Ashish Jha

In July the investigative journalists at ProPublica released an analysis of 17,000 surgeons and their complication rates. Known as the “Surgeon Scorecard,” it set off a firestorm. In the months following, the primary objections to the scorecard have become clearer and were best distilled in a terrific piece by Lisa Rosenbaum. As anyone who follows me on Twitter knows, I am a big fan of Lisa –she reliably takes on health policy group think and incisively reveals that it’s often driven by simplistic answers to complex problems.

So when Lisa wrote a piece eviscerating the ProPublica effort, I wondered – what am I missing? Why am I such a fan of the effort when so many people I admire– from Rosenbaum to Peter Pronovost and, most recently, other authors of a RAND report – are highly critical? When it comes to views on the surgeon scorecard, reasonable people see it differently because they begin with a differing set of perspectives. Here’s my effort to distill mine.


Paul Levy 1There are few neurologists I admire more than Martin Samuels, chief of service at Brigham and Women’s Hospital in Boston.  So it truly pains me to see him engaging in a convoluted approach to the issue of mistakes.  Read the whole thing and then come back and see what you think about the excerpts I’ve chosen:

“The current medical culture is obsessed with perfect replication and avoidance of error. This stemmed from the 1999 alarmist report of the National Academy of Medicine, entitled “To Err is Human,” in which the absurd conclusion was propagated that more patients died from medical errors than from breast cancer, heart disease and stroke combined; now updated by The National Academy of Medicine’s (formerly the IOM) new white paper on the epidemic of diagnostic error.”

No, the obsession, if there is an obsession, is not about perfect replication and avoidance of error.  The focus is on determining the causes of preventable harm and applying the scientific method to design experiments to obviate the causes.  The plan is, to the extent practicable, implement strategies to help avoid such harm.

[T]here is actually no convincing evidence that studying these mistakes and using various contrivances to focus on them, reduces their frequency whatsoever.

Yes, there is convincing evidence (from Peter Pronovost’s work on central line protocols, for example) that the frequency of errors that lead to preventable harm can be dramatically, and sustainably, reduced.


Martin Samuels“How much of the medicine that you now use, did you learn during medical school?”

My answer may be surprising. It is not the response given to me by my professors, when they were asked similar questions. I recall them telling me that virtually nothing that I was learning in medical school would be correct 20 years later.

I have thought about this since and will reveal my answer shortly, but before I do, we should pause for a moment to reflect on the process of medical education. I will refer here to natural selection as an analogue of this process, a concept that I have adapted from some ideas gleaned from David Dawkins and Susan Blackmore.

Darwinian natural selection is based on the concept that replicators (eg genes, viruses, prions) compete for their locus based on the phenotype produced. In the case of genes, these replications are done with high fidelity, but not perfectly, so that there are a few imperfect copies (mutations) produced, such that there are alternative genes meant for the same chromosomal locus (alleles). It is the competition among the alternative alleles, measured by their phenotypic expression that is the basis of natural selection.   This process accounts for all of the dramatic variation seen in nature, including the present state of the information processing hardware (the brain), but it does not account for more rapidly changing behaviors and beliefs (cultures).


THCB is excited to present “Measured Outcomes.”  This short film featuring Michael Porter and a cast of international experts may be the best discussion of where value-based care is headed that you will ever see.

THCB congratulates underwriter @HealthCatalyst for producing an amazing film.


Susan-Dentzer-For-Post“Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it’s the only thing that ever has,” goes the quotation usually attributed to the late anthropologist Margaret Mead. Today, huddled around conference tablesand hatching ambitious plans, relatively small groups of committed leaders are trying to improve health and transform health care in their communities.

Consider these examples:

  • In California, Live Well San Diegois attacking a tidal wave of chronic diseases and rising costs, and is halfway through a 10-year plan to improve the health and well-being of county residents. More than 100 partnering organizations, including the county health department, are working to halt tobacco use, increase healthy eating, improve access to quality health care, and even make the area more resilient in the event of natural disasters or other emergencies.
  • In Georgia, the Atlanta Regional Collaborative for Health Improvementhas brought together local government officials, philanthropies, health care systems, public health authorities, and others to chart a strategy that could lead to lasting improvements in the community’s health. ARCHI aims to improve quality and save money in health care, and reinvest those savings to raise local citizens’ education and incomes, which are fundamental determinants of community health.
  • In Colorado, the Pueblo Triple Aim Corporation, a nonprofit organization, has worked for the past five years to make Pueblo County the state’s healthiest based on theircounty health ranking(Pueblo ranked among the bottom 5 of the state’s 64 counties when the effort began). The local health department, hospitals, federally qualified health centers, the Pueblo Latino Chamber of Commerce, and other organizations have banded together to fight obesity and unintended pregnancy, and deter unnecessary emergency department use and avoidable hospital readmissions.
  • In Minnesota, Hearts Beat Back: The Heart of New Ulm Project is working to create “a world without heart disease,” starting in the rural communities of New Ulm (population 13,500), Springfield (pop. 2,215) and Sleepy Eye (pop. 3,600). Beginning in 2009, this collaboration of The Minneapolis Heart Institute Foundation and two local health systems launched several initiatives to reduce heart attacks and heart disease. For example,with more than two-thirds of local adults overweight or obese, they launched a media campaign thataims to persuade people to “swap it to drop it” – that is, to exchange sugary sodas for water when shopping in local grocery or convenience stores.


