By now I am sure most people are aware of this but if not, the Meaningful Use Final Rule came out yesterday. Here is one initial, brief take on the changes from the Interim Rule pertaining to immunizations:

http://www.ofr.gov/OFRUpload/OFRData/2010-17210_PI.pdf

• A subtle but important change is that the recipient of transactions is omitted (the immunization registry) from the criterion language. This is supportive of submission through the intermediary of a Health Information Exchange (HIE)
• Both HL7 2.3.1 and 2.5 are still included as standard ways to submit data.
• Providers doing direct data entry into immunization registries will qualify under this criteria.
• Inclusion of HITSP and C32 (CCD standard) is added to Meaningful Use

Details below:

Omission of Recipient

See Interim vs. Final text below, copied from table on page 90. We see this as an important technical clarification that emphasizes that certification is on the EHRs, not on the Immunization registries. Also, by clarifying that certification is on the submitter side, it suggests support for Immunization registries that receive or might in the future receive data through intermediaries such as Health Information Exchanges (HIEs). For me, the previous language was unclear and could have suggested that interfaces have to be point-to-point two-party transactions.

§170.302(m) - Submission to immunization registries Meaningful Use Stage 1 Measure Certification Criterion

Interim Final Rule Text:

Submission to immunization registries. Electronically record, retrieve, and transmit immunization information to immunization registries in accordance with: (1) One of the standards specified in §170.205(h)(1) and, at a minimum, the version of the standard specified in §170.205(h)(2); or (2) The applicable state-designated standard format. Capability to submit electronic data to immunization registries or Immunization Information Systems and actual submission in accordance with applicable law and practice Performed at least one test of certified EHR technology's capacity to submit electronic data to immunization registries and follow up submission if the test is successful (unless none of the immunization registries to which the EP, eligible hospital or CAH submits such information have the capacity to receive the information electronically)

Final Rule Text: §170.302(k) Submission to immunization registries. Electronically record, modify, retrieve, and submit immunization information in accordance with: (1) The standard (and applicable implementation specifications) specified in §170.205(e)(1) or §170.205(e)(2); and (2) At a minimum, the version of the standard specified in §170.207(e).

Direct Data Entry

It appears providers doing direct data entry into an IIS *will* meet this criteria. This was not previously clear, and seems to be good news for early adopter providers who already use data entry screens. Here is a quote:

Comment. “One commenter recommended that we revise the certification criterion combined with associated standards to state “For the purposes of electronically submitting information to immunization registries Certified EHR Technology must be capable of using a certified EHR module or portal provided by a state immunization registry which is capable of submitting and retrieving coded immunization information or capable of using HL7 2.3.1 or HL7 2.5.1 as a content exchange standard and the CDC maintained HL7 standard code set CVX—Vaccines Administered as the vocabulary standard.” The basis for this commenter’s suggestion was that providers in its state link to the state’s immunization module through EHRs and that all immunization data are stored immediately in the state’s registry. The commenter further clarified that since the data resides in the state registry natively, there is no need to transmit this information.”

“In light of this commenter’s suggestion, we have revised the certification criterion to replace the word “transmit” with “submit” to better align this certification criterion with the meaningful use objective and measure. We believe that submission of immunization data would encompass this commenter’s existing method.”

Inclusion of C32

Page 154
“We also agree, that the HITSP C32 (version 2.5) implementation specification for CCD would be appropriate to adopt….”

-Alean

I now am ready to return to  Paul Hamm's web site to see how his recovery went.  I find a video of his amazing workouts, posted just three weeks and one day after surgery.  Since I am three weeks and two days from surgery, I find this very inspiring!

I am working on ways to reduce atrophy in my right forearm and upper body generally.  Prior to the accident, I could do about 3 pullups in a row and a maximum of about 12 in one workout before failing.  Now I can barely open a refridgerator with my right hand!

I received clear instructions from Dr. Gelb not to bear weight on the metacarpal until 4 weeks. I go to tell my crossift coaches that I simply will not be back for a couple of weeks.  However this just doesn't feel right, so I go into the gym at a time when no one else is there, and see what I can do.  I push the envelope on Dr. Gelb's tacit agreement that I could exercise with a light bar with only the thumb and forefinger  I can actually push or lift 15 lbs with two hands with only a thumb and forefinger.  I can do multiple reps of overhead presses and sumo deadlift high pulls this way.  By also using my shoulders to bear the weight, I can do front and back squats with a 30 lb bar.  I used to do this with over 100 lbs! but now am greatful to be able to do anything that could possibly make my muscles sore .

The next day, the swelling could possibly be slightly more but I can't really even say that for sure.  I decide my mini-upper body workout is probably okay.

I dive into my textbook on healing fractures.  It is full of technical terms I don't understand like "anatomical" and "callus".  But I still get a lot out of it.  I understand for instance that fractures can and do actually heal even if the bone segments aren't brought into perfect contact as in surgery.  This explains why Dr. Gelb said he considered not doing surgery on my hand, although I feel certain it was necessary.  I understand that, even though the bone may bear full weight at 8 or 12 weeks or whatever, in fact the healing process is not fully complete for several years.  Biological changes still take place.  Finally, I see that all the drawings show swelling around the healing area.  So, as I first began to suspect, and Dr. Gelb confirmed, the swelling of a fracture site is part of a natural process, and no matter how much care you take, it cannot be fully brought for quite a few weeks.

