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Let’s see a show of hands. Who among us, doctor, nurse, patient, family member, wants to give or get health care inspired by a factory—Cheesecake or any other?

Anyone?

I didn’t think so.

True confession: I have never actually eaten at a Cheesecake Factory (hereinafter referred to as the Factory). My wife, Mary, and I did enter one once. We were returning from a summer driving vacation. Dinnertime arrived, and we found ourselves at a mall walking into a busy Factory.

It seemed popular. The wait was long—really long. We got our light-up-wait-for-your-table device. We perused the menu. There was a lot there. Portions seemed gigantic. We looked at each other and, almost without speaking, walked back to the hostess, returned our waiting device and left.

You got me—I cannot say 100 percent that I wouldn’t love Factory food. We were so close that one time!

A young woman in our small New Jersey town recently opened a new restaurant here. We tried it the other night. She and her business partner tended us and all the other patrons with such attention and care. We waited some, true, but she seated us near the bar while we waited—brought over pieces of cheese (no light-up device) for us to enjoy. The menu was ample and varied—not enormous. It’s also true that two items on the menu—including my first choice—were no longer available that evening. The chef however crafted the dishes that we did select with flare and pride. Dinner was a delicious, wonderful, relaxing experience—made better because of the human touch.

It’s probably not fair to contrast my one near-Factory dining experience with this other. Big chain restaurants have clearly figured out a way to provide a consistent meal for millions of satisfied customers. But the Factory way is not for everyone. People, I think, crave customized, attention-to-detail service experiences—in their dining choices. And—I’ll go out on a limb—in their health care too.

Continue reading “Big (Box) Medicine”

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Robert Berenson“Not everything that counts can be counted, and not everything that can be counted counts.”

This aphorism has been deliciously, but, alas, incorrectly attributed to Albert Einstein (the saying actually has mixed origins, but credit properly might be given to sociologist William Bruce Cameron, writing in 1963).

But, whatever its provenance, the saying is particularly appropriate in describing the woeful lack of attention paid to the long-standing problem of diagnosis errors in the provision of health care services.

Last week academic researchers from Baylor and the University of Texas published important research estimating that one in 20 adults in the U.S., or roughly 12 million people every year, receive an error of diagnosis—a wrong, missed or delayed diagnosis—in ambulatory care.

This likely represents a conservative estimate of the incidence of such errors in ambulatory care and does not attempt to include inpatient hospital care or care provided in nursing homes and post-acute care facilities, such as rehab hospitals.

The news media correctly decided that this peer-reviewed finding deserved prominent attention—it was a lead story on “NBC Nightly News” and other national news programs.

It seems that attaching a large number to the prevalence of such errors provided the needed news hook to give the problem the attention it has long deserved. Surveys reveal that the public is worried as much about a misdiagnosis or missed diagnosis as any other quality and safety issue in health care.

Autopsy studies performed over time find that unacceptably high rates of diagnosis errors persist; similarly, diagnosis errors continue to represent a leading cause of medical malpractice suits.

But even without newsworthy body counts, the problem of diagnosis errors has been known to clinicians for decades, if largely ignored by stakeholders and policy-makers as a major quality and safety problem.

Continue reading “Placing Diagnosis Errors on the Policy Agenda”

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Figure 1 acaview

With this post, we are pleased to introduce ACAView, a joint initiative between the Robert Wood Johnson Foundation (RWJF) and athenahealth.

2014 marks the launch of the Affordable Care Act’s (ACA) most important coverage expansion provisions, designed to dramatically reduce the number of uninsured Americans. Between now and the end of 2016, millions of individuals are expected to sign up for subsidized insurance coverage through newly established health care exchanges, or marketplaces.

Other tracking initiatives are closely monitoring the number of individuals that sign up for this coverage as well as those that take advantage of expanding Medicaid coverage in some states.

With ACAView, we will take a different approach. We will focus on the provider perspective; more specifically, how the ACA affects the practice patterns and economics of physicians and other care team members around the country. This is also part of a wider effort, Reform by the Numbers, RWJF’s rich source of timely and unique data about the impact of health reform.

ACAView will monitor the impact of coverage expansion on a monthly basis, mining insights from athenahealth’s cloud-based network of more than 50,000 providers and 50 million patients.

athenahealth is a technology and services provider that delivers physicians the tools and support needed to manage the business and clinical aspects of their medical practices. Our cloud-based, centrally hosted software platform provides us with near real-time visibility into practice patterns of physicians around the country.

Our goal is to inform, exchange ideas, and provide a timely, front-row view of how this landmark legislation affects a robust cross-section of providers across the nation. In subsequent reports, we will examine an evolving set of metrics that address a broad range of topics.

We will also share our analyses on the extent to which our providers represent all providers in the US. For more about our data on practices and patients, as well as our preliminary list of metrics, please read our Methodology report.

No Meaningful Change to Date in New Patient Volumes

Among the many unknown questions surrounding coverage expansion is the number of new patients physicians will accommodate. This is a critical issue because one of the goals of health care reform is to allow individuals to form stable physician relationships, rather than seek care in high-acuity settings or forgo care altogether.

