making it unwind and orient as
the microscope requires. Branton assumes it will
eventually replace sequencing
Nanostraws are 100-500 nm diameter aluminum
straws formed by templating high-aspect ratio pores,
allowing precise control of height, diameter and
thickness. They can deliver a wide variety of
materials that otherwise could not pass through the cell
wall. The process does not detectably disturb natural
cell function. Nanostraws are easy to fabricate with
multi-stage etching: atomic layer deposition + reactive ion
etch + oxygen etch.
Narrow networks - When all health insurance
plans are comparable on line people are expected to choose
narrower less costly plans. This has the effect of
encouraging providers and PCP to
compete to be part of the narrow plan by reducing their
charges and driving down the prices of the plans. By
limiting the number of providers/doctors offered in the
plans the few that are included should get more
business. Across the US in 2015
39% of health plans offered in public exchanges are narrow
(30 - 70% of areas providers) or ultra-narrow (30% or less
of providers). In large cities narrow networks are
even more common. Typically if consumers go outside of
the choices offered in their narrow network they will be
responsible for the high bills. There are problems
induced by narrow network constraints:
is non-alcoholic steatohepatitis.
- Queuing issues - while a surgeon and a hospital may be
in-network other agents in an operation, such as anesthesiologists or anesthetists, may not have
the same set of insurance contracts. Even if a
subset do, once these are allocated to a task the hospital
must then manage a complex set of resource constraints to
keep its ORs running. If it
does this by ignoring the 'out of network' status of these
necessary resources the patient will be impacted by a high bill.
- Success is more likely when the plan maintains a broad
list of PCPs but a narrow list of specialists and
Natalizumab is a used to treat MS and Crohn's
disease. It is a humanized MAB.
It is assumed to reduce immune cells' ability to pass
through the cell layers lining the intestines and
blood-brain barrier. It is co-marketed by Biogen & Elan
There is a worrying association with PML.
National Housing Act of
1934, the New Deal's Capehart
Act aimed to stop banks forclosing on family homes during
the Great Depression and make housing and mortgages more
affordable. It created the FHA,
Federal Savings and Loan Insurance Corporation
(administering S&L deposit
insurance until this was transfered in 1989 to the FDIC) and US Housing Authority (which
became the FPHA in 1942) to support
Naxitamab is a humanized anti-GD2 3F8 MAB (IgG1) developed by Memorial
Sloan-Kettering cancer center, and commercialized by Y-mAbs
Therapeutics, for treatment of high risk
is a cell surface antigen generated by CD177. It is
expressed by neutrophils.
is the national cancer act of 1971. The determined
advocacy of Mary Lasker convinced President Richard Nixon to
support the bill and sign the act. It had driven $200
billion in funding to cancer research by 2004.
- A type of cancer that forms in
nerve tissue (neurons and glial cells)
- It most frequently starts in an adrenal gland.
- It typically occurs in young children before the age of
5 and is rare in adults.
is the national
center for biotech information.
is the national
is the national
community pharmacists associations, a lobby for
is the national council for prescription drug
programs. It was accepted as a NCVHS
NCPDP SCRIPT standard for electronically
transmitted medical prescriptions. SCRIPT was first
approved in 1997 by the NCPDP and
was adopted by CMS in 2008
effectively mandating through reimbursement
constraints its use for medical providers using electronic
prescriptions, and was proposed by CMS as a rule in June
2010. The Surescripts
pharmacy consortium adopted version 10.1 to help its
members successfully participate in EHR
incentive programs regulated by HITECH.
is the National Commission on Physician Payment Reform,
which is funded in part by the Robert Wood Johnson
is the National
Committee for Quality Assurance. It defines
metrics for medical success including HEDIS.
It identifies primary care
practices that meet the standards and processes to be
recognized by the NCQA as a PCMH: BSVMG.
They reward collection of performance data on:
immunizations, treatment of upper respiratory infections,
mammograms, Pap smears, colonoscopies, imaging for lower
back pain, control of hypertension, medications for
CHF; and scheduling transformation,
integrated behavioral and mental health, analysis, setting
goals and acting to improve practice performance and sharing
practice performance data and analysis. The NCQA is
developing standards for certifying SMH.
is the National
Committee on Vital and Health Statistics which advises
the Secretary of HHS on health data
is new drug application for F.D.A.
approval. Every drug has to obtain NDA approval before
it can be commercialized in the US.
INDs along with the data from higher animal studies and
human clinical trials are evaluated to assess if the drug is
safe and effective for the proposed use, that the labeling
is appropriate, and the methods and quality control
procedures for manufacture are adequate.
is the National Defense Authorization Act of 2003. It
is the national drug code. Each drug prescribed to
humans in the US has a unique code
registered with the FDA. The
code includes the manufacturer (labeler) product and
- The VA and DoD
work together to establish bidirectional exchange of
reference quality medical images.
is New Delhi metallo-beta-lactamase 1 plasmid which
provides bacterial populations globally with total current antibiotic resistance.
is the National
is the National
is the National Information Exchange Model. It is a
collaboration of the U.S. Department
of Justice, U.S. Department of Homeland Security, and HHS designed to develop disseminate and
support enterprise-wide information exchange standards and
Neonatal progeroid syndrome
is an autosomal recessive progeroid
syndrome due to mutations in FBN1.
The mutation damages the eyes, nose,
fat cell lining of the skin and due to an inability to
generate asprosin to signal the liver
for more blood glucose, the sufferers are constantly on the
edge of hypoglycemia.
occurs when to much protein is excreted in the urine.
It can occur for many reasons but often indicates damage to
the small blood vessels in the kidneys
which filter waste and excess water from the blood.
Network model plan is a
type of HMO where the HMO contracts
with any combination of physician group, IPA
and individual physician. MCOs
operating multiple business models: PPO,
POS, Indemnity, HMO; usually
select the network model plan for their HMOs.
Neuropathic pain is pain caused by damage to sensory neurons. It can be due to
impacts of sensory neurons in the central or peripheral
nervous systems. It can be induced by spinal injury, MS and some strokes.
Neuroscience deals with
the structure, development,
chemistry, pharmacology, function and pathology of networks
of biological neurons.
is near edge x-ray absorption fine structure
Next generation sequencing
describes methods of DNA sequencing,
that replace traditional Sanger
sequencing, which have been implemented in commercial
DNA sequencers after 2000. The methods include:
is neurofibromatosis, a highly heritable and relatively
common malignancy, affecting 3,000 Americans a year, which
is inherited as a dominant trait. The gene has a high
mutation rate, so many cases occur without any family
history. It induces flat brown spots on the skin and
skin tumors. It can compomise bodily function and
induce learning disabilities and cancer.
is the National Governors Association. It includes the
State Alliance for
is a gene for N-glycanase 1, an enzyme that deglycosylates
misfolded glycoproteins, supporting the endoplasmic
reticulum based recycling of cellular waste. Genetic
disorders, of NGLY1 are rare but damaging to diploid
carriers. They can be treated with
is the National Health and Nutrition Examination Survey, a
program that continuously monitors the health and
nutritional status of Americans.
is the NIH's national
human genome research institute which aims to advance
human health through genomics
was the National Health Information Network and is now eHealth Exchange. It
is an HHS initiative that awards
contracts to health care and HIT
consortia to develop NHIN prototypes. Several states
have prototypes including Massachusetts MA-SHARE.
A variety of prototypes have been developed:
is National Hospital Inpatient Quality Measures. HHS AHRQ
provides a clearinghouse
for NHIQM. The goal of these measures is based on the
IOM view of quality of care as 'the
degree to which health care services for individuals and
populations increase the likelihood of desired outcomes and
are consistent with current professional knowledge'.
Measures can relate to structure, process and health
commission in cooperation with CMS
provides a specifications manual for NHIQM to promote
hospital measurement alignment.
- Connecting for
health prototypes use the common framework to
build NHIN clients and infrastructure. The clients
use SOAP to encapsulate HL7 query transactions with SNO services. The user making
the request is encoded in HL7 2.4 XML for logging.
However any patient medication dispensing history is
encoded using NCPDP.
is non-Hodgkin lymphoma, It is:
is the national
institute of allergy and infectious diseases, a part
of the NIH.
is the national
institute on alcohol abuse and alcoholism, a part of
- A group of blood cancers that include all (> 60)
types of lymphoma except HL.