A basic rule of scientific discovery is that the answers you get are only as good as the questions you ask.

That is certainly the case in health care. Traditionally, it has been the sole responsibility of health researchers to develop questions for study that, when answered, can provide reliable and relevant information for patients and clinicians. For the most part, they’ve done an exceptional job, as evidenced by countless discoveries about the nature of disease and remarkable advances in diagnosing, preventing and treating them. But when researchers are the only ones determining scientific inquiry, other critical perspectives can be missed – most notably, the practical, frequent questions asked by patients, caregivers and clinicians about the best choice among two or more for options that are available.

But what if we tried something different – still soliciting the best ideas for studies from the research community but focusing on questions most important to patients, their families, clinicians and other healthcare stakeholders not traditionally involved in the research process? What if we then brought those same stakeholders, plus top scientists, into the room where proposals to study those questions are judged? What if we also sought to make them partners on the research teams that design and conduct the studies and help get the word out on results that could improve care and outcomes?


Screen-Shot-2012-12-14-at-11.05.59-AMA long, long time ago, hospitals existed to admit patients when they were sick, treat them with medicines or surgery and good nursing care, and discharge them after they became well.

Hospital care was at one time a charity, which evolved into a nonprofit service, before it became a Very Big Business.

In olden days, nonprofit hospitals charged patients straightforward fees for their services. Then, when you were just a young whippersnapper or perhaps merely a gleam in your father’s eyes, Medicare and Big Insurance started collecting premiums from workers and dole it out to hospitals when the workers or retirees needed hospital care.

At that point, hospital fees became confusing. The people who received care didn’t see what the charges were, and the payers didn’t really know how much care was medically necessary or even actually delivered by the increasingly profit-driven hospitals, let alone how much it cost to provide those services.


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The NIH (National Institutes of Health) recently released initial results from its SPRINT (Systolic Blood Pressure Intervention Trial) study, suggesting more aggressive treatment for hypertension may reduce risk for cardiovascular events by 30 percent and the risk of death by 25 percent.

The SPRINT group recruited over 9,000 non-diabetic subjects aged 50 or older with systolic blood pressure (SBP) over 130. Individuals were then randomly assigned to either a standard treatment goal of lowering SBP below 140 or a more intensive treatment goal of lowering SBP below 120. The findings were sufficiently compelling that results were released more than a year in advance of the study’s planned conclusion.

While the SPRINT researchers have only released very high level findings, the general sentiment appears to be supportive of releasing this information early as the New York Times Op-Ed by Eric Topol, MD, so rightly notes. However, the lack of detail has generated sharp questions on several issues, including whether a reduction of cardiovascular risk by 30 percent actually translates into substantial numbers of individuals affected, potential side effects of increasing the number of medications, and general caution regarding findings released before peer reviewed publication.


I’m working on a long piece about Sharecare. Today at Health 2.0 my partner Indu Subaiya will be interviewing Jeff Arnold CEO of Sharecare about the progress they’ve made in the 5 years since he launched the company on stage at Health 2.0 in 2010.

Just to give you a little taster, I’m posting an interview with one of Sharecare’s clients and investors, the big Catholic hospital chain Trinity. I think this interview with Bret Gallaway at Trinity will whet your appetite for Jeff today and the longer article coming shortly. But it’s a great story about what is now a major platform for consumer health.


Screen-Shot-2012-12-14-at-11.05.59-AMBack in August, 2015 IBM announced their bid to acquire Merge Healthcare for $1B dollars. (Forbes article here) Merge is a product that helps to manage, store, report, and bill for the medical images of patients as read by Radiologists.   (More here) Today between the 7500 Merge customers they have access to roughly 30 billion images.

The promise for Watson Health is to learn how to “see” through machine learning from the vast amount of medical images that Merge Healthcare manages. Currently, Watson reads 66 million pages a second. It is predicted by IBM researchers that 90% of all “Big Data” stored by healthcare systems is related to medical imaging.

The offer to hospitals, healthcare systems, Radiologists, and ultimately patients is that Watson will be able to have information, including medical images, uploaded to the cloud for analysis. Based on the symptoms and a cross referencing of medical images against images of previously diagnosed medical conditions and diseases, Watson would be able to provide an initial recommendation. (supporting article)