It feels dangerous to write this, but…my practice seems to be working.
I am now running and hiding from lightning bolts, meteors, or stray arrows shot in the air by a Scottish soldier. I am also expecting a raid on my office by the IRS, CDC, and BBC tomorrow morning. I don’t know why I wrote that.
But as afraid as I am to admit it, the thing that was once just a good idea is now actually growing and improving. We are up to about 300 patients (with a big infusion when a local TV network did a story on my practice) and have enough money to pay bills without a visit from uncle bouncy. While we’ve started to discuss when we will hire another staff person (probably a nurse), neither me nor my nurse Jamie (may her name be ever blessed) feel overwhelmed at this point. We can handle this volume, which speaks well for the future when we actually have a fully-working system.
The past few weeks have been totally consumed by my need to have an underlying system of organization. After fighting valiantly against the idea for the first two months, I succumbed to the necessity of building my own IT system and have been seeing the many benefits of that decision. Despite being totally obsessed with how data tables connect and whether I’ve left a parenthesis off of a script I’ve written, I now have a place to put data, have a pretty decent task management system, have an integrated address book, and have discussed integration with my phone system vendor, my secure messaging developer, and a lab order/result integration vendor. I’ve also found some strong local tech talent who gets what I am doing and yet doesn’t simply see the market potential for my software.
The reality is, my whole focus is on the practice model, and that model seems to work. As my business and medical care management systems click into place and become more functional, growing the practice should not be a problem. We continue to get several new patients signing up every day, and now the reluctant spouses of establish patients are joining (which is a very good sign – for both my practice and for their marriages).
Let me appease the gods and state clearly that this is by no means a sure thing. There are many, many things that could go wrong. A successful start-up requires not only a good idea and hard work; it also needs requires luck (or at least to avoid bad luck). I could get cancer, my building could burn down, or our city could be overrun by a mob of psychotic llamas. We all know the llama apocalypse is happening; it’s just a question of when, not if. So I accept the fact that I am, to a great extent, in the hands of the fates (and llamas).
Continue reading “The Doctor Is Happy”
Filed Under: THCB
Tagged: Larry Einhorn, model, practice management, primary care, Rob Lamberts
May 22, 2013
[This post is the third and final part of a commentary on “Medicine in Denial,”(2011) by Dr. Lawrence Weed and Lincoln Weed. You can read Part 1 here and Part 2 here.]
It seems that Dr. Larry Weed is commonly referred to as the father of the SOAP note and of the problem list.
Having read his book, I’d say he should also be known as the father of orderly patient-centered care, and I’d encourage all those interested in patient empowerment and personalized care to learn more about his ideas. (Digital health enthusiasts, this means you too.)
Skeptical of this paternity claim? Consider this:
“The patient must have a copy of his own record. He must be involved with organizing and recording the variables so that the course of his own data on disease and treatment will slowly reveal to him what the best care for him should be.”
“Our job is to give the patient the tools and responsibility to organize the knowledge and slowly learn to integrate it. This can be done with modern guidance tools.”
These quotes of Dr. Weed’s were published in 1975, in a book titled “Your Health Care and How to Manage It.” The introduction to this older book is conveniently included as an appendix within “Medicine in Denial.” I highlighted it this section intensely, astounded at how forward-thinking and pragmatically patient-centered Dr. Weed’s ideas were back in 1975.
Thirty-eight years ago, Dr. Weed was encouraging patients to self-track and to participate in identifying the best course of medical management for themselves. Plus he thought they should have access to their records.
Continue reading “Medicine in Denial: What Larry Weed Can Teach Us About Patient Empowerment”
Filed Under: THCB
Tagged: Diagnosis, Disease Management, e-patients, Evidence Based Medicine, Larry Weed, Lawrence Weed, Leslie Kernisan, Medicine in Denial, patient engagement, Physicians, SOAP
May 22, 2013
As we look back over the past year and some of the amazing medical breakthroughs like wearable robotic devices, genomic sequencing and treatments like renal denervation that are improving people’s lives, it bears reflection on what else we could be doing better. Our world has changed more in the past century than in thousands of years of human history. We not only know more about our biology than ever before, but science and technology are unlocking the secrets of the very building blocks of our health. Somehow, in the midst of this incredible innovation, we’ve gotten fat, and not just a little. The result? Alarming rates of obesity and related chronic disease that threaten to crush us physically and financially.
