Friday, July 20, 2018
Blog Page 4

The EBM Wars: Manufacturing Equipoise (Part 1)

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By ANISH KOKA

The phone rings.  It’s not supposed to be ringing.  It’s 2 am.   The voice on the other line is from an apologetic surgery resident.

Resident: There is this patient..

Me: Yes, go ahead. Please.

Resident: He’s tachycardic.

Me: How fast?

Resident: 160 ?

Me: What’s the blood pressure?

Resident: 130/90

Me: Rhythm?

Resident: An SVT I think.. I gave adenosine.  Nothing happened

Me: Audibly groaning.  I’ll be in..

Forty five minutes later I’m at the bedside of a decidedly ill appearing man.

I want to be triumphant that his heart rate is only 145, and a quick glance at the telemetry monitor above his bed uncovers juicy p waves in a cadence that suggests this is no primary electrical arrhythmia.

Something is very wrong somewhere – the heart in this case is an innocent bystander being whipped into a frenzy to compensate for something.

At the moment the whip is a norepinephrine infusion being used to keep his blood pressure up.

I ask the nurse if the amount of norepinephrine infusing has been stable.  She replies that his dose has been slowly escalating.

Eureka! I think – the heart rate response in this case is being driven by the norepinephrine – a powerful adrenaline that acts on beta receptors and alpha receptors within the body that increase heart rate and constrict the blood vessels to raise blood pressure.  Fix the cause of the low blood pressure, come down on the norepinephrine, and perhaps the heart rate would be better.

But it turns out this particular post surgical patient doesn’t have a medical cause of low blood pressure I can find.  I cycle through cardiac ultrasounds, blood gases, steroid and volume challenges, and try inching down on the norepinephrine.

All of it is to no avail.  I’m growing more and more convinced this problem is surgical in nature. Perhaps an infarcted piece of bowel?  All I know is that the man acts like he has no peripheral vascular tone.

An interesting thing happens shortly after.  The norepinephrine drip runs out.

As one nurse runs to get another bag from the pharmacy – a quick cascade of events unfolds.

The brisk upstroke from the arterial line that marks the pressure wave generated with every beat of the heart starts to dampen.  The color seems to visibly drain from the patients face, and he begins to complain that his vision is getting blurry.  His systolic blood pressure is 70 – an almost forty point drop within a minute of the norepinephrine running out.

I call for help.

I try to keep a level tone.  Project control, not panic.

“Open the code cart, I need a half a milligram of epinephrine”

“You’re going to be ok, sir.  Hang with me.”  I squeeze his hand.

He closes his eyes

The code cart – a fully stocked cabinet on wheels with almost everything you need for resuscitation efforts – is wheeled into the room. The epinephrine vial is handed to the nurse, and hurriedly pushed.

Within seconds, I can see the blood pressure and heart rate rise.  The patient’s grip on my hand relaxes.  Or maybe its my grip on his hand.  I forget which.  His vision returns to normal as his blood pressure ‘normalizes’.

Of course nothing has been fixed.  Why his blood pressure remains low continues to be a mystery.  The bag of norepinephrine soon isn’t enough even at its maximal dose.  The same scenario (hypotension -> pallor -> vision loss ) recurs 30 minutes later, and another bolus of epinephrine aborts a rapid spiral towards pulselessness.

Health in 2 Point 00 Episode 32 — Takeover Edition

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It’s a #Healthin2Point00 #Takeover edition — in which I get the boot and Jessica DaMassa invites Eugene Borukhovich who runs Bayer’s Digital Health Division and oversees the #Grants4Apps program to answer all he knows about ICEE Health (the conference they’re at), startups in Romania & biotech in China in just 2 minutes — Matthew Holt

Health for coins, not dollars ;) – The “not so serious” Mapping of Healthcare Cryptocurrencies

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At this years’ SXSW it was all about blockchain and cryptocurrencies, but it was like that at HIMSS, JPM, CES, etc. as well. Since we wrote already about the first of the two buzzwords – blockchain as a trend in Healthcare, we decided to tackle the idea of cryptocurrencies in healthcare. First, we checked around the office and found out that several devs have been in a couple of Telegram chat rooms as they tried to buy “health coins” in a presale (ICO – initial Coin Offering; Pre-ICO).

Will you be buying your next health plan with ethereum? Or is the new health coin going to solve the problem of fragmented healthcare records?