I also see that of all the methods of immobilization (i.e. cast, pins, and tiny screws like I have), weight bearing is "delayed" for me.

Why do I need to understand all this?  Do I not trust the doctor?  On the contrary - I have followed his instructions to the letter - pushing the envelope with the thumb-and-forefinger lift question notwithstanding.  

It helps me fill in the margins of my therapy if I understand a little about the process.  Just enough to be dangerous?  Possibly.  But, for instance, it helps to know that waiting until summer instead of two months to return to surfing might make sense, and continuing nutrition measures for a long time, up to two years, might also be a good idea.

I also see in many places in literature that osteoporosis is a risk factor for fractures.  Given family history, I ask Dr. Gelb about a bone density scan, and he orders one.

Another x-ray is taken.  Dr. Gelb "could not be happier" with the healing.  WHEW.  I am relieved given the risks I took in delaying therapy by my extensive search for the right therapist, and by my aggressive approach to returning to workouts and activity.  I feel validated in my "throw the book at it" approach to taking care of myself during healing.

One question I asked was:  Can I let pain and swelling be my guide in returning to activity?  and Dr. Gelb said "Yes". 

Never since the surgery did I have any real pain.  I did have some swelling after activity, but I also learned ways of controlling it.  I feel that the combination of having an outstanding surgeon, of having strong wellness habits before the injury, of a support system of healers and therapists, and of simply making the effort, lowers that curve of tension between the immobilization requirements of bone healing and return to activity.  By firmly immobilizing the fracture with three screws, Dr. Gelb gave me a little more safety against any excesses of activity.  Perhaps this opens up bandwidth for earlier return to activity than current hand therapy protocols allow?

I now know what I need from therapy.  I have worked on my own all around the edges of resuming activity.  I reason that if I can return to some portion of my life, my hand will be active (up to its limit) all day long, typing, playing piano, and so forth.  This has to be better than stopping 5 times a day to exercise the hand and staying immobile the rest of the time.  Each day, I have introduced something new.  At the end of the day, my hand is tired.  I know from Crossfit that recovery is just as important as exercise, so I take time each day for rest.  I have continued my special dietary adjustments, supplements and herbs.

Still, the 4th finger is extremely weak.  I cannot lift it to stretch my hand flat - it droops.  Range of motion of that finger does not equal the other hand, although range of motion of other fingers and my wrist seems normal.  I now know what I need from therapy.

I meet my therapist, Erin Olson, of Healing Hands (an auspicious name!).  The fit is right.  She's a triathlete and so understands my need to push the envelope physically.  We discuss many subjects including:

• all my many questions
• reducing swelling
• condition of the rest of the body including arms and shoulders
• specific exercises for the injured finger

We make a list of questions for my next surgeon's visit.

Still, I am concerned about the weakness of that finger, continued swelling, and lack of range of motion.  What is my prognosis?  I find a scientific publication on a study about recovery when metacarpal fractures are immobilized with miniature screws (as was mine).  I pay $34 to get a copy.   I find that prognosis is good - the vast majority of patients studied made a complete recovery.  This strengthens my attitude.

I also want to know more about hand fractures generally.  I find a textbook on fracture treatments and order it using expedited delivery.  It costs $79 plus shipping.

Pushing the envelope again!  This time I try a little upper body.  I try ring rows with an assist of grips on my wrist, which I theorize does not involve the hands.  Wrong!  This hurts.  I back off.

I also try pushing a 15-lb bar overhead multiple times using my immobilizer (splint) to balance the bar.  This seems fine.

I don't recommend these types of experiements without the involvement of a therapist and the doctor!

I wake up wondering if I can play piano yet.  Lo and behold - I am able to do simple pieces such as Christmas carols.   More complex pieces - such as Chopin's Prelude in B Minor, which carries the melody in the left hand and uses the right hand for the haunting chord sequences - strain and hurt.  Piano requires lifting (the 4th finger onto black keys) and splaying the fingers.  I back off the harder pieces.

I am excited to see the progress.  On Tuesday, I could not do this.

Today is the all-day Christmas meditation.  The usher finds me a seat next to a shelf where I can prop my arm to the level of my heart.  I pass 8 hours with no discomfort at all.  I'm on an enzyme fast. 

Swelling is greatly reduced.

I thnk I overdid it yesterday.  Hand swelling is really increased.  I'm in a panic.  I now take what I read on Paul Hamm's site extremely seriously...

With the help of my understanding coaches, I returned to a U.S. Crossfit workout.  Ahhhh!  did it ever feel good to get that heartrate up!  Coach Alex had a special abs and legs workout for me - no Olympic lifts for me for awhile.  However I found that I could practice clean-and-jerks with a PVC pipe (which doesn't weigh anything). 