But is it technology’s fault that we’ve become fat? A recent study by the Milken Institute that tied the amount an industrialized country spends on information and communication technologies directly to the obesity rates of its populations thinks so.
Most of us are guilty of a little overindulgence around the holidays but for many, overindulgence is a normal way of life. As economies transition to more sedentary, the physical movement that burned calories and kept us fit simply does not occur. Our lifestyles compound the issue — dual-income homes rely on the convenience of packaged meals, and our leisure activities have shifted to heavy “screen time” with movies, games and social media.
Continue reading “Is Technology Making Us Fat?”
Filed Under: THCB
Tagged: Diabetes, mHealth, Microsoft, Neil Jordan, Obesity, prevention, Tech
May 22, 2013
There has been a lot of controversy in health policy circles recently about hospital market consolidation and its effect on costs. However, less noticed than the quickened pace of industry consolidation is a more puzzling and largely unremarked-upon development: hospitals seem to have hit the wall in technological innovation. One can wonder if the two phenomena are related somehow.
During the last three decades of the twentieth century, health policymakers warned constantly that medical technology was driving up costs inexorably, and that unless we could somehow harness technological change, we’d be forced to ration care. The most prominent statement of this thesis was Henry Aaron and William Schwartz’s Painful Prescription (1984). Advocates of technological change argued that higher prices for care were justified by substantial qualitative improvements in hospitals’ output.
Perhaps policymakers should be careful what they wish for. The care provided in the American hospital of 2013 seems eerily similar to that of the hospital of the year 2000, albeit far more expensive. This is despite some powerful incentives for manufacturers and inventors to innovate (like an aging boomer generation, advances in materials, and a revolution in genetics), and the widespread persistence of fee for service insurance payment that rewards hospitals for offering a more complex product.
Technology junkies should feel free to quarrel with these observations. But the last major new imaging platform in the health system was PET , which was introduced into hospital use in the early 1990’s. Though fusion technologies like PET/CT and PET/MR were introduced later, the last “got to have it” major imaging product was the 64 slice CT Scanner, which was introduced in 1998. Both PET and CT angiography were subjects of fierce controversy over CMS decisions to pay for the services.
Continue reading “Hospitals’ Twenty First Century Time Warp”
Filed Under: THCB
Tagged: Costs, device regulation, EHR, Hospitals, Innovation, Jeff Goldsmith, market consolidation, Tech
May 21, 2013
Monday’s massive tornado ripped through Moore, a suburb of Oklahoma City, devastating homes and businesses and killing at least two dozen people. The disaster came just over a month after an explosion at a fertilizer plant devastated the town of West, Texas, killing 15 people and injuring some 200 others. Just two days earlier the bombings at the Boston Marathon left three dead and more than 260 injured.
Three mass mass-casualty events occurring in three very different settings show that disaster preparedness should not be limited to large cities or “target” areas in the United States. One trait that is common to all such events—whether urban, suburban or rural—is the need for coordinated, responsive trauma care for victims.
Boston had an advantage over the rural community of West in that seven hospitals, including facilities with readily available, highly specialized trauma and burn care, were in close proximity to the site of the blast. In contrast, the majority of casualties in West had to be transported to hospitals in Waco, 20 miles away. The main receiving facility, Hillcrest Baptist Medical Center, is a hospital with trauma care capability. Other victims were treated at Providence Hospital, which is not a trauma center, and Scott & White Memorial and McLane Children’s Hospital in Temple, Texas, about 50 miles away. Several patients were transported as far as 75 miles to Parkland Hospital in Dallas, the closest facility with burn and highly specialized trauma units. Most of these victims had traumatic injuries. In the case of Moore, the tornado inflicted significant damage to Moore Medical Center, requiring 145 casualties, including 45 children with minor to severe injuries, to be taken to other area hospitals in and around Oklahoma City.
Continue reading “From Boston to Oklahoma -Lessons for the Regional Trauma Response System”
Filed Under: THCB
Tagged: disaster preparedness, Emergency Medicine, Mashid Abir, Rand, Regional Trauma Centers, Stewart D. Wang, The States, Trauma Response
May 21, 2013
What if the next time you step into your doctor’s office for an examination, she reaches into her white coat pocket and pulls out an iPhone instead of a stethoscope? That’s the idea behind The Smartphone Physical, a re-imagination of the physical exam using only smartphones and a few devices that connect to them. These include a weight scale, blood pressure cuff, pulse oximeter, ophthalmoscope, otoscope, spirometer, ECG, stethoscope, and ultrasound. Want to know more? I’ve answered some questions here for THCB. And have a few myself.