Health in 2 Point 00, Episode 31

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Jessica DaMassa asks me about PlugandPlay’s health day, people talking to bots in health care, the rumors of Softbank dropping a wad of cash on Science37, and we can’t resist some Thernos cracks. This one also has pictures! Sadly the video somehow got corrupted so it’s not your eyes, we are looking like green martians! — Matthew Holt

Can Supportiv fill the mental health peer support gap?

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As promised I’m going to be featuring more interesting companies I’m working with on THCB. Supportiv, which is launching today in beta (App store/Play) is a thoroughly modern answer to the problem of scaling peer support in mental health. It’s aimed in the space between the mediation apps like Headspace & Calm, and the online therapy services like AbleTo or Lantern. The target market is anyone feeling stress or wanting support in a quick and easy format–that’s basically everyone! Using the magic of NLP, those looking for support are steered into a chatroom where a trained moderator (usually a Masters student in psychology) making sure the experience is smooth. In its trials earlier this year of the 48,000 users, 96% reported improvement. The business model? It costs 15 cents a minute, or $4.50 for 30 mins (which is roughly the expected length of a session). There’s lots of science behind the idea that peer support works but to hear more Jessica DaMasssa interviewed the co-founders Pouria Mojabi & Helena Plater-Zyberk.

Announcing the Digital Health Marketplace Summer Matchmaking Event!

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SPONSORED POST

The New York City Economic Development Corporation and Catalyst @ Health 2.0 are thrilled to announce another round of Digital Health Marketplace matchmaking coming up on August 23rd! Since 2013, the Digital Health Marketplace has connected digital health “Sellers” offering technology solutions to a diverse range of healthcare “Buyers” or institutions looking for tech-enabled solutions and partnerships. At the center of the Digital Health Marketplace is the successful curation of needs and solutions that lead to the development of commercialization and the rapid adoption of new health technologies. If you are an early stage startup looking for relevant pilot/commercial partners or a healthcare organization interested in adopting leading technologies, apply for your opportunity to be matched with relevant partners for one-on-one, in-person sales meetings.

For those interested in applying, submit the matchmaking application form by July 20th, 2018 at 11:59p ET. At that time, the Digital Health Marketplace team will match Buyers and Sellers based on expressed technology needs and relevant solutions. Selected participants will join us for a series of ~15 minute sales meetings at the NYC Genome Center on August 23rd, 2018. With the ultimate goal of a mutually beneficial partnership, the event is structured to bring the most relevant pairs together based on prioritized initiatives, with the goal of facilitating follow up discussions and potential long-term partnerships.

There is no shortage of digital health solutions in today’s healthcare climate and, as a Buyer, it is often challenging to find the time and resources to sift through them all. On the Seller side, it can be difficult to connect with prestigious institutions where your technology can be most impactful; the August Digital Health Marketplace Matchmaking session aims to address both obstacles in one convenient and exciting event! We’ve seen great success over the years as the Digital Health Marketplace matchmaking events have facilitated over 900 connections between health tech Buyers and Sellers to date.

Calling all NYC health tech Buyers! Calling health tech Sellers around the world! Submit your matchmaking application! Again, the deadline to apply to the Matchmaking Event is July 20th, 2018 at 11:59p ET. The Matchmaking Event will be taking place at the New York Genome Center on August 23rd, 2018 8:30a-12:30p. If you have any questions about the matchmaking process, please email [email protected]. We hope to see you in August!

Health in 2 Point 00, Episode 30

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Jessica DaMassa asks me about Jonathan Bush’s exit and the future of Athenahealth, celebrity suicide and the future of mental health apps, and who Amazon/Buffet/Chase should choose to be their CEOMatthew Holt

Apple, Cerner, Microsoft, and Salesforce

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… all rumored to be in the mix to acquire athenahealth.

Nope.