Still, I think I might have overdone it.  See tomorrow's entry.

I continued my search for the right approach to therapy.  Actually, my surgeon directed me to several hand therapists, all of whom I interviewed (I understand that hand therapy and physical therapy are not the same).  I nevertheless felt that, while the people I spoke with were obviously qualified, that they probably had similar training and followed the same fixed protocols.  I wanted to push the envelope, and throw all possible resources at healing.   I was looking for a fresh approach. 

I started Google-searching.  It turns out that Paul Hamm, the American Olympic gold medal gymnast, had the same fracture I did (4th metacarpal right hand) 11 weeks before the Beijing Olympics.  His case was well-documented.  I read with interest. 

I learned that reducing swelling so as to achieve full range of motion as early as possible was key.  I was interested in what techniques he used to return to training while the hand healed.  I sent email inquiries.

I do not come into this with a good impression of physical therapy.  I have limited experience:  the main one was helping my friend during recovery from an aortic dissection and open heart surgery.  I saw physical therapists get him out of bed during rehab and walk him through a bunch of fairly simple exercises.  I thought - that's it?  That's physical therapy?

My first visit to the hand clinic did nothing to change my mind.  I was given a number of exercises which more or less resembled the movements I had been doing on my own as healing permitted while my cast was on.  In addition, the splint that was made for me was more restrictive than the one that I woke up from surgery with.  All my alarm bells went off.  I decided to look further for physical therapy options.

Physical therapy is one area where I suspect (but really don't have enough evidence to know) that healthcare costs could be cut.  I am sure it is expensive to be walked through multiple times per week through exercises that an active, vigilant patient could probably do on his own. 

In addition, I sensed that protocols were fairly rigid and not highly tailored for the individual patient.  My surgery was very clean and successful - does that not change the equation for activity a week after a surgery?  I felt ready to return to activities like typing, and didn't want to be overly restricted by an immobilizer.  And why did the exercises I was given treat all five fingers the same?  I get the feeling there is one treatment plan for all patients.

Electronic medical records:  I again gave my medical history two more times.

The cast came off, stitches out and a further x-ray done. 

Very satisfactory!  No pain, finger straight again, nothing sticking out (like a pin or anything).  The surgeon still can't believe he got three screws in there .  I am thrilled because I have figured out by this time that this is going really well.  When you break something in your right hand, you know you are in trouble, and you just hope God, your efforts, and your medical team can get you out of it.

I begin collecting advice and recommendations from healers I know - my chiropracter sister Jocelyn, nutritionist friend Janelle, therapist friend Hilary.

Diet:  eat 3 times the protein

Nutrition:  increase Vitamin D and calcium supplements

Herbal remedies:  arnaca, a homeopathic remedy

Exercise:  I have always seen dramatic healing results from simple, hard exercise. I believe this is due to increased blood flow and the physical effects of more efficient circulation.  I can't do much but take walks and climb stairs at the beach bluffs.

To set the bone.  Dr. Gelb inserted three microscrews to hold the bone in place.

I was very lucky to have Dr. Gelb.  I have since understood that hand surgery is a rare skill and hospitals sometimes have difficulty covering demand.  I was so tardy getting in for an Xray that he had to clear his calendar to do the surgery the next day.  He was hoping to insert two screws but gave me the news when I woke up that happily, he managed three.  Three helps immobilize the fracture especially against torque. 

I also had almost no pain.  I took three Tylenol that night but never picked up my pain prescription.  By the next morning, I had no pain at all.  Since the surgery, I have not lost one hour's sleep to pain or discomfort.

A hand fracture is a race between the opposing requirements of immobilization and return to movement.  If too much immobilization, range of motion and hand function may not return fully.  If too much movement, the healing of the fracture may be disrupted.

Thus, I believe a very clean surgery changes the equation between these competing forces and allows for quicker return to functionality, and a better prognosis. 

BTW, speaking of electronic medical records - I had to give my medical history two more times.

To my complete shock, an x-ray revealed I had broken my 4th metacarpal bone (that's the one that joins your finger to your wrist) in my surfing accident nine days earlier.  The x-ray also revealed that the bone was separated and rotated.  My finger did not line up completely with the others, and the knuckle was depressed.  Surgery to set it would be required.

How is it possible I waited nine days to find this out?  It is evidently common to not realize a metacarpal has been fractured.  Paul Hamm, Olympic gymnast, finished his parallel bar routine after a similar injury.  I had had no prior fractures.  There was no immediate swelling, although it did swell that night.  In no way did I feel the injury warranted a trip to the Emergency Room on a Saturday!

I called an orthopedic practice for an x-ray on Monday but couldn't get an appointment until Wednesday.  By then, the injury was so improved that I really thought it was nothing.  I tried to feel this out with the appointment scheduler, who could of course give me no advice.

An immediate Google search, and/or a trip to an urgent care facility, maybe even a storefront clinic, would have easily set my misconception straight! and saved me nine days delay in getting treatment.  Either the depressed knuckle (which I noticed) or the misalignment of the finger (which I did not) would have pointed to a fracture.  I later easily found this information on a short Google search.