- Risk factors include: poor immune function, autoimmune disease, Helicobacter pylori
infection, hepatitis C, obesity, Epstein-Barr virus
infection, HIV infection, radiation
therapy, chemotherapy, PCBs,
dioxin, phenoxy herbicides.
is nurses improving care for healthsystem elders is a nurse
designed to help health care organizations improve the care
of older adults.
is neonatal ICU also called an
intensive care nursery.
is the National
Institute of Diabetes and Digestive and Kidney Diseases.
is the National
Institute of Health, Bethesda Maryland. It is
the primary federal agency for the support and conduct of
biomedical and behavioral research. It is also one of
the four US special containment units
of the CDC.
is the National
Institute of Mental Health.
is the National
Institute of Neurological Disorders and Stroke which
seeks fundamental knowledge about the brain and nervous
system and to use that knowledge to reduce the burden of
virus is a Paramyxoviridae
Henipavirus. It can cross to humans from pigs.
The higher animal reservoir is fruit bats.
Niraparib is a small molecule PARP inhibitor
targeted at ovarian cancer.
It was developed by Tesaro.
is the National Institute of Standards and Technology.
the Networking and Information Technology Research and
Development program coordinates federal research and
development investments in computing, networking and
Nivolumab is a PD-1
inhibitor monoclonal antibody.
It is sold branded as Opdivo.
Its mode of action means it is likely to be toxic to a
developing fetus. It is used to treat:
- NIST has released the CIF to
encourage the standardization and enhancement of testing
of EHR systems.
is the national library of medicine, which maintains the UMLS. It defines complete data
sets integrated within RxNorm for code sets from any RxNorm drug data source
provider. These NLM identified complete data sets are
viewed as the compliance criteria of certified EHR
is natural language processing.
is nuclear localization signal.
It is an amino acid sequence that tags a protein as being
for import into the cell nucleus via a nuclear membrane
is a new molecular entity, including: biologics, biosimilars and some other specialty medications.
- Inoperable or metastatic melanoma
(with no BRAF mutation) in
combination with ipilimumab.
- As a second-line treatment when the cancer has a BRAF
mutation - with an added BRAF inhibitor.
- Certain Hodgkin lymphomas.
- As a second-line treatment for squamous non-small cell lung cancer.
- As a second-line treatment for renal cell
is narrow network.
is number needed to treat. Austin Frakt and Aaron
Carroll explain in the NYT Upshot that it is a number
that describes how many people must be treated for one to
gain a benefit. For aspirin
protection from heart attack
it is about 2000. That means 2000 people taking
aspirin for two years will result in 1 person not having a
heart attack, while 3.6 will have a heart attack anyway,
1995.4 will never have heart attacks any way. But we
don't know who the one person is and aspirin are cheap and
don't have many side effects. The NNT for catching influenza is between 37 and
77. Since millions can catch flu, and thousands of
those die the payoff of flu vaccination
is the National
Oceanic and Atmospheric Administration.
is a bitcoin proof-of-work that
when included in the new block's header and hashed, results
in a block hash that is smaller than the networks difficulty
target. The nonce is computationally easy to verify
but very costly to generate. The difficulty target is
varied according to a pre-defined algorithm to maintain the
six-per-hour block average no matter how many miners are attempting to generate
Nosocomial infection is
a health care facility (hospital) acquired infection.
is national provider identifier standard is a 10 digit
number to identify covered health care providers, health
plans and health clearing houses. It is required in HIPAA transactions. It is a
HIPAA administrative simplification standard.
is notice of proposed rulemaking, which is a legally
required public notice issued by the independent agencies of
the US government when they intend to
issue, change or delete an executive rule.
is the national quality forum.
is the national rifle association.
is the Natural Resources Defense Council a centrist lobbying
is a nonsteroidal anti-inflammatory drug, such as
ibuprofen. They inhibit the production of prostaglandins. They
are often used to treat pain and
inflammation. Since prostaglandins are involved in
collagen production NSAIDs can undermine healing. They
are also associated with increased risk
of heart attacks (May
is the national
surgical adjuvant breast and bowel project.
is nurse support program which aims to improve the number of
nurses available to hospitals. Maryland's HSCRC has developed a number of NSP
is the National Technology Transfer and Advancement Act
1995. It requires Federal agencies to use, unless
prohibited, technical standards that have been developed or
adopted by voluntary consensus standards bodies.
is the National
Uniform Billing Committee.
Nuclear medicine is a
branch of medical imaging that uses radioactive materials to
diagnose and treat diseases.
Nurse care managers, at
are employees of the health
plan who are embedded in primary care offices, and
especially advanced medical
homes (Geisinger's PHN).
Nurse care managers are tasked with support of the sickest
patients in the practice: medication adherence,
keeping appointments, encourage use of preventative
measures; to maintain health and avoid repeated
hospitalizations. Their focus on these patients
ensures they detect problems early, and makes them ideally
placed to support patient safety and minimize the impact of
Nusinersen is an RNA
based treatment for SMA converting
the SMN2 gene to produce additional SMN protein. It is
an antisense oligonucleotide discovered by Adrian
Krainer of Cold
Spring Harbor Laboratory and Ionis
Pharmaceuticals. Preclinical studies at the University
of Massachusetts were funded by Cure SMA.
It is marketed as Spinraza.
The F.D.A. identified side effects
are respiratory infections, constipation, low blood platelet
counts and poisoning of the kidneys.
is nitrogen-vacancy center. These are negatively
charged and support fluorescence in FND.
is National Vaccine Injury Compensation Program is a US
program which protects vaccine manufacturers from law suits,
but requires them to contribute to a fund which compensates
anyone hurt by a vaccine.
Newborn screening uses a
few drops of blood from the baby's heel, absorbed onto a
filter paper card for laboratory analysis. It can
provide powerful information for recessively inherited
conditions. It is used for: sickle-cell anemia, Phenylketonuria, hypothyroidism,
galactosemia, congenital hearing impairment and cystic fibrosis; with
differing effects. The increased availability of low
cost DNA sequence analysis will
increase the screen size and information but presents
privacy difficulties. As of 2015 the March of
Dimes recommends newborn screening for 29
is the Office of the Actuary within the CMS.
is the Old-Age and Survivors Insurance trust fund.
is Medicare Outcome
and Assessment Information Set. Any HHA seeking Medicare certification is
required to meet the conditions of participation prior to
certification. This includes compliance with the OASIS
collection and transmission requirements.
is an open standard for authorization. OAuth
provides client applications with a secure delegated access
to server resources on behalf of a resource
is an addictive disorder where
the brain is induced to require more eating, often because
of limits to the number of fat cells available to report
2016). Brain images of drug-addicted people and
obese people have found similar changes in the brain.
Obese people's reward network
tends to be less responsive to dopamine
and have a lower density of dopamine receptors.
Obesity spreads like a virus through a social
network with a 171% likelihood that a friend of
someone who becomes obese will also become so. Obesity
is associated with: metabolic
syndrome including inflammation, cancer
2016), high cholesterol, hypertension,
type-2-diabetes, asthma and heart disease. It is
suspected that this is contributing to the increase in
maternal deaths in the US (Sep
2016). Obesity is a complex
condition best viewed as representing many different
diseases, which is affected by the: Amount of brown adipose
2016), Asprosin signalling by white adipose
2016), Genetic alleles including 25 which guarantee an
obese outcome, side effects of some pharmaceuticals for:
Psychiatric disorders, Diabetes, Seizure, Hypertension,
Auto-immunity; Acute diseases: Hypothyroidism,
Cushing's syndrome, Hypothalamus
disorders; State of the gut microbiome.
Infections, but not antibiotics,
appear associated with childhood obesity (Nov
Observation means outpatient
is the Omnibus Budget Reconciliation
act of 1987. It included mandating of an
outcome-oriented home care survey process.
is the Omnibus Budget Reconciliation
act of 1990. President George H. W. Bush used it to
introduce a tax increase. It was faught by Newt
Gingrich's conservative Republicans.
is the Omnibus Budget Reconciliation
act of 1993. President Clinton used it to reduce
deficits by $433 billion over five years through:
is Oncology Care Model, a CMMI bundled-payment
demonstrator. It targets a hogh-cost medical specialty
forcing integration of PCPs and specialists. It begins
payment at the initiation of an episode of chemotherapy and covers six
subsequent months of care. CMS
partnered with 16 commercial payers
to aggregate more payments. OCM offers oncologists a
bonus for reducing a patient's total cost of care. 190
practices with over 1,000 oncologists enrolled.
- Tax increases
- Spending cuts. Newt Gingrich's conservative
Republicans all voted against the measure.
is HHS Office of Civil Rights.