Why not?

a) Apple doesn’t do “verticals.” It’s that easy. Apple sells products that anyone could buy. A teacher, a doctor, my mom. Sure – they have sold high-end workstations that video editors can use, but so could a hobbyist filmmaker. Likelihood of Apple buying athenahealth? ~ .01%

b) Cerner? Nah. While (yes) they have an aging client-server ambulatory EHR that needs to be replaced by a multi-tenant SaaS product (like the one athenahealth cas built), they have too much on their plate right now with DoD and VA and the (incomplete) integration of Siemens customers. Likelihood of Cerner buying athenahealth?  ~ 1%

c) Microsoft. Like Apple, it’s uncommon for MSFT to go “vertical.” They have tried it. (Who remembers the Health Solutions Group?) But the tension between a strong product-focused company that meets the needs of many market segments, and a company that deeply understands the business problems of health (and health care) is too great. The driving force of MSFT, like Apple, is to sell infrastructure to care delivery organizations. Owning a product that competes with their key channel partners would alienate the partners – driving them to AMZN, GOOG and APPL. Likelihood of Microsoft buying athenahealth?  ~ 2%

d) Salesforce. I’d love to see this. But it’s still unlikely. athenahealth has built a product, and they (now) have defined a path to pivot the product into a platform. This is the right thing to do. Salesforce “gets” platform better than everyone (aside from, perhaps, Amazon). But Salesforce has struggled with health care. They’ve declared times in recent years that they are “in” to really disrupt health care, and with the evolution of Health Cloud, and their acquisition of MuleSoft, they have clearly made some investments here, but the EHR is not the “ERP of healthcare” as they think it is. (Salesforce’s success in other markets has been that they dovetail with – rather than replace – the ERP systems to create value and improve efficiencies.) The way that Salesforce interacts with the market is unfamiliar (and uncomfortable) to most care delivery organizations. So if Salesforce “gets” platform, and athenahealth wants to be a platform when it matures, could these two combine? It’s the most likely of the three, but I still see the cultures of the two companies (I know them both well) as very different, and not quite compatible. Likelihood of Salesforce buying athenahealth?  ~ 10%

e) IBM. yup. I forgot that one. Many recent acquisitions. This would fit. I don’t think it would work very well, but it could happen. ~6%

Others?

The verdict is in: All three of CMS’s “medical home” demonstrations have failed

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Between September of 2016 and last month, CMS released “final evaluations” of all three of its “medical home” demonstrations. All three demos failed.

This spells bad news not just for the “patient-centered medical home” (PCMH) project, but for MACRA. The PCMH, along with the ACO and the bundled payment (BP), is one of the three main “alternative payment models” (APMs) within which doctors are supposed to be able to find shelter from the financial penalties inflicted by the MIPS (Merit-based Incentive Payment System) program which was recently declared to be unworkable by the Medicare Payment Advisory Commission. Medicare ACOs and virtually all Medicare BP programs are also failing. Thus, we may conclude what some predicted a long time ago – that neither arm of MACRA (the toxic MIPS program and the byzantine APM program) will work.

In this post I describe each of CMS’s three PCMH demos, review the findings of the final evaluations of the three demos, and then explore the reasons why all three demos failed. I’ll conclude that the most fundamental reason is that the PCMH is so poorly defined no one, including the doctors inside the PCMHs, knows what it’s supposed to do. That’s not to say that the hopes and dreams of PCMH proponents were never clear. They have always been clear. PCMH proponents have said over and over the PCMH is supposed to lower costs and improve care. But a clear expression of hopes and dreams is not the same thing as a clear description of what it is you’re dreaming about.

Fighting Hubris in Medicine

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By ANISH KOKA

The weekend started with a tweet about an elderly man with atrial fibrillation.  Atrial fibrillation is an arrhythmia of the heart that predisposes those who suffer with it to strokes.  The strokes are a  result of clots being thrown from the heart into the brain.  The typical treatment for this condition in those deemed high enough risk is to thin the blood to help prevent these clots from forming, and thus reducing the risk of stroke.

The problem with thinning the blood is that the risk of bleeding increases, and it does so especially as one advances in age.  It doesn’t help matters that the risk of having a stroke also increases with age.

In a 101 year old deciding on the best course of action is thus a challenging one.  It is easiest when patients are adamant about a certain path.  Far be it from me to tell a centenarian what to do.   In this case, the man who had been alive for two world wars chose to come off the anticoagulant he had been dutifully prescribed.

I queried the audience

Most leaned towards stopping Pradaxa, and some responded that there wasn’t a wrong answer.

I asked the question because this was a decision that had been made four years earlier.  The consequences of that decision were playing out now.

No one lives forever.  In a parallel world, the anticoagulant continues and this is a discussion about the brain hemorrhage that resulted.  These aren’t the only two possibilities. He could also have avoided both types of stroke, attended a few more great grand kids birthdays and passed away in his sleep from a cardiac arrhythmia.