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The Social Context and Vulnerabilities that Challenge Health Care in the San Joaquin Valley of California

By ALYA AHMAD, MD

Call it what you want, white privilege and health disparity appear to be two sides of the same coin. We used to consider ethnic or genetic variants as risk factors, prognostic to health conditions. However, the social determinants of health (SDOH) have increasingly become more relevant as causes of disease prevalence and complexity in health care.

As a pediatric hospitalist in the San Joaquin Valley region, I encounter these social determinants daily. They were particularly evident as I treated a 12-year old Hispanic boy who was admitted with a ruptured appendix and developed a complicated abscess, requiring an extensive hospitalization due to his complication. Why? Did he have the genetic propensity for this adverse outcome? Was it because he was non-compliant with his antibiotic regimen? No.

Rather, circumstances due to his social context presented major hurdles to his care. He had trouble getting to a hospital or clinic. He did not want to burden his parents—migrant workers with erratic long hours—further delaying his evaluation. And his Spanish-speaking mother never wondered why, despite surgery and drainage, he was not healing per the usual expectation.

When he was first hospitalized, his mother bounced around in silent desperation from their rural clinic to the emergency room more than 20 miles from their home and back to the clinic, only to be referred again to that same emergency room. By the time he was admitted 2 days later, he was profoundly ill. The surgeon had to be called in the middle of the night for an emergency open surgical appendectomy and drainage. Even after post-operative care, while he was on broad-spectrum intravenous antibiotics, his fevers, chills and pain persisted. To avoid worrying his mother, he continued to deny his symptoms. Five days after his operation, he required another procedure for complex abscess drainage.

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Autonomous Pharmacy: An Industry Movement to Free Hospital Pharmacists | Randy Lipps, CEO, Omnicell

By JESSICA DaMASSA, WTF HEALTH

From the point at which a medication arrives at a hospital’s receiving dock to the time it’s given to a patient, Omnicell systems are relied on to “store it, package it, barcode it, order it, issue it, and charge it.” Now, CEO Randy Lipps wants to automate ALL OF IT — getting medications from dockside to bedside, without the help of human hands. The Autonomous Pharmacy is not only Omnicell’s bold vision for the future of medication management for hospitals that brings in robotics and software to improve the safety and accuracy of every aspect of the drug delivery process, but as Randy says, it’s an “industry movement” to free the hospital pharmacist from the “basement pharmacy” and allow them to truly practice at the top of their license. Although integrating new tech into healthcare systems is never easy, this CEO says that it’s less the tech — and more the lack of urgency in shifting our mindset as an industry — that’s slowing us down. What exactly needs to change? Bold visions require big plans…

Filmed at the American Society of Health-System Pharmacists (ASHP) Midyear Clinical Meeting in Las Vegas, December 2019.

Medical Records in Primary Care: Keeping the Story of Phone Calls and Medication Changes with Less than Perfect Tools

By HANS DUVEFELT, MD

I need the right information at the right time (and in a place that makes sense to me) to make safe medical decisions.

Here’s another Metamedicine story:

In learning my third EMR, I am again a little disappointed. I am again, still, finding it hard to document and retrieve the thread of my patient’s life and disease story. I think many EMRs were created for episodic, rather than continued medical care.

One thing that can make working with an EMR difficult is finding the chronology in office visits (seen for sore throat and started on an antibiotic), phone calls (starting to feel itchy, is it an allergic reaction?and outside reports (emergency room visit for anaphylactic reaction).

I have never understood the logic of storing phone calls in a separate portion of the EMR, the way some systems do. In one of my systems, calls were listed separately by date without “headlines” like “?allergic reaction” in the case above.

In my new system, which I’m still learning, they seem to be stored in a bigger bucket for all kinds of “tasks” (refills, phone calls, orders and referrals made during office visits etc.)

Both these systems seem to give me the option of creating, in a more or less cumbersome way, “non-billable encounters” to document things like phone calls and ER visits, in chronological order, in the same part of the record as the office notes. That may be what IT people disparagingly call “workarounds”, but listen, I need the right information at the right time (and in a place that makes sense to me) to make safe medical decisions.