It enforces four key privacy and security laws:
- Include a clinician who is available 24/7 and has
real-time access to the patient's EHR
- Develop a 13-point care plan with specific treatment
& advanced care planning goals
- Guarantee the chemotherapy strategy follows national
guidelines such as NCCN's
preferred chemotherapy regimens.
is optical coherence tomography, which uses light to perform
micrometer-resolution cross sectional imaging.
- HIPAA Privacy Rule.
- HIPAA Security Rule.
- HIPAA Breach Notification Rule.
- Confidentiality provisions of the Patient Safety
is optically detected magnetic resonance uses double
resonance combining optical techniques such as
(fluorescence, phosphorescence) with electron spin resonance
is the Office
of Government Ethics.
is oral glucose tolerance test, a sensitive test of how
effectively a person's body can move glucose into
cells. A fasting blood glucose test level is compared
with the level after consuming a sweetened drink. The
body should be able to manage the blood glucose level by signalling cells to absorb
glucose with insulin. If
the blood glucose level remains high the patient is
exhibiting pre-diabetes or diabetes.
is an organized health care arrangement where multiple
participants need to share (HIPAA)
protected health information about their patients to manage
and benefit from a common operation. It is:
is the HHS Office of Inspector
is the Office
of Information and Regulatory Affairs within the OMB, approves government data
collections and ensures that agencies have sufficiently
addressed problems during rule making.
- Clinically integrated
- Organized so that it is clear to the public that
participants are working in a joint arrangement
- A combination of group health plans or group health
plans and insurers.
Olarparib is a PARP
inhibitor developed by
KuDOS Pharmaceuticals and subsequently AstraZeneca,
branded as Lynparza.
is the Office
of Management and Budget. It:
Omburtamab is a is a humanized B7-H3
targeting MAB, developed by Memorial
Sloan-Kettering cancer center, and commercialized by Y-mAbs
Therapeutics, for treatment of human solid tumors:
embryonal tumors, carcinomas,
sarcomas and brain tumors.
is the Office of the National Coordinator for Health
Information Technology of the US
Department of Health and Human Services. It was
required to support the President's 10 year goal of
interoperable EHR, and lead the
nation in the strategic planning for nationwide
interoperable HIT. It develops
the US HIT
strategic plan. It specifies the standards,
implementation specifications and certification criteria
used to certify meaningful use.
It develops key programs: RECs,
HITRC, State HIE
Cooperative Agreements, Beacon
Communities, Health IT Workforce Development, SHARP, National
Health Information Network, FHA,
CONNECT. It must
encourage the development of RHIOs
to facilitate community and regional clinical data
Onchocerciasis is a form of filariasis. It:
- Creates and promotes the President's federal budget and
hence indirectly his priorities.
- Has the power to advance or constrain federal regulation
as many proposed rules must be signed off by the O.M.B. (OIRA) before they are issued.
The rules it can constrain include those relating to:
- Environmental standards
- Labor protections
- Food safety
- All administration policies affect the budget directly
or indirectly so they are constrained by the
Oncogenes encode proteins that promote cell
growth: crestin, Ras. They are important both in
growth and cell repair. When mutations occur in the
control regions of these genes cells can start growing
aggressively. Mutated Ras is found in a high
proportion of colon and bladder cancers.
Melanoma is initiated by crestin reactivation (Jan
- .ind.include ('html/awffwglossary.html', 'riverbl1',
Oncotype DX is a trademark of Genomic
Health. It is a diagnostic test based on RNA
biopsy assays and gene sequencing,
of disease recurrence in sufferers of various types of cancer including:
is the office of national drug control policy, setup by the
ADAA of 1988. It is part of the
Executive Office of the President. It is designed to
be led by the federal administration's drug czar who advises
the President on drug control issues.
is organic nano-particle. These have a high level of
Open model plan is an HMO
where the physicians maintain their own offices and can see
non HMO patients.
OpenNotes is a research project, in which
105 doctors shared their notes with more than 19,000
patients in Boston, based at Beth
Israel Deconess Medical Center , supported by the
Robert Wood Johnson Foundation Pioneer Portfolio. It
has been adopted by the VA and Geisinger.
OpenStack is an open source cloud operating
system providing pools of virtual machines running resources
including Hadoop which are all accessible via APIs,
networking services including OpenFlow (software defined
networking), and storage including distributed object
storage and high performance block storage; running on top
of OpenStack shared services.
is out patient department providing ambulatory care for
patients who do not stay over night.
is the CDC's office of public health genomics.
It established the EGAPP
Ophthalmology deals with the anatomy,
physiology and diseases of the eye.
is the occupational performance model (Australia) an
approach to OT.
is ongoing professional practice evaluation, a Joint Commission (JC)
requirement intended to encourage ongoing measurement of the
performance of privileged practitioners. The data to
be measured is defined by individual departments but the JC
includes a standard rational. The OPPE must result in
evidence of operation that can be assessed in a JC
review. The OPPE requires demonstration of a process
is the Medicare outpatient
prospective payment system
- Shows who will be responsible for reviewing performance
- How often the data will be reviewed.
- The process to be implemented to use the data to make
decisions about constraining privileges.
- How data will be incorporated into the credential
is outpatient surgery.
is operating room.
is the Office of Research and Demonstrations, an HCFA agency. It conducts and
supports data collection efforts and research on health care
providers, reimbursement, beneficiary behavior and health
Order sets are specifications of medications
and procedures to be performed on a patient. It is
envisioned that EHR will ensure that
these orders are validated against allergic
reactions and drug interactions that may occur for the
is a tiny ball of brain cells grown from stem cells and mimicking early
brain development. The
stem cells have differentiated into most types of brain
cells. A 100-day-old organoid resembles a late second
- The orphan drug act of 1983 which aims to facilitate
development of drugs for rare diseases. The F.D.A. ensures that qualifying
manufacturers obtain reduced costs of some parts of the
testing process, and has tax incentives, enhanced patent
protection, clinical research subsidies and support of a GSE to do research and
- Official development
assistance, funds donated by rich country governments to
poor countries. ODA is measured by the OECD's DAC.
Orthopedics is the treatment of the
musculoskeletal system which supports multi-cell higher
animals and allows them to move about: including correcting
deformities, breaks, tears, compression, tendonitis, disc
failures, misalignment, fusion to treat damaged discs.
is the office
of Refugee Resettlement within the ACF.
is the office
of research on women's health.
is the occupational safety & health Act of 1970, which
required employers to keep the workplace free of hazards and
to comply with standards induced by the act and for
employees to comply with safety standards, rules,
regulations and orders induced by the act. It does not
cover mines, energy or the coast guard.
is the occupational safety and health administration, the
main federal agency charged with developing rules and
carrying out enforcement of safety and health legislation
driven by the OSH act of
Osteoarthritis is a common inflammatory
disease of the joints. Prophylaxis
can mitigate the eventual development (Sep
2016). Factors that increase likelihood of
developing osteoarthritis includes: Obesity,
Joint injuries, Joint surgery to repair a torn meniscus;
with athletes who develop a tear getting osteoarthritis at a
rate five to ten times greater than people who do not have
this surgery. Osteoarthritis accounted for 95% of the
757,000 total knee replacements and 80% of the 512,000 total
hip replacements in the US in 2011.
Osteocalcin is a hormone
generated by bone. It acts on many organs including
the brain where it influences the production of serotonin, dopamine, GABA
and other neurotransmitters, promoting spatial memory and
Osteoporosis is a set of diseases where the
bones are being broken down faster than they are being
renewed. The effect is for bones to lose strength and
become brittle. The more bone mass developed the less
likely osteoporosis becomes. The risk increases with
age and more often impacts women. Certain hormone levels have an impact:
and reduced sex hormone levels increase bone loss, over
active: Thyroid, Parathyroid and
Adrenal glands. Some medical treatments can accelerate
bone loss (prostate cancer
treatments). Osteoporosis treatments include:
is occupational therapy which aims to support the ability to
perceive, desire, recall, plan and carry out roles,
routines, tasks and sub-tasks for the purpose of
leisure and rest in response to demands of the internal
and/or external environment as defined by OPMA.
- Amgen's Evenity
(romosozumab) a sclerostin inhibitor (Apr
parathyroid hormone analog which encourages bone growth
but is very expensive. And it is only allowed to be
taken for two years since it was associated with bone
cancer in rats.
