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Tech Skool

An article in Information Week caught my eye recently . It reviews a new program offered by Texas A&M with support from Dell to help medical students and other healthcare professionals “come to terms with  the ways technology is changing their jobs”. The article, Doctors Can Go Back to Tech School, says Texas A&M will launch its new health technology academy later this year as part of its continuing medical education program.

Now, don’t get me wrong. I’m all for education and career improvement. I’m just not sure that the best way to improve Health IT is to get more physicians trained in IT so they can, as the article suggests, move into IT roles. How about giving full time clinicians who have an interest in improving Health IT some extra support and time so they can help those who work in IT better understand what clinicians need to do their jobs efficiently and safely? How about just a little paid time away from the daily treadmill of patient care to educate IT about the nuances of medicine and clinical workflow? I believe understanding that would do more to help IT deliver better solutions.

Over the course of my career, I’ve been many things. First and foremost, I am a physician. Only a true clinician understands how clinicians think and work. For many years, I continued to practice even when it no longer made a whole lot of sense with regards to my income or available time. I was a biology major in college. I went to medical school and did a residency in family medicine. I never had any formal training in either business or technology. I learned the ropes by doing. It was often trial by fire. I’ve had my share of success as well as a few failures along the way. When I advanced into the role of a hospital CIO and CMIO, it wasn’t because I knew tech. When my then CEO asked me to step into the CIO role, I’ll never forget what he said to me. He said, “I want to put a civilian in charge of the military”, meaning a doctor in charge of a department that existed to serve clinicians and their patients but had become a renegade army running out of control and way over budget.

Continue reading “Should We Send Docs to Tech School?”

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VA Chron

Earlier this month, the U.S. Senate passed a Department of Veterans Affairs health reform bill in response to scandals in patient care at VA centers. The $16.3-billion bill,signed by President Barack Obamaincludes measures that will attempt to overhaul information technology and introduce telemedicine procedures at VA clinics and hospitals.

But who’s going to implement these reforms? Infield Health President Doug Naegele talked with G2Xchange Health Cofounders David Blackburn and Eric Klos to understand how the bill might create new opportunities for health entrepreneurs. 

Can you talk for a minute about how some of the bill’s provisions make room for entrepreneurs?

This bill has a number of specific information technology mandates for the VA that are ripe for innovation. Many of the mandates are a direct response to excessive wait times, the need for information sharing when our veterans access care outside the VA, and the gaming that was done by VA staff to hide wait time issues at VA facilities. Three examples of opportunity areas for entrepreneurs include:

1)     Digital Waiting List – You may have seen billboards on the highway that show the Emergency Room wait time at a local hospital. This is an example of the type of transparency that would permit veterans to monitor the average wait times by facility and type of care.

2)     The VA has 90 days to establish a system to monitor and issue Veterans a “Veterans Choice Card,” which will facilitate the receipt of care from non-VA health providers.

3)     Data for patient safety, quality of care and outcomes must be extrapolated from the existing VA electronic health records (VistA) and published as a comprehensive database within 180 days. This data must be “fed”’ into the HHS Hospital Compare website. Again, transparency is a key driver for the VA.

Continue reading “HIT: How the VA Reform Bill Benefits Entrepreneurs”

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Dear Doctor,

The future is in your hands.

You have the opportunity to make primary care better.

More efficient.
More accessible.
And more affordable.

We know you and other primary care doctors have more responsibilities than ever. But you also have great influence, along with the ability and opportunity to change this country’s health care system for the better.

Primary care is essential to the quality of health care, and we need you now more than ever.

Maneuvering the Minefield

According to research firm Harris Interactive, “the practice of medicine is … a minefield. … Physicians today are very defensive – they feel under assault on all fronts.’’* Harris questions, “how much fight the docs have left in them. Some are still fired up … while others have already been beaten down.’’

Those who feel frustration, anger and burnout say they are squeezed by administrators, regulators, insurance companies and more. They worry about the possibility of a lawsuit that could destroy your career.