What are the pros and cons of using smartphones for clinical data collection?
Smartphone penetration in virtually every market has exceeded expectations, and healthcare is no exception. More than 80% of physicians in the US have smartphones, and of those three-quarters use them at work. Much of this is currently personal communication, but increasingly physicians are using smartphones as reference tools; between 30-40% report using their smartphones for clinical decision support. It seems like a logical next step to go beyond reference apps and to start using peripheral devices, such as cases that convert the smartphone into an ECG or otoscope as well as peripherals such as pulse oximeters and ultrasound probes, for easy and reliable data collection.
At TEDMED we found that using our smartphones and the clinical devices actually improved our ability to engage with the “patient,” because we were able to share and explain the physical exam findings directly at the point of care. We could take a quick snapshot of the carotid arteries and tympanic membrane and, for the first time ever, show the patient what theirs looked like and field any questions they may have. Ideally in the near future we’d be able to go one step further and upload this data to the patient record. That is one of the most powerful aspects of the Smartphone Physical because we will be able to establish baselines for individuals. For example, instead of the current model of a primary care ophthalmologic exam, where a physician will write “W.N.L” or “unremarkable” for a patient without a concerning optic disc finding, we will be able to take and store an actual image of what the patient’s optic disc looked like at an earlier time-point. This may be particularly useful for patients who present years later with concerning visual changes.
Furthermore, smartphone-based collection of clinically-relevant data will help patients become their own data collectors. This may abstract away the mundane and standardize the unreliable aspects of the physical exam, and allow for trending data that needs to be taken in context and not just at once-yearly visits (e.g. blood pressure, temperature, etc).
Continue reading “The Smartphone Physical”
Filed Under: Tech, THCB
Tagged: Apps, mHealth, Screening, Shiv Gaglani, Smartphone Physical, TEDMED 2013
May 20, 2013
Years ago, as a family physician in Louisiana, I made house calls. Certain patients were too sick or too hurt to get to my office. Sometimes a condition or injury had worsened, requiring my evaluation bedside. I would visit patients at home for the simplest of reasons: home was where they needed care.
By the mid-1980s, the pressures of time and money prevented most physicians from making house calls anymore. But I kept seeing patients at home until I retired from my practice after 29 years. Home visits enabled me to better detect, diagnose and treat most health conditions. Many of the patients I saw might otherwise have wound up in an emergency room and eventually been admitted to a hospital.
If we hope to rein in health care costs and improve quality, we need, in effect, to bring back the house call. Americans are living longer than ever before and a higher percentage of the population is elderly, with both trends sure to accelerate drastically in the decades ahead. Baby Boomers are now turning age 65 at the rate of roughly 10,000 per day.
As the older demographic expands, so, too, does the number of people who live with chronic diseases, chiefly diabetes, high blood pressure and heart failure. About three in four of Americans age 65-plus suffer from more than one such chronic condition. The single biggest and fastest-growing contributor to healthcare costs is chronic disease. That’s why an estimated, 49% of our health care costs go toward 5% of Medicare beneficiaries.
Yet the U.S. health care system is still based on a massive misconception: that health care for the sickest of the sick, typically the elderly and the chronically ill, should be carried out almost exclusively in institutions, primarily hospitals, but also nursing homes and assisted living facilities. And that health care delivery should consist largely of, say, a trip to the emergency room or a four-day hospital visit for pneumonia. That kind of episodic engagement represents short-term thinking. When it comes to health care, hospitals are essential, but are only a part of the answer.
Continue reading “Bringing Back the House Call”
Filed Under: Physicians, THCB
Tagged: Home Health Care, Hospice, Long Term Care, Michael Fleming, Patient-centered care
May 20, 2013
This summer, Tufts University School of Medicine’s Health Communication Program will be offering the 2013 Health Communication Summer Institute.
The Institute will feature three professional development courses, described below.
Mobile Health Design examines the impact and potential of mobile devices for consumer health at a national and global level. The focus of the course is on how to design evidence-based health apps that incorporate mobile user experience, predictive analytics, and big data to help people achieve their health goals. The online course runs May 22—June 26, 2013.
Health Literacy Leadership Institute is for those working to improve patient-provider communication and healthcare quality, and those working directly with patients or adult learners in educational settings. Participants work on curriculum development projects of their choice resulting in final products that are comprehensive, informed by research, and reflective of best practice. The course is offered June 10-14, 2013 on Tufts’ Boston Campus.