- Biphosphonates reduce the rate of bone loss but have
frightening side effects in a small number of patients (Jun
require suppliers to return money to the health system if
the drugs fail to work as expected. Typically drug
makers pay rebates to insurers based on the number of drugs
sold. The manufacturers gain easier access to
insurers' members for their products. It appears
unlikely that outcomes-based contracts reduce prescription
drug prices (Jul
is a hospital that Medicare
identifies as having unusually high costs and so needs extra
Outpatient observation stays
observation stays are inpatient like stays in hospital,
except Medicare does not count
the stay towards the qualification for SNF
reimbursements and the copay for the observation may be
considerable. The volume of outpatient observation
stays has been rising.
Ovarian cancer is a relatively uncommon
disease but is often fatal. It has been associated
with use of talcum powder (May
Overdiagnosis is identification of disease
when no symptoms or impacts will occur. It typically
results from false positives during screening (Aug
2016). It can result in unnecessary and
Overtreatment is the application of
unnecessary health care. It is a complex problem:
Oxymorphone is an opioid analgesic. It
was developed in 1914 in Germany and patented in the US in
1955 by Endo.
It is prescribed for preoperative anxiety
and pain management.
Extended release tablets are prescribed for chronic pain.
- Overtreatment needs to be adaptive. As people age
their medicine levels typically need to be changed.
Often, as in the case of blood pressure, and blood sugar
reduction, they should be reduced to avoid inducing falls
- Patients with chronic diseases, such as type 2 diabetes, often
require different treatment settings. And again
these vary with age.
- Patients who have learned a regime, and been told it was
successful, may resist instructions to change it.
Some worry that they will impact their health care
provider's treatment performance measures.
is Project 100%, an initiative in San Diego County to
interview all TANF (CalWORKs)
applicants to verify eligibility information supplied by
applicants prior to benefits being granted.
PAC provider is a Post-Acute Care
provider. A three-day hospital admission and discharge
are prerequisite requirements to receiving Medicare PAC services. Acute
care hospitals become portals to the PAC business.
Referrals are key. PAC includes different types of
facility focused on different severity of illness (high to
- Long term care Hospital (LTCH),
- Inpatient rehabilitation facility (IRF),
- Skilled nursing facility (SNF),
- Home health agency (HHA) - most
acute care hospitals and EMR
providers have strategies for integration with home based
- Outpatient rehabilitation. SNF and HHA represent
80% of discharges and expenditures. Assisted living is not
part of federal Medicaid, but
states often include it through a waiver.
Paclitaxel is a microtubule inhibitor.
It is a plant alkaloid used in chemotherapy
for lung cancer, Kaposi
sarcoma, Ovarian tumor, and Breast
- Protecting Affordable Coverage for Employees Act of
2015, which amends ACA title 1 to alter the
definition of a small business, or
- Program of All-Inclusive Care for the Elderly, a Medicare program which pays for
facilities and services to keep older and disabled
Americans in their own homes instead of their having to
enter nursing homes. It was intended to consequently
save Medicare and Medicaid
money. All states are required to pay less than the
cost of a nursing home stay. It leverages the
success of Britain's Day
Hospitals. PACE started as On Lok, which
provided capitation funded
day care, to San Francisco's Asian & Italian immigrant
families trying to avoid use of nursing homes. This
payment model should encourage providers to keep their
patients healthy. The services include dentistry,
which constrains a problematic cascade of issues and
rehabilitation which protects against falls.
Medicare sanctioned the model in 1990. Its
implementation was restricted to non-profit organizations
but in 2016 CMS allowed for-profit
organizations to participate (Aug
is Picture Archiving and Communications System - a workflow
for radiology imaging. An alternative to RIS.
is patient aligned care team which aims to enhance patient
engagement and care
coordination by a partnership between patients and
their care teams with team-based relationships at the center
of the PACT. The primary team includes the: Patient, PCP, RN care
manager, CNA, administrative
assistant. The RN care manager helps support chronic
care and care transition success by:
is patient-centered transformation
is post-acute care unit - the surgical recovery
is peripheral artery disease. Its symptoms are leg pain when walking even short
distances. It is due to blocked or diseased arteries
in the legs. Onset is encouraged by risk factors:
smoking (*4), diabetes, hypertension and high
cholesterol. On average it develops around 70 years of
age but it will develop in the 50s and 60s in the presence
of the risk factors. PAD can contribute to serious or
fatal problems with the heart or brain. Walking for
thirty minutes a day can limit the onset of PAD. And
walking up to the point of pain, resting and then continuing
to walk for a cumulative 30 minutes can treat
is pandemic and all hazards preparedness act of 2006, which
resulted in the creation of the office of the ASPR.
is the 2013 reauthorization act for PAHPA.
Pain management is an iterative process,
overseen by a doctor, to limit a patient's pain. The process is doctor
prescribed, RN managed, pharmacist
validated, and patient administered. The process may
be coordinated by pain management specialists. Pain
management is central to modern surgery where it is
supported by hospital infrastructure. It is central to
process. It is a major aspect of ED
operations. It has been extended out to discharged patients
with chronic long term pain where it can lead to opioid
dependency. Treatments include: Opioids including: Fentanyl, Morphine, OxyContin,
NSAIDs, Cannabinoids, Acupuncture,
Massage, CBT, and Mindfulness.
Paliperidone is a dopamine
antagonist used as an antipsychotic. It can be used to
treat schizophrenia, mania
and at low doses to maintain bipolar
disorder. It is marketed by Janssen as Invega.
Palliative care aims to relieve and prevent
the suffering (symptoms, pain and
stress of serious illness) of patients what ever their
is the patient admitting manager oversees the hospital
admitting department. Responsible for:
is the Protecting Access to Medicare
Act of 2014. It includes:
- Manages and adminsters admission staff.
- Development of policies and procedures to ensure
consistancy with hospital standards and requirements and
quality control. Oversees development of reports to
- Ensures outpatient registrations and inpatient
admissions are screened for insurance coverage and
- Manages complaints about admissions.
- Coordinates service denial processes, appeals, and point
of service collections
- Manages admission department budget.
PAMA appropriate use criteria
- Delays of the SGR cut to Medicare
until March 2015 ('doc fix'). The delay is partly
funded with cuts to Medicare's funding of SNF, lab tests,
physician and other provider services. The rest is
offset by moving Medicare sequester
cuts from 2025 to 2024. This SGR cut has been
iteratively delayed for 10 years and was finally removed
- Helps states establish CCBHCs
through section 223 the Excellence in Mental Health Act
demonstration program. This stipulated that CCBHCs
may receive an enhanced Medicaid reimbursement rate based
on their anticipated cost of care.
- Directs HHS to develop VBP and readmissions
strategies for SNFs
- Directs HHS to: Develop, Promote
the use by ordering and furnishing agents of, Make the
interfaces public of; rules for imaging services appropriateness
criteria. The rules held in a radiology CDSS will remove the need for
pre-authorization of the procedure.
- Enhances clinical diagnostic laboratory tests coverage,
- Alters end stage renal disease payments, audits;
PAMA imaging services
are advanced diagnostic imaging services for which appropriate use
Pancreatic cancer is
most often an exocrine tumor. Islet cell tumors are
less common. These are rare cancers:
less than 200,000 US cases per year, but the five year
survival rates are extremely low 3%. They all have KRAS mutations. They are
associated with obesity.
Diagnostics are starting to leverage genomics
and big databases (23
and me). Treatments include:
Paper-based PoCT is a
flexible low cost, future IVD device
that will allow:
- Which assist ordering and furnishing professionals in
making the most appropriate treatment decision per
condition for this individual
- Developed or endorsed by national medical specialty
societies or other provider led entities. For
imaging services this is the ACR.
is NN-dimethyl-44-bipyridinium dichloride, a systemic weed
killer, used on oranges, coffee and suger cane, manufactured
and sold by the Swiss pesticide company Syngenta.
It is banned in the EU, but still
allowed to be sold and used in the US.
Drinking even a sip can be lethal. Recent research by
the NIH links paraquat to Parkinson's disease.
The 2011 research found Iowa and North Carolina farmers and
family members that handled paraquat or rotenone were 2.5
times more likely to develop Parkinson's disease. A
2012 study found paraquat increased the likelihood 11 fold
for people with certain genetic variations. The link
is disputed by Syngenta.
- Samples to be dispensed into spatially-segregated areas
enabling multiple simultaneous assays.
- Samples to be moved by capilliary action
- Small sample sizes to be used.
