By Angela Hart

The San Francisco Department of Public Health says it is ahead of the curve in rolling out databases that keep tabs on tens of thousands of patients across a citywide network of clinics and hospitals. The rollout is needed not just to make a local form of “universal health care” work, but also to meet a 2014 deadline under national health reform.

And the city says it spent just $3.4 million on new patient-tracking technology. Not bad for an unprecedented charity care initiative whose total budget has grown to $177 million just this past year.

But while clinics and hospitals across the city are now linked up to a common intake tool that eliminates overbilling and duplicated medical appointments, that is only the first step in making the Healthy San Francisco program successful, directors of local health centers and technology experts say.

A separate and much more complex piece of technology — electronic health records — is proving difficult and expensive. Knitting together incompatible computer systems across the 35 medical sites so they can easily share detailed patient medical records could costs the city millions beyond what is included in the official price tag.

An incomplete survey of technology costs borne by the clinics themselves this year reveals spending of at least $15 million in addition to what was budgeted for the whole program, adding at least 8.5 percent to the total cost. But that sum is likely millions higher, since eight clinics could not or would not say how much they spent or were planning to spend integrating their patient records.

The Department of Public Health claims that Healthy San Francisco costs just $276 per patient per year — a real bargain compared with the average for private insurance — at $402. But building something that looks like insurance on top of an established public-private safety net can mask the technology requirements and other hidden costs of reform.

Continue reading “Medical Records Supporting San Francisco’s Universal Care Add Millions to Official Cost”

By Paul Grundy, MD

In the next 10 years, data and the ability to analyze the data will do for the doctor’s mind what x-ray and medical imaging have done for their vision. How? By turning data into actionable information.

For instance, take Watson, IBM’s intelligent supercomputer. Watson can analyze the meaning and context of human language, and quickly process vast amounts of information. With this information, it can suggest options targeted to a patient’s circumstances. This is an example of technology that can help physicians and nurses identify the most effective courses of treatment for their patients. And fast: in less than 3 seconds Watson can sift through the equivalent of about 200 million pages, evaluate the information, and provide precise responses. With medical information doubling every 5 years, advanced health analytic systems technologies can help improve patient care through the delivery of up- to-date, evidence-based health care.

Continue reading “Now you have healthcare data. So where does it go?”

By DAVID SHAYWITZ

Monday’s WSJ (online now) features an exceptionally important and courageous op-ed by Harvard professor (and frequent co-author of mine, although not in this case) Tom Stossel, discussing a rule within recently enacted healthcare legislation with the Orwellian title, “The Physician Payment Sunshine Act,” focused on physician/industry relationships.

Taking its name from the assertion that “sunshine is the best disinfectant,” the Act apparently aims to help disinfect physicians who might be contaminated by industry contact, an interaction the Act seems to assume is intrinsically corrupting — in stark contrast, one suspects, to the many other activities in which physicians engage, and the many other factors in their environment that might influence their behavior, as Stossel and I previously discussed here and here; see here and here as well.

To restore physicians to their baseline state of virginal professional purity, the Act mandates a stultifying series of reporting requirements, impacting amounts as little as $10.  While such reports may be a Pharmascold’s wet dream, they are a logistical nightmare for the physicians involved, and serve to create an enormous compliance bureaucracy for everyone.

My recent experience at an innovation symposium at Duke University, as well as my frequent informal conversations with academic physicians at other leading institutes, suggest the increasing bureaucratic hurdles confronting university physicians seeking to strengthen the essential translational relationship between academia and industry are a particularly unfortunate problem, and are having the presumably intended effect of stifling these interactions.  Young physicians worry that the burdensome requirements are overwhelming, while senior leaders seek desperately to avoid the inevitable media takedowns predictably led by the NYT, public radio,  and the rest of the usual suspects.  (Not infrequently, these stories seem to originate with material selectively provided to a sympathetic journalist by a plantiff attorney — but of course, nothing cozy or sketchy here….)

Continue reading “Demonizing The Demonization Of Physician-Industry Relationships”

By Peter Pronovost, MD

I was reminded again recently of how important it is to sometimes just sit back and listen to what our patients have to say. Every month, as part of our hospital-wide patient safety efforts, I meet with staff and interview patients, seeking to learn how we can improve the care we provide to them.