If the ACA is working, we would expect physicians to see a higher percentage of new patients over the course of the year. Over the long term, this number should eventually return to historical levels as these new patients become established.

Continue reading “Measuring the Impact of Health Care Reform on Day-to-Day Physician Practice”

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First, let’s get the plug out of the way, shall we? Here’s the deal: The Robert Wood Johnson Foundation has a new initiative, Flip the Clinic—and we want you to join us.

We’re launching the new Flip the Clinic site this week. Here’s the trailer. Please take a look, and then let me know what you think:

So, what’s with all this flipping business?  What’s all this talk about health conversations?

Continue reading “TED 2014: Flip the Clinic!”

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Why should I be in the same room with these people?

That’s one of the many smart questions participants posed at a Stanford Medical School meeting I attended last weekend.  If I had been daydreaming (I’d never do that), I might have thought the question was for me. You see, the participants were a handpicked set of national medical education experts, folks nominally from the status quo medical-education-industrial complex—the very thing we’re trying to change.

You might think that they embodied that dreaded status quo.  I’m happy to report they did not—not even close.  I’m also relieved to tell you that the question (in spite of my paranoia) wasn’t for me. Instead, it was one of many challenges these thoughtful, passionate teachers tossed at each other.

“Why are we in the room?” was a challenge to each other. Why and when should teachers be in the same room with the learners?

When you think about it, that’s actually a central question if you’re attempting to use online education to flip the medical education experience.  It’s also a brave one if you’re a teacher: justify the time you spend with your students.

Continue reading “TED2014: Grandmother Avatar with TB Beckons Medical Education Her Way”

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In writing about OpenNotes last summer, I argued that the practice of sharing clinicians’ notes with patients had moved beyond the question of whether it was a good idea (the landmark study published in Annals of Internal Medicine was pretty clear on that) to questions of how best to implement it.

As more organizations adopt the practice, it’s clear that we’re now in a phase of implementation, and experimentation with different approaches and learning.  Tom Delbanco, MD, one of the project leads, often compares open notes to a drug — it does have some side effects and some contraindications for some people and some circumstances — and we all need to understand those nuances.

To make it easier for health care organizations to offer the service to their patients, the OpenNotes project team has just released a new toolkit.

The toolkit focuses on two challenges:  helping organizations make the decision to implement open notes and helping organizations with all the steps involved in implementing open notes.

It includes a slide deck that lays out the results of the study and makes the case for implementation, a video profile of how a patient and her doctor have used the practice, profiles of the implementations at the pioneering sites, FAQs for clinicians and patients, and tips for clinicians on how to write open notes.

Please check it out and tell the OpenNotes team what you think:  is it valuable? How could it be better?

Continue reading “The OpenNotes Toolkit”

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Since HIPAA entitles virtually all patients to obtain copies of their complete medical records at any time, it is always best to write notes with the assumption that patients may read them.

However, as electronic portals provide patients with easy access to their records, clinicians may feel new pressure to be more mindful about how they write their notes. They may alter their approach to or even omit sensitive information to avoid worrying patients unnecessarily. They may try to balance clinical and non-technical language to avoid confusing patients; they may feel they need more time to write notes that patients can read.

They may be concerned about how patients might choose to share their notes, including posting a clinician’s note on Facebook, medical forums, or other social media.

Most doctors in the OpenNotes study found that they generally didn’t need to change how they wrote their notes. Patients did not expect doctors to write notes aimed specifically at them and were grateful simply to have a window into their medical record.

However, a minority of doctors reported that they changed how they documented potentially sensitive topics. These included mental health, obesity, substance abuse, sexual history, elder, child or spousal abuse, driving privileges, or suspicions of life-threatening illness. These are not new dilemmas, but they gain urgency in an era of shared visit notes.

Recommendations

Unless you believe a conversation might harm your patient, a good rule of thumb is to write about things you discussed with your patients (and conversely, to talk about content you will write about). Many clinicians already follow this practice, and some choose to dictate notes with their patients present.

When documenting sensitive behavioral health issues, we recommend trying to describe behaviors descriptively, rather than labeling them or suggesting judgments. We also suggest highlighting the patient’s strengths and achievements alongside his/her clinical problems. This can help the patient gain a broader context within which to consider his or her illness and tackle difficult behavioral changes.

Continue reading “The Open Notes Toolkit: Writing Fully Transparent Notes”

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As the fashionistas might say, transparency in health care is having a moment. It made the PricewaterhouseCoopers top 10 list for 2014 industry issues, and there is every reason to expect transparency to be very visible this year and beyond.

Without a doubt, transparency is hot.

Despite this, there is increasing grumbling by observers who say that transparency is complicated and hard to operationalize. We also hear that transparency is “not enough” to constrain costs in our dysfunctional system, especially in the face of provider market power.

The word itself invites skepticism, in that it seems to over-simplify and promise a magical solution, as if daylight will provide health care pricing with a glow of rationality.