- Waste can be incinerated.
association area is a multi-sensory integration
area of the sensory signals
from parietal, temporal and occipital lobes.
corresponds to the breakdown of certain interneurons in the
brain. It is not fully understood why this
system neuron breakdown
generates the classical symptoms of tremors and
rigidity. In some instances an uncommon LRRK2 gene mutation confers a high
risk of Parkinson's disease. In rare cases Italian and
Greek families are impacted in their early forties and
fifties resulting from a single letter mutation in alpha-synuclein which
alters the alpha-synuclein protein causing degeneration in
the substantia nigra,
after a build up of Lewy bodies
in the neurons. But poisoning from MPTP has also been
shown to destroy dopamine system neurons. DeLong
showed that MPTP poisoning results in overactivity in the
subthalamic nucleus. People who have an appendectomy
in their 20s are at lower risk of
developing Parkinson's disease. The Alpha-synuclein
protein is known to build up in the appendix in association
with changes in the gut microbiome.
This buildup may support the 'flow' of alpha-synuclein from
the gut along neurons that route to the brain. Paraquat has also been linked to
Parkinson's disease. Parkinson's disease does not
directly kill many sufferers. But it impacts
swallowing which encourages development of pneumonia through inhaling or
aspirating food. And it undermines balance which can
increase the possibility of falls.
Dememtia can also develop.
Treatment with deep-brain stimulation, after surgical
implantation of electrodes in the subthalamic nucleus
removes the symptoms of Parkinson's disease in some
is poly ADP ribose polymerase. It repairs
single-stranded damage to DNA.
PARP inhibitor stops single stranded repair
of DNA. In cells with BRCA1/2 and PALB2 mutations this
additional DNA repair inhibition will increase the likeliood
that the cancer cells will die.
Patient-centered medical homes
The Patient-centered medical home
offers health care providers the potential to accurately
identify each patient. CCC is
working with Geisinger
?refers? to the use of healthcare workflow queuing models to
minimize hospital wait times.
- Describes a reorganization of the health care delivery
system to focus on the patient and care giver supported by
EHR infrastructure and some form of
which will be necessary to coordinate interventions by
each of the functional entities resources to treat
the patients specific problems. The
disadvantage of a PCMH is the administrative and
technology cost needed to support its complex
processes. The PCMH
- Was promoted as a way to incent more PCP
which had been seen as a low reward role by medical
students. HCI3 argues
this use of PCMH is flawed. PCMH is driven by
the medical home models
of the ACA. In this model the
PCMH is accountable for meeting the vast majority of each
patients physical and mental health care needs including
prevention and wellness, acute
care, and chronic care. It is focused on treating
the whole person. It is tasked with coordinating the
care across all elements of the health care system,
including transitions and building clear and open
communications. It must ensure extended access and
availability of its services and patients preferences
about access. It must continuously improve quality
by monitoring evidence-based medicine
and clinical decision support tools (NCQA).
Many argue that to be effective it must be connected to a
The PCMH brings together the specialized resources and
infrastructure required to develop and iteratively
maintain the care plans and
population oriented system descriptions that are central
to ACA care coordination.
Patient portal provides web and or
application based access to a patient's EHR
based health care information and services. Specific
portal services are mandated by meaningful use. They
include at a minimum lab test results, problem list,
medication list, and medication allergy
Patient Right to Know Drug
Prices act of 2018 blocks gag contracts that limit
pharmacy staff advising purchasers of the cheapest option to
obtain their prescription drugs. The act was sponsored
by Senator Susan Collins of Maine and signed into law by
is Potentially avoidable utilization, hospital care that is
unplanned and could be avoided through improved care, care coordination, cost
increases or effective community based care.
Maryland's healthcare financial management association
supports reducing PAU. Its HSCRC
calculates the percentage of hospital revenue attributable
Pay-for-delay is a practice used to extend
the high profits of a soon to be off-patent protected
drug. The companies pay generic manufacturers to delay
release of their generic competitor to sustain high
represents a number of programs:
Payer mix is a hospital's specific mixture
of the four different types of payer:
- Value-Based Purchasing Program
which includes mandatory pay-for-performance where a
percentage of hospital inpatient payments are withheld and
then earned back based on achieving quality metrics.
Withholds begin at 1% in 2013 and rise to 2% by
- HRRP which penalizes Hospitals
with a readmission rate that is greater than
expected. Penalties capped at 1% of total DRG in 2013, 2% in 2014 and 3% in
- CMS is also using a high HAC percentage as a penalty - 1%
penalty deducted from DRG payment (HACRP)
starting in 2015 to encourage reduction of HACs.
- MCMP EHR
deployment in physician practices.
include four types:
- From the 1930s the insurers Blue
Cross and Blue Shield catalyzed health care activity
by paying a daily per diem to hospitals for the diagnoses
and treatments the hospital's dispensed. At their
inception in 1966 Medicare and
Medicaid followed this reimbursement model.
- From 1983 Medicare and Medicaid switched to the PPS reimbursement mechanism.
This forced alignment of the
supplier, diagnosis, treatment, billing and reimbursement
processes. The health care network is still
structurally aligned around PPS. Under scrutiny of
ProPAC and its successor MedPAC,
as well as pressure of the BBA
after 1997, the payments per DRG
have been steadily reduced until it was below the cost of
care, forcing hospitals to seek margin from their other
payers. Medicare outlier
payments benefited hospitals that inflated charges and
thus became eligible.
- Employers as they experienced cost shifting from the
hospital's increased product charges moved their employees
over to managed care based
- Private payers pay hospitals directly for their
diagnosis and treatment. Typically this group has
little power. There are default rates for private
payers - typically 40% of billed charges that are not
covered by a fixed payment or a fee schedule. For
the uninsured poor until 2004 they obtained little
discount on the hospital's chargemaster
list price, because insurers and CMS
required to be charged the lowest value offered to any
patients. Medicare has now relaxed this
is the pension
benefit guarantee corporation. It is an
independent agency of the US government created by ERISA.
- .ind.include ('html/awffwglossary.html', 'glpayertype1',
benefit manager. These companies, such as Caremark, were
often originally PPMs. PBMs are
used by payers, such as insurance
plans, to manage drug provision from pharmacies to the
payer's plans subscribers. PBMs can constrain drug
flow to the pharmacies: CVS,
through the PBM's formularies.
is UCLA Health's
Peer CICARE Assessment Tool where
managers ask Patients if their experience was consistant
with the CICARE goals and World Class Practices. ALl
managers come together and are assigned areas of the
hospital to visit, and they ask standardized questions of
patients. They then gather together and discuss the
is polychlorinated biphenyl. These chemicals were
widely used as dielectrics and coolants but are now
is the patient centered outcomes research institute executes
a program that selects, designs, and conducts clinical
effectiveness research, comparing drugs, devices, medical
interventions and different delivery-system
it uses public and private funding to support President
Obama's goal of clarifying which approaches achieve better
health outcomes for patients at lower cost.
is proprotein convertase subtilisin/kexin type 9 an enzyme
activator. It is encoded as zymogen and autocatalysed
in the ER. It plays a major role in cholesterol homeostasis. It binds
EGF-A domain of LDLR inducing LDLR degradation.
Academic researchers Dr.
Helen Hobbs and Jonathan Cohen, studying large
populations found reduced LDLR results in reduced metabolism
of LDL which can lead to hypercholesterolemia.
Drugs that can inhibit PCSK9 can lower cholesterol much more
than first generation cholesterol inhibitors.
is programmed cell death protein 1 (CD279) is encoded by the
PDCD1 gene. It is a cell surface receptor that belongs
to the immunoglobulin superfamily. It is expressed on
T-cells and pro-B cells. It acts as an immune
checkpoint preventing the activation of T-cells to help
self-tolerance and reduce autoimmunity. When it fails
people can suffer from: Lupus, Crohn's disease, Rheumatoid arthritis.
PD-1 inhibitor drugs activate the immune system to attack
tumors. PD-1 inhibitors are being approved for
Melanoma and squamous-cell form of lung cancer.
is programmed death-ligand 1, is a ligand for PD-1.
is the prescription drug user act. It included a
scheme to improve the drug review time by setting up
Pediatrician is a doctor who specializes in
the treatment of infants, children and adolescents.
They are represented by the American
Academy of Pediatrics.
- Standard for drugs offering little improvement over the
current products and
- Priority for drugs offering significant
improvements. The FDA add
additional resources to drugs on priority
Pembrolizumab is a humanized mouse MAB, marketed as Keytruda,
which binds to the PD-1
is pulmonary embolism, a
blockage of an artery in the lungs by an object transferred
there by blood flow.