A young patient shared two stories with me, one telling me how we get it right and one reminding me how we sometimes get it wrong, even without realizing it. She was nervously awaiting a procedure in Interventional Radiology when a nurse sensed her anxiety and called in a child life specialist. The specialists came and significantly helped relieve the patient’s suffering. She listened to the patient, offered a comforting touch, and provided her age-appropriate reading material and Sudoku puzzles, a brilliant though infrequently used intervention. If anything could take your mind off of your illness, it is Sudoku.

What was amazing was that after all the patient had been through―weeks in the hospital, countless procedures, scores of clinicians―what she remembered was the nurse’s act of kindness by caring enough to call the specialist. The patient reminded me that though we can cure disease sometimes, we can relieve suffering always, often with nothing more than a kind word, a gentle touch or a warm smile.

As I listened, the patient, along with her mother, went on to tell me more. They told me how the patient has complex allergies and that her mom knew her disease better than any clinician. They had lived with the disease for a decade. Yet at times, neither the patient’s mother nor the patient felt they were being heard by the doctors. The mom expressed frustration that clinicians often dismissed her concerns and discredited her knowledge.

Continue reading “What I Learned from Listening to a Patient”

By JOHN GOODMAN

Of all the people in the health care system, none is more central than the physician. Fundamental reform that lowers costs, raises quality and improves access to care is almost inconceivable without physicians leading and directing the changes. Yet of all the actors in modern health care, none are more trapped than our nation’s doctors. Let’s consider just a few of the ways your doctor is constrained, unlike any other professional you deal with.

No Telephone. Sometime in the early part of the last century, all the other professionals in our society — lawyers, accountants, architects, engineers, etc. — discovered the telephone. It’s a handy device. Ideal for communicating with clients. Yet even today I find that I can rarely talk to a doctor by phone. Why is that?

The short answer is: Medicare doesn’t pay for telephone consultations. Medicare has a list of about 7,500 tasks it pays physicians to perform. And talking by phone isn’t on the list — at least in a way that makes it practical. Private insurance tends to pay the way Medicare pays. So do most employers.

At a time when doctors feel like they are being squeezed on their fees from every direction by third-party payers, most become very focused on which activities are billable and which are not. And most are going to try to minimize their non-billable time. Continue reading “How Doctors Are Trapped, Part II”

By Michael Schrage

While working away on my laptop at a hotel breakfast, I couldn’t help but overhear the four gentlemen poring over an iPad two tables way. Their intense discussion revolved around rolling out their high-tech prototypes in a medical care complex. Since I’ve written about prototypes and prototyping, I couldn’t help but eavesdrop.

Forgive me.

The foursome represented a mix of medical care complex personnel and what was clearly an entrepreneurial innovator with a potentially high-impact idea. I’ll skip the technical details, but this was clearly a sophisticated group who were both smart and ambitious. The prototypes were their gateways to success. Their debates included whether it made more sense to field one or two more “finished” prototypes or whether they could get more information more quickly by fielding “roughs.” Were “staggered roll-outs” more cost-effective than “staggered builds”? They talked about the need to be able to “patch” quickly and whether their prototypes should optimize particular subsystems or overall system performance. They argued timelines and sequencing for test.

These questions are classic and it’s always fascinating to hear how — and what — decides them. Getting great value and insight from prototypes and pilots is more an art and craft than a science. Successful tech prototyping in health care contexts is particularly demanding.

That’s why the more passionately they spoke, the more nervous I got. Something was missing. Whenever innovators gather, I always listen for what’s not discussed. In almost 50 minutes of detailed discussion (yes, I am that kind of eavesdropper), I heard not a single mention, reference or allusion to the challenge of training the people onsite on how best to use or learn from the prototype. Details of prototype design and roll out were discussed as if the medical care personnel were irrelevant to the process. It reeked of “over the wall” technology transfer. OMG.

Continue reading “Listen to What Innovators Don’t Talk About”

By John Halamka, MD

We’re halfway through the most challenging cycles of chemotherapy, Kathy has lost her hair,  and her fatigue is getting worse but her mood is still very positive.

On Friday January 20th, Kathy received Cyclophosphamide (Cytoxan) 1200 mg, Doxorubicin (Adriamycin)  120 mg and her pre-chemotherapy supportive medications Fosaprepitant 150 mg, Dexamethasone 12 mg and Ondansetron 8 mg.

She tolerated it well.

Her Complete Blood Count shows that her Granulocyte Count has dropped from 6690 to 3610 since the chemotherapy affects her fast multiplying white cells as a side effect of targeting the cancer.   Her hematocrit has fallen from 42 to 32.   She tires more easily but her appetite is good.   Small frequent meals enable her to overcome any GI symptoms.