As usual, the truth lies somewhere in the middle. Transparency can and will provide information about price, quality, and consumer experience that market participants need in order to better understand the health care system and increase its value.

While this information is surely necessary, we have seen many examples of when it is not sufficient. Clearly, transparency is not the only tool that we need.

Here are a few thoughts about transparency issues for 2014.

Transparency tools will hit Main Street.

Increasingly, consumer-facing tools with various kinds information about health care prices are being created, whether it is okcopay or Change Healthcare. These entries join a growing list of transparency tools from carriers or third-party vendors.

The Robert Wood Johnson Foundation’s Hospital Price Transparency challenge, designed to promote awareness of hospital charge data, had a record number of entrant and the winning submissions are downright inspiring. RWJF also awarded grants for research on the use of price data in health care, including a number of studies of promising transparency tools aimed at consumers and providers.

The field is becoming more crowded, and it is increasingly important to determine the optimal way to reach the consumer with price and quality information.

There will be greater focus on the customer experience.

There is no doubt that the customer experience in health care lags behind the rest of the service sector, and consumers are increasingly demanding responsiveness and convenience in their encounters with the medical profession. The growth of evening and weekend hours, email communications with physicians, and patient portals are all harbingers of a new age where medicine is far more customer friendly.

RWJF’s Open Notes initiative allows patients to share notes with their doctors, while the Foundation’s Flip the Clinic program completely reimagines the doctor patient encounter in the ambulatory care setting.

Continue reading “Transparency a Go Go?”

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The developers of  the app Pain Care, the winner of the Robert Wood Johnson Foundation’s Project Health Design challenge two years ago,  have this to say about THCB contributing writer Dr. Leslie Kernisan’s recent post wondering why the winning entries of development challenges have a habit of  disappearing and never being heard from again:

We are the app developer. We are also disappointed with the outcome of the app. But I think we also learned valuable lessons here.

One of the challenges small business facing is the need to rapid prototype and test the market, and then move on to another idea when the previous idea fails to gain traction. That is especially true with grant funded projects — they need to “make money” after the grant ends in order to justify continued development effort.

Pain Care was developed in the early days of mHealth, and it was indeed very physician focused — the reason is that we believe we must engage physicians to look at the data. We still hold that belief. It is a learning process for us. We put in our own money to develop the app, and fortunately, won the developer challenge.

We made the app public after the challenge to “test the market” — so to speak. But, as you know, essentially *none* of the pure app-based “patient journal” has turned out to be a success (let alone a financial success). Our app is no exception. It is enormously costly keep the app updated for all those iPhone, iPad, iOS released every year, as well as thousands of Android devices released since then.

So, the app becomes one of those “outdated” apps in the app store, and I think it is quite obvious to users as well. However, I think the app did contribute significantly to the “science” of mHealth. We now understand much more what works and what not in “patient engagement”. Many other “pain management” apps have since emerged, and many have done a better job than ours. I think that was what RWJF wanted when they challenged developers back then. :)

Today, we do things a lot differently. We no longer release research grant-funded apps to the public. Instead, we run clinical studies to test them in much smaller / controlled groups. We do not attempt to tackle vague “big problems” like general pain management any more — instead, we are much more focused on managing specific diseases that include pain. We are also moving beyond “pure software” and “simple reminders” to engage people in multiple modalities.

All of these would not be possible without the generous award RWJF gave us in picking Pain Care as the winner of one of the first developer challenges.

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If you’re going to get ambitious about your next task, don’t go and talk to normal people about it. You’ll only get normal answers. Get out of your comfortable little world and step into a completely alien one. As we say round here, when worlds collide, transformation happens.

Love that passage from Brian Millar’s 2012 Fast Company piece. (Plus, it gives me the awesome chance to nod to the eccentrics and outliers—like Millar’s dominatrix and tattooed hipster set—and their unlikely importance to pioneering, breakthrough ideas).

Recently RWJF extended another grant to the Khan Academy; this one for $1.25 million.  I say another as we started this health education journey with Sal, Rishi and the Khan team—right after Sal’s outstanding 2011 TED/Long Beach talk. That discussion resulted in a preliminary 2012 $350,000 bet on this great team. We were intrigued by their big idea—and we thought the world might be too.

What’s that big idea again? Just this: an entirely free, utterly fantastic health education for anyone in the world with a computer and an Internet connection.

Potentially crazy? Perhaps. Ambitious? No kidding. But for RWJF’s pioneering work, that’s right where we like to be. We thought there just might be something there. One year later, we are even more convinced. In that time, the Khan team has pushed intensely and hard—creating its new Healthcare and Medicine Initiative basically from scratch.

For instance, with our support, Khan staff have developed about 200 videos now posted on that Healthcare and Medicine Initiative site—as well as their YouTube medical channel. These videos have received about 800,000 views, and the site has over 10,000 new subscribers. Khan continues to work with Stanford Medical School. That collaboration includes developing and posting Stanford Medical School content on the Khan site as well as integrating the online format into traditional medical school courses. Continue reading “The Not Normals Break Through — An Update From the Khan Academy”

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