5th Tufts Summer Institute on Digital Strategies for Health Communication covers how healthcare and public health organizations develop and implement digital strategies to drive the success of their online presence, with a focus on how to use web, social media, and mobile technologies to reach a target audience. The case study is Massachusetts Medical Society. The course is offered July 14-19, 2013 on Tufts’ Boston campus.
Filed Under: THCB
May 18, 2013
Last week, CMS unilaterally released chargemaster data from 300 hospitals around the country. As David Dranove summed up well in his recent piece, this is an old hat. Yes, there are big variations in hospitals’ chargemasters. And yes, there is a lot of buzz around consumer price shopping.
A Kayak for hospitals is all well and good, but hospitals are cash-strapped as it is and there is only so much money to be saved by driving down the costs the hospital charges the health care plan unless the waste within the hospital is addressed. I would like to highlight perhaps one of the most exciting things going on under the radar in US healthcare today: using price transparency data within the hospital.
Hospitals are now reimbursed a capitated amount according to each patient’s diagnostic-related group. Capitated payment means, essentially, that the hospital receives a set amount of dollars for each patient that walks through its doors with a given diagnosis — say, $X for a patient with pneumonia or $Y for a patient with MI. Regardless of how many drugs, tests, or scans the hospital uses for the patient, it will still get the same compensation from the insurance company.
Yet, the physician up until now still acts as a kid in a candy store, running up a bill without awareness of cost or value. This is largely because the doctor is ordering from a menu without prices. I have talked to many physicians, in both out-patient and in-patient settings across seven health care systems around the country — they want a menu with prices.
I have seen firsthand the motivation for this, as pay-for-performance model is beginning to take over with my own practice. Gone are the days where doctors’ salaries are unhitched to the cost-effectiveness of care. Everyone is now in the same boat.As a neurologist, I want to share a few examples regarding stroke care that illustrate the potential savings available from educating physicians regarding cost, and also some pitfalls to avoid that could compromise patient care.
Continue reading “Using Price Transparency Data Within the Hospital”
Filed Under: THCB
Tagged: Costs, David Halpert, Hospitals, pricing data, Transparency
May 16, 2013
“Why is Wal-Mart speaking at a health care summit?” the company’s vice president for health and wellness, Marcus Osborne, rhetorically offered up at a conference back in January.
“Wal-Mart’s in retail, we’re not in health care.”
But as analysts, researchers, and other experts who spoke with me. took care to point out, Wal-Mart is in health care, and getting further entrenched by the year. In the past six months alone, Wal-Mart launched a major contracting initiative with half-a-dozen major hospitals, and dropped hints — since retracted — that the company is exploring new services like a health insurance exchange.
Notably, Osborne teased a broader health care strategy for Wal-Mart that would include “full primary care services over the next five to seven years,” in a Q&A at that January conference captured by the Orlando Business Journal.
Wal-Mart has since denied Osborne’s comments — the second time in about 18 months that the company has had to walk back stories about its planned primary care services — and Osborne subsequently stopped talking to the press. (Wal-Mart declined to comment, and Osborne did not respond to an interview request for this story.)
But Osborne’s remarks from that January conference, and his other archived speeches, are still readily accessible. And they paint a vivid picture of a company that’s not just a potential market-mover and disruptive innovator, but an organization that could do a lot to positively reform health care.
Background: Wal-Mart’s Growing Role in U.S. Health Care System
In many ways, this isn’t a new story. Back in 2007, Princeton University’s Uwe Reinhardt suggested to NPR that Wal-Mart could be “taking aim at the entire health care system” by expanding its new discount drug program.
“I think it’s a really fascinating way to come out of the corner and really slug the system,” Reinhardt said at the time. “At the moment, the body blows don’t hurt. But they add up. I’m watching this with great fascination, and expect more from them.”
And in subsequent years, Wal-Mart did grow its health care footprint, from launching retail clinics based within its stores to advocating for national health reform. Considering its history — as recently as 2005, Wal-Mart had little involvement in the health care market and was being pilloried for skimping on its own employees’ benefits — it’s been a significant turnaround for the firm, and has positioned Wal-Mart as one of the leading disruptive innovators in health care. Continue reading “Wal-Mart Could Transform Care–But Does It Want To?”
Filed Under: THCB
Tagged: Access, Affordable Care Act, Dan Diamond, Quality, Retail Clinics, Walmart
May 15, 2013