Pelvic mesh implants are
medical devices, surgically deployed to support organs that
are prolapsing because of weakened pelvic muscles.
They are built from fiber that is designed to bond with the
Pericardium is a double-walled sac that
surrounds the heart, and blood vessels that route blood to
and from the heart, and which contains pericardial
is: Politics, Economics, Sociology-Culture, Technology; signals and actions, complex
adaptive effects on the business environment.
is the President's
emergency plan for AIDS Relief. It was setup by
President George W. Bush.
is the care of a patient prior to and after surgery.
Pernicious anemia is an
with a deficiency in red blood cells due to a lack of
intrinsic factor limiting absorbtion of vitamin B12.
The cells in the stomach that make intrinsic factor are
damaged by the autoimmune attack by antibodies
to intrinsic factor.
are (poly|per)flouroalkyl substances. They help with
non-stick and water and stain resistance. They have
been implicated in testicular and kidney cancer, hypothyroidism, ulcerative
colitis and other health problems.
is perfluorooctanoic acid, a legacy
chemical, which has been linked to kidney cancer,
birth defects, immune system
disorders, and other health problems.
how genes affect a person's response to drugs so as to
develop personalized drug treatment plans, tailored to a
person's specific phenotype.
The process optimizes the treatment process but there are
barriers to its deployment:
is the Pennsylvania
health care cost containment council aims to: increase
access to health care, and address the growing cost.
It develops independent assessments of health care quality
- Large scale clinical trials may test 20,000 individuals,
but if a toxic response impacts only 0.1% of them there
would only be 20 cases found which is often too few to
identify the cause of the response. Instead a
process for capturing adverse drug reactions
after approval and marketing must be used along with the
ability to take a blood sample in these cases.
- Simplified studies on a subset of individuals that have
the target allele should be cheaper but are unattractive
to pharmaceutical companies which typically want to
maximize their target market (Aug
- F.D.A. has not required genomic testing for most
- Health care providers are being slow to use
pharmacogenomics. Often third-party payers are unwilling to reimburse
- Transportation to centralized laboratories for genomic
testing causes delays which makes some drug therapy
applications impractical. An alternative solution
would be to have a patient's EHR
contain their genome sequence for immediate genomic
Phenylketonuria is a single gene recessive
disease where a mutation in the gene encoding phenylalanine
hydroxylase stops the breakdown of phenylalanine resulting
in its buildup to dangerous levels causing brain damage and
death. By severely limiting protein intake to avoid
phenylalanine and using a special dietary formula, of
supplements that provide all the other amino acids, patients
can develop normally.
is a Personal Health Record. Goal is to place patients
in control and make them accessible. Early vision
differentiated between standalone PHR and EHR tethered patient portals. There
are various PHR
services. Privacy, security, data integrity,
ownership, cost, and quality are all unresolved
issues. Can be loaded onto a cell phone or app but
then the health care privacy regulations don't
Personalized medicine is
a medical strategy where decisions,
practices, and products are tailored to the individual
patient. Research is looking at the impact of
providing potentially deleterious genomic testing information
to people: The REVEAL study found
no increased anxiety induced by
hearing that one's genome implied increased risk of
developing late onset Alzheimer's
disease. The take-up of personalized medicine
benefits from the focus on genomics,
enabled by next
generation sequencing of DNA,
and detailed by the NIH director
Francis Collins and includes:
Pertuzumab is a MAB used in treatment of
HER2-positive breast cancer.
is positron emission tomography which uses a radioactive
tracer (Nuclear medicine) to look for disease
processes. The tracer is intravenously deployed
through the blood stream where it collects in organs and
tissues. A whole body scanner is then used to count
the indirect gamma ray emissions and a computer builds a 3
dimensional representation. If the tracer is an analog
of glucose such as fluorodeoxyglucose the concentrations of
tracer imaged will indicate tissue metabolic activity
(glucose uptake). This can be used to explore for
early signs of cancer (unusually
active cells) metastasis.
is peripherally inserted central catheter
which is a long tube that is inserted into a vein to enable
long-term intravenous antibiotic, medication, nutrition
Pidilizumab is a blood cancer targeted MAB. It attenuates apoptotic
processes in lymphocytes (effector and memory T cells).
Pioglitazone is a TZD.
It stimulates transcription
are phosphatidylinositol-3 kinase related kinases, a class of serine/threonine
kinases that have four protein domains: FAT, KD, PRD and
is a Yersinia pestis bacterial infection of humans,
typically vectored by fleas, although it can be spread
through the air between humans via infected
Play or pay is a health care policy
insurance coverage model that
requires employers to offer qualified health insurance
coverage to their workers and their families, or pay the
federal government for coverage. Such federal coverage
could include a Medicare
universal guaranteed insurance scheme that would cover all
the benefits of Medicare parts A,
B, C (Advantage) and D.
Pleiotropy is where one gene affects more
than one phenotypic
is point-of-care testing. It allows:
- .ind.include ('html/awffwglossary.html', 'poct1', 'poct1',
is a paralysis caused in a small percentage of cases of
infection with poliovirus. It is transmitted by the fecal-oral route
and less commonly from droplets from a sneeze or
cough. Epidemics of
be related to lack of immunity due to reduced
infection rates in babies.
- Immediate diagnosis in the PCP
office, an ambulance, the home, the field or in hospital
rather than waiting for the lab. It includes over
the counter: glucose monitoring and pregnancy testing and
professional: critical care, infectious disease (HIV, Chlamydia), cardiac monitors,
diabetes, lipids, coagulation
and hematology; with 'over the counter' providing the
largest market and infectious disease PoCT the fastest
growth. Devices range from: sticks and small
hand-helds, to bench top versions of laboratory
devices. Timely diagnosis allows rapid
treatment. Predictive personalized and
preemptive medicine can be designed based on PoCT.
It is difficult to deliver a: timely - within 5 minutes -
flexible, cost effective - $20 for infectious disease,
accurate, easy to use, safe; PoCT device. PoCT
patients require tests to be free or appropriate while
clinicians want to maximize simplicity and coverage.
Diagnostics [will] include:
- Operator interface
- Bar code identification
- Chemical reactors (large sample diagnostics: Early
LOC, LFS; and molecular
diagnostics: LOC, Paper-based;) which
only require a small amount of blood. Preparation
of the sample avoiding contamination have been major
challenges often requiring a laboratory-like
- Molecular diagnostic sample amplification: PCR, LAMP, RCA;
- Optical or electochemical probes
- Low cost imaging devices
- Reagent storage
- Networking and storage
Polony sequencing was
developed at Harvard
by George Church's lab. It uses an invitro paired-tag
libarary with emulsion PCR, an automated
microscope, and ligation-based
is physician orders for
life-sustaining treatment. It is an approach to
end-of-life planning based on conversations between
patients, loved ones and medical providers. It aims to
ensure that seriously ill patients can choose the treatments
they want and their wishes will be honored by medical
Popcorn lung is the scarring and obstruction
of the lungs' smallest airways.
is a complication of shingles, affecting nerve fibers and
skin. It is sensed as a burning pain.
is the process of recording amounts as credits and debits in
the general ledger.
provides physicians with access to the EHR.
is the physician quality reporting initiative.
is the United States Public
Health Service, a division of the HHS.
It was structured by the PHSA.
is the public health
service act. It has been amended over time and now
includes a statutory definition of a qualified EHR. The PHSA
Title X Family Planning Program is the only federal program
dedicated solely to providing individuals with comprehensive
family planning and related preventative health
340B required drug manufacturers to discount the price
of outpatient drugs to eligible health care
is phosphatidylinosotol-4,5-biphosphate 3-kinase is a family
of cellular signal
transducers, phosporylating the 3' of the inositol ring of
lipids. Class I PI3Ks are activated by G protein-coupled receptors & tyrosine kinase
receptors. Class II PI3Ks participate in clathrin-mediated endocytosis. Class III is
involved in trafficing of proteins and vesicles. They
Class IV include ATM, ATR, DNA-PK
and mTOR serine/threonine
kinases. By helping signalling proteins to be
recruited to cell membranes they support cell growth,
proliferation, differentiation, motility, survival and
intracellular trafficking, often by activating protein
kinase B. Different isoforms regulate different
aspects of the immune response, and the insulin signalling
PI3K inhibitors are pharmaceuticals designed
to inhibit various isoforms of PI3K,
to inhibit the growth of cancers
and inflammatory respiratory disease.