The question is: What can be done about it? Some of you may choose to remain in the status quo. Some of you have chosen to retire early or otherwise leave the field of medicine entirely. Yet some of you have said enough is enough and found specific solutions that mark a pathway forward. You sought – and found – specific solutions that mark a pathway forward.

If you’ve rejected the status quo and joined your fellows in search of innovations from other practices that you have applied at home, congratulations. You’re a physician leader who’s doing great things for your patients, your colleagues and yourself. You are undoubtedly more satisfied in your work than before, and you are quite likely providing better care.

Continue reading “An Open Letter to Primary Care Physicians”

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Jeff GoldsmithOrginally published June 6th 2014, back by popular demand. – The Eds

Sometimes big game hunters find frustration when their prey moves by the time they’ve lined up to blast it. That certainly appears to be the case with the health policy target de jour: whether providers, hospital systems in particular, exert too much market power. A recent cluster of papers and policy conferences this spring have targeted the question of whether hospital mergers have contributed to inflation in health costs, and what to do about them.

Hospitals’ market power appears to be one of those frustrating moving targets. The past eighteen months have seen a spate of hospital industry layoffs by market-leading institutions, and also a string of terrible earnings releases from some of the most powerful hospital systems and “integrated delivery networks” in the country. These mediocre operating results raise questions about how much market power big hospital systems and IDNs do, in fact, exert.

The two systems everyone points to as poster children for excessive market power-California-based Sutter Health and Boston’s Partners Healthcare, both released abysmal operating results in April. Mighty Partners reported a paltry $3 million in operating income on $2.7 billion in revenues in their second (winter) quarter of FY14. Partners cited a 4.5 percent reduction in admissions and a 1.6 percent decline in outpatient visits as main drivers. Captive health insurance losses dragged down Partners’ patient care results. Sutter did even worse, losing $22 million on operations in FY13 (ended in December), — compared to a gain of $697 million in FY11 — on more than $9.6 billion in revenues.  A 3 percent decline in admissions led to FY13 revenue growth of 0.9 percent (that is, nine-tenths of one percent), against 7.3 percent in expense growth.

Continue reading “How Much Market Power Do Hospitals Really Have?”

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Apple store NYC

MU stage 2 is making everyone miserable.  Patients are decrying lack of access to their records and providers are upset over late updates and poor system usability. Meanwhile, vendors are dealing with testy clients and the MU certification death march.  While this may seem like an odd time to be optimistic about the future of HIT, nevertheless, I am.

The EHR incentive programs have succeeded in driving HIT adoption. In doing so, they have raised expectations of what electronic health record systems should do while bringing to the forefront problems that went largely unnoticed when only early adopters used systems.  We now live in a time when EHR systems are expected to share information, patients expect access to their information, and providers expect that electronic systems, like their smartphones, should make life easier.

Moving from today’s EHR landscape to fully-interoperable clinical care systems that intimately support clinical work requires solving hard problems in workflow support, interface design, informatics standards, and clinical software architecture.  Innovation is ultimately about solving old problems in new ways, and the issues highlighted by the current level of EHR adoption have primed the pump for real innovation.   As the saying goes, “Necessity is the mother of invention,” and in the case of HIT, necessity has a few helpers.

Continue reading “Why I Am Still Optimistic About the Future of HIT”

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Screen Shot 2014-08-16 at 10.04.17 AMIt’s a seductive idea. We doctors possess knowledge and experience which can not only help people, but can save their lives. We get opportunities to be the right person at the right time to offer the right help that makes all of the difference. It’s one of the greatest things about our profession. It’s also one of its greatest traps.

I’ve heard many doctors refer to themselves as “healers,” as if we have some special power to bring about healing in our patients. This idea confers some sort of a higher status and originates, to some, from a “higher calling” to a more noble life. Again, this is a logical step, in that we have opportunities on a regular basis to help and even save the lives of people. It’s natural to believe that somehow the healing power comes from our touch, or even from our knowledge.