We’ve been told that the Adriamycin/Cytoxan is the most difficult chemotherapy.  Only two more cycles to go.

The photograph above shows Kathy and me at age 21 in our Stanford graduation photo.  She’s always had long, luxuriant hair, even a waist length braid at one point.

On January 21st, her hair began falling out in clumps.   It was not exactly painful, but felt very odd, as if her hair had not been washed in months and just did not lie on her scalp properly.   In consultation with her cancer survivor friends, she decided to shave it off.    Her hairdresser gave her a “GI Jane” cut realizing that the small hairs left will fall out soon, but in a more manageable and comfortable way.    I seriously considered shaving my head in solidarity, but she asked me not to.

Continue reading “Our Cancer Journey – Week 6″

By Anne Dachel

Reports of autism cases per 1,000 children grew dramatically in the US from 1996 to 2007. Source: Wikipedia.

It’s hard to imagine more chaos in the world of autism than what we see happening right now.  Autism is more and more in the public spotlight.  The numbers are huge and no one can explain them.  Since 2009 we’ve been told that one percent of children have autism.  Among boys alone, it’s almost two percent.  Mainstream medicine can’t explain the stunning increase in a once rare disorder.  For years health officials gave doctors credit for all the autism everywhere.  They said it was the result of “greater awareness” and “better diagnosing.”  Children who were mislabeled as something else were now correctly called autistic.  The criteria for diagnosing autism was laid out in the Diagnostic and Statistical Manual of Mental Disorders (DSM) and a child with symptoms would be placed somewhere on the autism spectrum, as it came to be known.  This included very high functioning autism and Asperger’s syndrome all the way over to the other end of the spectrum to those with severe intellectual impairment and all the signs of classic autism. Continue reading “DSM-5: You’re Still Autistic. You’re Just Weird. You We’re Not Sure About. Call Us Tomorrow.”

By Connie Chen and Laura Montini

Wrapping up the CI Summit with a Health Affairs Chat

By Laura Montini

The Care Innovations Summit wrapped up with a fireside chat, and moderator Susan Dentzer observed that there hadn’t been much discussion about the Medicaid population throughout the day, even though the summit was co-hosted by the Centers for Medicare and Medicaid Services. Dentzer asked Deputy Administrator Director of CMS Cindy Mann how innovation could play into the care of the Medicaid population.

Mann mentioned three major ways: experimentation (with payment rules and service delivery), peer to peer learning and data. Though she mentioned data last, she emphasized it the most.

“We need to be much more intentional about getting the data that we need to see what’s working, what’s not working,” Mann said.

Continue reading “Care Innovations Summit Live Blog”

By Sanjay Bansu, MD

When we say our products are made “in China”, what we really should say it that they’re made in Shenzhen–a city in Guangdong Province, just north of Hong Kong. Shenzhen is one of China’s “special economic zones” (SEZs)–754 square miles of industrial space in which foreign corporations are permitted unique rules and regulations, permitting them to run high-throughput factories that currently use 3.3 million people to make products for the Western consumer market. This is where Xboxes and cell phones come from, produced by Chinese contractors like Foxconn (which makes the new iPhone). There is an unusually high rate of suicide in Shenzhen, and in Foxconn factories in particular; behind these suicides are a broader set of public health issues among electronic workers–from those who make the new gadgets, to those who dismantle them after we throw them away.

From T-shirts to MacBooks–the new sweatshop scene

College students first drew attention to the problem of clothing sweatshops by  demanding that several universities (who raise considerable money from selling sweatshirts and hats to sports fans) put their logo on products manufactured under basic fair labor conditions. They created the Worker’s Rights Consortium (WRC) to enforce codes of conduct among factory workers, which several universities agreed to after mass protests in the 1980’s and 90’s. The industry created the Fair Labor Association (FLA) as a looser alternative. But both groups ultimately contributed to the improvement of sweatshop working conditions in places like Cambodia. While famous New York Times columnists like Nicholas Kristof like to say that sweatshops improve economic growth and are better than starvation, further analysis of the historical and economic evidence suggests that this growth really shifts towards workers (rather than their bosses) when accompanied by stronger labor protections and protests, often facilitated by unions. In China, such unionization has begun to strengthen, in spite of dangerous conditions for their development, given government crackdowns.

Continue reading “Occupational Health In the Electronic Age”