Pioneer ACO Model is a CMS Innovation
Center initiative to support ACOs
in providing more coordinated care to beneficiaries
(individuals and populations) at lower cost to Medicare. It leverages the ACA shared
savings program and tests an alternative 'pioneer
Pioneers are assumed to be organizations with experience
offering coordinated, patient-centered care, and operating
in ACO-like arrangements. A first performance period
Jan 1 2012 - 2014 tests a shared savings and shared losses
payment arrangement with higher levels of reward and risk than in the shared savings
program. In year three Pioneer ACOs that have showed
savings over the first two years can move to a population based
payment model. Two alternative payment models
were added which allow pioneer ACOs more flexibility in the
speed at which they assume financial risk.
Pioneers must also commit to having greater than 50% of primary care providers meet meaningful use of certified
EHRs for receipt of payments through
Medicare and Medicaid EHR Incentive Programs. Pioneers
must have > 15000 beneficiaries enrolled in original FFS
part A and part B Medicare. Organizations
were selected using these criteria.
Polymerase chain reaction
(PCR) is a method for amplifying a small DNA
sample into thousands or millions of copies. It was
developed in 1983 by Kary Mullis. It uses cycles of
heating and cooling to force DNA melting and enzymatic
replication of the DNA. DNA primers containing
sequences complementary to the target region and heat stable
DNA polymerase are
added. As the process progresses the DNA generated by
the process becomes part of the template causing exponential
Population based payment model
is a per-beneficiary per month payment amount intended to
replace some or all of the ACO's FFS payments with a prospective monthly
are percutaneous coronary interventions which include
angioplasty and angioplasty with AMI.
is patient centered medical homes:
is pathologic complete response.
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Phage Display is a genetic engineering
technique, developed by Dr. George Smith and Dr. Gregory
Winter, where bacteriophages have genes of unknown function
embedded in their DNA, so that the
gene is expressed as part of the phages outer coating.
Modified phages that attached to known antibodies, provided signals about the DNA's
is the pure food and drug act of 1906. After Upton
Sinclair's best seller The Jungle, described the horrific
conditions in the Chicago stockyards, panic at the
exposure of the highly adulterated urban food supply and
President Roosevelt's interest, caused Congress to develop
and pass the act. It was the precursor of the FFCDA.
is the Pharmacy
Health Information Technology Collaborative. It
is Pharmacist/Pharmacy EHR. It
is a EHR functional profile promoted by the PHITC to promote meaningful use of
standardized EHR and jointly developed with HL7.
is a chromosome fragment generated by a mutation copying
bits of chromosome 9 including part of gene BCR and part of gene ABL
from chromosome 22. In the majority of cases of CML Philadelphia chromosome is present
and generates an aways on tyrosine
kinase signalling protein
which causes vast proliferation of white blood cells.
Since the protein is aberrant blocking its production
pathway with drugs such as Gleevec
stop the excessive white blood cell production.
is either a population care registry or polymerase chain
reaction. Population care registries are online
registries of diseases (updated via HL7 interfaces) and
tools: such as Framingham
automatic risk stratification; automated identification of
registry candidates; medical assessments required for
population management (foot care exam, eye
care exam, cardiac risk assessment, asthma)
enhancing the ability of clinicians to care for chronic
disease patients. It may support health risk
assessments. It may report on practitioner adherence
is pre-implantation genetic diagnosis which enhances IVF. After IVF at the eight-cell
stage one cell is removed to perform sensitive DNA testing.
This allows identification of problematic -- or undesired --
characteristics which can be used to screen which embryo to
implant. PGD was initially developed to help prevent
severe recessive diseases: Tay-Sachs,
Fanconi anemia. Then
its use was broadened to include: Cystic fibrosis,
Adult-onset conditions: BRCA1.
in health care is physician group practice a CMS demonstrator program that led to
the promotion of ACOs.
use antecedent reappraisal to stimulate the dlPFC which then inhibits the amygdala's pain
means that a large number of genes contribute a small effect
to an inherited characteristic. Such inherited
characteristics have not been easy to analyze with
family-based genomic testing.
Population Health aims
to segment a patient population by treatment acuity and
patient derived impact to raise outcomes efficiently without
being rejected like the early HMOs.
Small numbers of patients follow life styles which impact
themselves and the health care network very
significantly. Specialized treatment regimens focused
on these high impact patients can improve outcomes and lower
costs for these patients and the rest of the geographic
patient cluster and the health care network.
Population health includes techniques for understanding the
health characteristics of a patient population by leveraging
business intelligence etc. so as to determine the patient
population's health trends.
Pharmacy Kit is a pack of life-saving
medications and equipment that is loaded by the hospital
pharmacy and then deployed throughout the hospital for use
in emergencies by doctors, nurses or care providers.
Once opened the kits are sent back to the pharmacy where
they check the stock replacing used or out-of-date
items. This is time consuming and error prone with the
Joint Commission citing
out-of-date pharmacy kits as one of the most common
citations for non-compliance. Historically on average
20% of these kits have come with out of date
is either population health
improvement or protected health information of an EHR.
is population health
management. It aims to use big
data to extend the EHR
infrastructure to provide cost effective personal
treatment. This implies reengineering the health care
payment and delivery process.
Plasmacytoid bladder cancer
is a rare and aggressive bladder
- IT tools must be developed.
- Administrative structures must be updated.
- Clinical processes must be redesigned and
accepted. Successful workflow process reengineering
will depend on integration with existing workflows and
presence of added value!
- Payment mechanisms must be overhauled ensuring that the
physicians get incented to move on from FFS.
- It must be financed. It is not obvious where this
will come from! Providers like fixed costs.
ROI seems limited atleast initially. Subscriptions
may work for both vendors and providers.
Plasmonics is the coupling of
electromagnetic radiation with nanoparticles that are much
smaller than the wavelength of the radiation. It is an
effect based on the dialectric metal interface between the
medium and the particle. Such particles have
scattering, absorbance and coupling properties that can be
leveraged in sensor development.
Platelet aggregation inhibitors
block the formation of clots and
Clots are usually initiated by the aggregation of
platelets. Clots can be a risk factor in heart attack. The
inhibitors include: Low dose aspirin,
is Practice Management.
is FDA premarket approval. PMA
is the most stringent type of device marketing application
required by FDA. PMA is based on the FDA determining
that the PMA contains sufficient scientific evidence that
provides reasonable assurance that the device is safe and
effective for its intended use(s).
is progressive massive fibrosis, a deadly form of the
coal-mining disease 'black lung'. It is caused by
inhaling silica dust released during mining coal
is Pneumonia in health
Pneumonia is an inflamed lung. It can
be caused by infection with viruses
or bacteria, drugs and autoimmune
diseases. HAP, including
VAP can be very troubling.
is psychoneuroimmunology which studies neuronal control of the immune
- Progressive mulitifocal leukoencephalopathy, a rare but
fatal viral infection that attacks the brain's myelin.
- Promyelocytic leukemia tumor
suppressor gene, DNA which
encodes a protein that
modulates cell growth and division, and induces apoptosis.
is the parieto-occipital area.
is president of the US.
plan is a point of service plan which uses a managed care foundation to
trade reduced choices for lower costs. It combines
aspects of an HMO and a PPO plan.
Powassan virus is a tick vectored flavivirus
disease in humans.
is the pension protection act of 2006. It:
- Requires companies that underfund their pension plans to
pay higher premiums to the PBGC.
- It required the appointment of the PBGC director by the
President of the US, and
confirmation by the Senate.
- Requires actuaries to use projected accrued benefit cost
method (or equivalent) to determine the annual normal
- Makes statutory authority for automatic enrollment in
defined contribution plans.
- Removed the confict of interest fiduciary liability when
giving self-interested investment advice on retirement
- Extends EGTRRA contribution
limits for IRAs and 401(k) plans.
is proton pump inhibitor, which irreversibly block operation
of gastric parietal cells' hydrogen/potassium ATPase, used as a medication: esomeprazole; to treat GERD. They are among the most
widely prescribed drugs in the world.
- Posterior parietal cortex.
Its neurons receive visual,
auditory and somatosensory inputs and are involved in:
- Cognitive intermediaries (encoded as firing rates): Attention, Salience, Decision variables;
of sensorimotor transformations. PPC areas LIP and PRR
are involved in transforming target locations into a
common reference frame.