It doesn’t. I am not a healer.

Healing is what the patient does, not the doctor. As a physician, I am certainly one who can help the patient find a faster road to healing, but I don’t heal. I help.

Why am I taking the time to talk about this? Why get stressed out over whether I am a helper or a healer? I think that the belief in doctors as healers causes significant harm to both doctors and patients, and that getting a better perspective about the roles of each will greatly improve the care given. Here’s why I believe this is a topic that needs addressing:

1. Doctors Often Fail at Healing (And Will Always Ultimately Fail)

There are many patient problems that do not get better, despite my best efforts. There are countless pains I can’t remove, and many problems I do not solve. Even when I succeed, the success is always temporary, as a new problem will eventually come back. And if healing is our ultimate goal as physicians, we all are total failures, as all of our patients eventually die. If healing is held as our goal, we fight a losing battle. We are the soldiers in the Alamo, offering impotent resistance to an overwhelming force.

Continue reading “Why Doctors Shouldn’t Be Healers”

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flying cadeuciiHaving the best evidence at hand is vitally important for making health care treatment decisions. But even when the right—or best—information is available, it isn’t always put to use in clinical practice.

Why? Although we are getting better at generating evidence, we’re still not doing a great job of using it.

Our progress in creating a robust pipeline of comparative effectiveness research (CER) is clear. By 2019, the Patient Centered Outcomes Research Institute (PCORI) is expected to receive an estimated $3.5 billion from the PCOR Trust Fund to fund CER. CER is not new, but the investment in PCORI represents a national appetite for a robust and reliable queue of research to overcome one of the greatest perennial challenges in health care delivery—knowing what works, for whom it will work and under what conditions.

CER offers every provider, patient and payer the promise of better care, yet its impact on patient outcomes remains on the horizon, rather than a reality in health care settings today. Why? Research published recently in the American Journal of Managed Care suggests that changes are needed in order to see more consistent translation of research findings into clinical practice. In short, at the moment, we have a hard time using what we learn from CER.

This research examined how major CER studies have impacted care. We evaluated real-world utilization trends before and after a) publication of CER findings and b) the release of relevant clinical practice guidelines (CPGs) from four high-profile CER studies published within the last decade.

The research we examined tells the story. Under the microscope were four major studies, including: PROVE-IT, an examination of cholesterol-lowering treatment strategies from 2004; MAMMOGRAPHY WITH MAGNETIC RESONANCE IMAGING (MRI), a comparison of diagnostics to detect breast cancer from 2004; SPORT a comparison of surgical and non-operative treatments for herniated disks from 2006; and COURAGE, a comparison of percutaneous coronary intervention (PCI) to optimal medical therapy (OMT) for people with coronary artery disease, from 2007.

These studies delved into pressing therapeutic questions, and the findings of each study revealed new thinking in optimizing care for patients. But, despite the shifts in care that could have—or should have—occurred, our analysis revealed no clear pattern of utilization in the first four quarters after publication. Even after the studies were incorporated into CPG, we were not able to consistently find changes in utilization or clinical practice.

Continue reading “How Effective is CER?”

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flying cadeuciiWhat motivates a healthcare executive?

Remember Flower’s Laws of Behavioral Economics? The first two are:

  1. People do what you pay them to do.
  2. People do exactly what you pay them to do.

That is, it’s not general. It’s not “be a good doctor.” It’s more like, “Do lots of complex back fusion surgeries.” What’s more profitable gets done more.

I know that some people say that money has nothing to do with people’s motivation in healthcare, and that’s fine, I totally respect that opinion. You’re just in the wrong section. You want Aisle C, between Dr. Seuss and the Disney fairy tales.

But what about healthcare executives? What gets them more money? What constitutes hitting it into the cheap seats for them?