- Potentially preventable complication
is physician practice management. This consolidation
of PCP practices was partly a
response to Wall Street's capitalization of HMOs and hospitals in early
1990s. As Wall Street switched to financing PPMs,
purchase of Mullikin Inc., hospitals responded by buying up
the PPMs. Most PPMs struggled to control costs in the
capitated care framework of the
1990s. Some of these PPMs shifted to become PBMs.
plan preferred provider organization health plan
allows direct access to any health specialist although there
is typically a network of contracted specialists as opposed
to a HMO health plan.
is the physician payments sunshine act of 2010. It is:
Practice management (PPM) includes the business and
administrative aspects of operating a physician's
- Section 6002 of the ACA.
- It requires pharmaceutical and medical device companies
to release details of payments to doctors and US teaching
Pragmatic trials are
designed to show real-world effectiveness of the trialed
intervention in a broad patient group. They aim to
overcome the problems with ideal trials, which include:
Patients won't participate when they feel one trial arm will
harm them, They will be trapped by the trial agreement, and
will be tagged a failure if they abandon the trail.
Pre-diabetes is a condition where the
subject's blood sugar levels are higher than normal but they
are not yet suffering from irreversible type 2 diabetes. In 2016
the CDC estimates 86 million adults,
including at least 22 million people 65 or older, are
pre-diabetic increasing their risk of heart disease, stroke and diabetes. Doctors
test for pre-diabetes with a blood test: FPG,
with fasting required in the first two. Pre-diabetes
is treatable but only about 10 percent with the condition
are aware they have it. Left untreated, up to
one-third of people with pre-diabetes will develop diabetes
within five years. The YMCA
developed a pre-diabetes
treatment program. People can use a test devised
by the CDC to assess their risk of
Pre-eclampsia is a potentially dangerous
pregnancy complication which includes high blood pressure,
swelling of hands and feet and organ damage. It
typically occurs in the third trimester. Women are at
higher risk with: Hypertension,
Obesity, Type 2 diabetes, and
age. Pre-eclampsia is associated with increased risk of subsequent vascular dementia.
Precision medicine is
the integration of molecular research: genomics, proteomics,
transcriptomics, metabolomics, cell signalling; and clinical data
through a taxonomy based on CAS
modeling overlaid on an information commons.
It aims to support treatment of disease and remove the organ
and symptom based methodological flaws in the ICD. Supporters of the D.S.M. note the aggressive shift to
precision medicine at the NIMH under
Dr. Insel, constrained useful clinical research (Nov
Predictive health analytics
aims to improve patients' healthcare outcomes and contain
costs by using modeling
technology integrating lifestyle information with
patient data and modeling healthcare outcomes. At the
population level the hope is to create a total view by
combining and structuring big data.
Then by segmenting the data at the cohort and patient level
by risk, interventions and programs
tailored to each person can be designed, supported by
coordination. A Shewhart
cycle is then used to iteratively learn and optimize
Pregabalin is 3-isobutyl GABA.
It was developed by Parke-Davis. Parke-Davis was
purchased by Warner-Lambert which was later acquired by Pfizer.
Pfizer markets pregabalin as Lyrica.
Pregnancy sickness is
morning sickness, a universal part of pregnancy. Evolutionary psychology
Premium support is a Republican strategy for
limiting government commitments for Medicare
It includes two key aspects:
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act of 2005 is public readiness and emergency preparedness
act. When the HHS Secretary
declares a public health emergency vaccine
makers are exempted from all liability except for willful
- Subsidy set to a level established by the market rather
than the government following legislative formulas.
This could use the mechanism used by both Medicare part D to set
its drug premium subsidy and the ACA
(Title I) to set its market
place plan subsidies: BCBS
- Capping the growth in subsidies. The current
Medicare subsidy grows at the rate of health care
inflation but premium support may allow the subsidy to
grow at a lower rate. If traditional Medicare
becomes less attractive and loses subscribers to other
types of plan it may lose its influence to set premium
Presenilin is a gene which encodes the APP. John Hardy of UCL followed a
family with a history of Alzheimer's
disease who inherited the gene with a mutation that
Pretomanid is a MDR TB
drug treatment. It is a nitroimidazole. It was
developed by Pathogenesis Corporation but was transferred to
Pricing by indication is
where the price of a drug is linked to the value it provides
for each disease it is being used to treat. Currently
Medicare pricing of specialty pharmaceuticals
is not value based. Pharmaceutical companies can
gather data on the value of their drugs on different tumor
types for example allowing the less valuable treatments to
cost less. The American
Society of Clinical Oncology and the NCCN
are developing scoring methods.
Primary care consists of providing
accessible, comprehensive, longitudinal, and coordinated care in the
context of families and community. Interpreting the
meaning of many streams of information and working together
with the patient to make decisions based on the fullest
understanding of this information relative to the patient's
values and preferences is key to PCP
Prior authorization is a
constraint imposed by some insurance companies prior to
their agreeing to cover some prescribed medications or
medical procedures. The constraint may be due to: age,
medical necessity, availability of a generic alternative, or
to check drug interactions. After a healthcare
provider orders a service for a patient, the provider's
staff will contact the patient's insurer to determine if
they require prior authorization. This should result
in an exception process which may involve the provider's
staff manual faxing a prior authorization form to the
insurer. If the service is rejected, the healthcare
provider may file an appeal based on the provider's medical
review process. It may take 30 days for the insurer to
approve the request.
Private equity is the pooling of commitments
from fund investors, to: buy assets that are not publicly
traded: companies, real estate, and debt; improve their
acquisition's value and sell them again, returning the sale
cash to the fund investors. Private equity companies
gain competitive advantage from being lightly regulated, and
wealth from the fees and special
tax privileges. Private
equity companies were initially corporate
Product-hopping is evergreening of a soon to be
Progeroid syndromes are
rare genetic disorders which mimic aging. They
is an intravenous sedative that
takes effect quickly and wears off within minutes.
When Propofol won the approval of the FDA
in 1989 as an anesthesia drug, it carried a label advising
that it "should be administered only by those who are
trained in the administration of general anesthesia"
because of concerns that too high a dose could depress
breathing and blood pressure to a point of requiring
- Hutchinson Gifford progeria.
- Familial Alzheimer's
& familial Parkinson's
progeroid syndrome, where an inability to deploy collagen
and bone wrinkles the skin prematurely.
is proline-rich synapse-associated protein 2 a multidomain
postsynaptic scaffold protein which connects membrane
proteins to the actin cytoskeleton and G-protein-coupled signalling pathways. It
orchestrates the assembly of postsynaptic density
macromollecular signalling complex. Disrupted mouse
models show autism like behavior.
Prostaglandins are lipid based hormones derived from arachidonic
is a male only gland positioned between the bladder and
rectum. It generates part of the seminal fluid.
It enlarges during puberty to the size of a walnut
stimulated by androgens and the remains stable or grows
slowly with age. The prostate includes several types
of cells including the gland cells that make the prostate
fluid. The Urethra passes through the middle of the
Prostate biopsy is taken with a rectal
probe. It finds cancer
in only 30 - 40% of men with abnormal PSAs.
They can result in infections and can miss more aggressive
cancers because they examine only tiny snippets of the prostate. Research and
development of liquid biopsys
aims to replace and enhance the traditional biopsy. MRI has also been found to enhance
targeting of prostate problems.
Prostate cancer is cancer
of the prostate gland. Genomics detected several common DNA variants associated with increased
risk of prostate cancer. Dr.
Francis Collins explains that a cluster of these risk
variants lies in a stretch of 1 million DNA base pairs on chromosome 8. The
cluster contains seven or more risk variants, each of which
can raise the risk of prostate cancer by 10 to 30%.
The high risk variants occur more frequently in
African-American men than European or Asians.
African-Americans die from prostate cancer at more than
twice the rate of Europeans. Research in mice may
explain a link between obesity
and prostate cancer (Jan
2018). The average diagnosis is at age 66.
Worldwide in 2012 there were 1.1 million cases from which
307,000 died. A common life-saving (Feb
2017) treatment is androgen
deprivation therapy, but it has worrying side
effects. Various classically defined types of cancer
can occur. The most common is adenocarcinoma associated
with the epithelial gland
cells that generate seminal fluid. Epithelial cell
differentiation potency makes these significant cancer
agents. Other very rare types of cancer that can start
in the prostate are:
Proton beam therapy
irradiates diseased tissues, including cancers,
with protons. The particles destroy the DNA of cells they interact with
stopping their reproduction. The powerful control of
the large charged particles allows acute focus and limited
exit dosage. Cyclotrons, synchrotrons and linear
accelerators are used to accelerate and control the
protons. A significant drawback is the cost and size
of the particle accelerator. The therapy is viewed as
- Small cell carcinomas
- Neuroendocrine tumors
- Transitional cell carcinomas