There are of course lots of compensation surveys. There’s a whole industry of people who do that. But they don’t tie compensation to anything specific. So when someone does a study that does look at correlations, that’s interesting information. One came out a few months ago in JAMA’s Internal Medicine .

Karen Joynt, MD, and her colleagues used 2009 data, so things might be beginning to change now. And they only looked at CEOs, so we will have to speculate whether the same things apply to other C-suite suits.

What did they find? They found great variation in the salaries, with a mean (average) salary of $595,781, a median (half are above and half below) of $404,938). The nearly $200,000 difference tells us that the sample is skewed by a smaller number of really large salaries at the top.

There is nothing surprising in the size of the salaries or their variation. That’s normal for any industry. No matter how much you might think that healthcare is special and different and sacred, it is nonetheless a very big business. In many or most towns, the hospitals and health systems are the biggest businesses in town. A typical suburban three-hospital system might have an annual budget in the $5 billion range.

What correlates with a higher salary? Size.

More beds means a higher salary ($550 for each extra bed, to be exact). Teaching status means $425,078 more — in other words, doubling the median. And most teaching hospitals are much bigger than average. Urban location gets you more, but this is likely also a marker for size, or the cliché phrase “big city hospital” wouldn’t roll off the tongue so easily. High tech gets you more, too. Hospitals with high technologic capabilities paid their CEOs $135,862 more than hospitals with low levels of technology — but this again is likely a marker (a co-variate) for size and teaching status.

Continue reading “So That’s What You Get The Big Bucks For?”

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Is healthcare going to the dogs?  In at least one way, it probably should.

While not often spoken of together, physicians and veterinarians share an otherwise unique position of helping people make healthcare decisions in the awkward and charged space between risk, benefit and cost.  Both share an ethical requirement to provide the information necessary for informed decision making. Before starting a treatment or procedure, patients (and pet owners) need to understand the potential risks and benefits of their care, as well as the reasonable alternatives.

But veterinarians often share some other important information, information that physicians seldom share, or even know – that being: exactly what will it cost.

When our family dog recently became very sick, my veterinarian shared not only about the diagnosis, her recommended treatment, its risks, benefits and the plausible alternatives, but she also provided a detailed estimate of what Cosmo’s care was going to cost me.

Isn’t it crazy that when it comes to our own healthcare, we don’t get the same information?

Continue reading “Informed Consent 2.0″

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John Haughom MD whiteWe need to design a system of health care that optimally meets the country’s needs while also being affordable and socially acceptable. Clinicians should be at the center of this debate if care delivery is to be designed in a way that puts quality of care before financial gain.

This challenge is too important to be left to politicians and policymakers. There is an urgent need for clinicians to step up, lead the debate and design a new future for health care. Placing professional responsibility for health outcomes in the hands of clinicians, rather than bureaucrats or insurance companies with vested interests, must be an ambition for all of us. We need to find the formula that meets the needs of the patients and communities we serve. A sincere collective effort by committed clinicians to design an effective system will lead to a health care system that has a democratic mandate and the appropriate focus on optimizing the outcomes patients and society need.

As clinicians enter the debate, they should keep three things in mind.

Promote the leadership role of clinicians

We need to help politicians and policymakers recognize the role of clinical leaders in shaping a transformed but effective health care system. Clinicians must redefine the debate so that it focuses first and foremost on patients and health outcomes. Cost effective care can and should be a byproduct of optimal care. Accomplishing this will provide a strong common purpose for efforts to address the challenges of designing outcome-based funding structures and improving access to care.

Continue reading “A Time For Revolutionary Thinking”

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Matthew Holt
Founder & Publisher

John Irvine
Executive Editor

Jonathan Halvorson
Editor

Alex Epstein
Director of Digital Media

Munia Mitra, MD
Chief Medical Officer

Vikram Khanna
Editor-At-Large, Wellness

Joe Flower
Contributing Editor

Michael Millenson
Contributing Editor

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