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Health in 2 Point 00, Episode 107 | SoftBank Money, Judy Faulkner’s Letter, & Practice Fusion Gossip

Today on Health in 2 Point 00, we have SoftBank Money! I managed to beat Chrissy Farr to this piece of gossip by about 3 weeks, but digital pharmacy startup Alto raises $250 million from SoftBank. Medloop raises 6 million euros doing communication with patients, and mental health startup Spring Health raises $22 million as well. Turning to the EMR drama, I also give a rundown on Judy Faulkner’s letter, and explain the cautionary tale that is Ryan Howard of Practice Fusion. —Matthew Holt

Ouchie, a Chronic Pain Management App Mapping “Pain Journeys” | Rachel Trobman, Upside Health

BY JESSICA DAMASSA, WTF HEALTH

Not only is ‘Ouchie’ what you say when you’re in pain, but now it’s also what you say when you need to find relief! Rachel Trobman, CEO of Upside Health, introduces us to Ouchie, a remote patient monitoring and treatment tool for chronic pain that patients can download onto their phones. Central to the patient experience of the app is the focus on documenting the patient’s “pain journey” where they answer a series of important lifestyle questions that inform the platform to come up with ways to receive support and other health resources. Not only does this self-reported data help patients identify triggers and patterns that impact their pain level, but it is also a treasure trove of information for physicians who can use it to better (and more quickly) tailor treatment to suit individual needs. The business behind Ouchie, called Upside Health, is starting to take off too and Rachel talks through revenue model, funding, and future plans.

Filmed at Frontiers Health in Berlin, Germany, November 2019.

Why the Centene and WellCare Merger is the Biggest Deal in 2020

By ANDY MYCHKOVSKY

I feel like the healthcare world just skipped over the $17.3 billion mega-merger between Centene and Wellcare, which just received final regulatory approval last Wednesday. With their powers combined, this new company will create the Thanos of government-focused health plans, hopefully without any of the deranged plans to take over the world. I do get it, 181 million lives are covered by employer-sponsored insurance, between full-risk and self-insured plans. These employer populations have the most disposable income and their HR departments are willing to provide supplemental benefits. However, in my opinion, the future growth of health insurance will be governmental programs like Medicare Advantage (MA), Medicaid managed care, and ACA exchanges. But instead of me telling you this, here is exactly what Centene and WellCare said in a press release to defend the merger:

“The combined company would be the leader in government-sponsored healthcare with increased scale and diversification both geographically and in its managed care service offerings, and enhance access to high-quality services for members. It will offer affordable and high-quality products to its more than 12 million Medicaid and approximately 5 million Medicare members (including Medicare Prescription Drug Plan), as well as individuals served in the Health Insurance Marketplace and the TRICARE program. The combined company will operate 31 NCQA accredited health plans across the country and will have increased exposure to government-sponsored healthcare solutions through WellCare’s Medicare Advantage and Medicare Prescription Drug Plans. It will also benefit from leveraging Centene’s growing position in the Health Insurance Marketplace to new markets. The transaction creates a company with the size and scale to better serve members through enhanced healthcare programs, expanded capabilities and increased investment in technology.”

Simply put, here’s some of quick stats provided at the JP Morgan Healthcare Conference presentation on January 13, 2020:

  • National footprint now serving 1 in 15 Americans
  • Clear market leader in Medicaid managed care and ACA exchange marketplace
  • Dominance serving most complex populations, #1 leader in LTSS and #2 in dual eligible
  • Competitiveness in the Medicare Advantage (MA) enrollment wars
  • $500 million in proposed savings due to annual cost synergies
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Livongo Takes on Hypertension | Zane Burke, CEO, Livongo

BY JESSICA DAMASSA, WTF HEALTH

Livongo CEO, Zane Burke, has been a busy guy since the company’s IPO late last year. The applied health signals company has seen triple-digit (148%) growth and a robust expansion of the weight management and behavioral health platforms they’ve been building to support the ‘whole health life’ of people with diabetes. Case-in-point, Zane talks through the outcomes of the company’s latest clinical research on Livongo’s hypertension management tool, which showed that clients who used both Livongo’s diabetes management tool and hypertension tool in tandem experienced significant decreases in their hypertensive blood pressure in as little as four weeks. As traditional healthcare companies and digital health startups alike continue to watch Livongo’s every move for an indication of ‘what’s possible’ for health tech startups, we asked Zane to clue us in on how he’s keeping his team focused on product development, market expansion, and issues related to reimbursement.

Filmed at Frontiers Health in Berlin, Germany, November 2019.

Quantum Theory of Health

By KIM BELLARD

We’re pretty proud of modern medicine.  We’ve accumulated a very intricate understanding of how our body works, what can go wrong with it, and what are options are for tinkering with it to improve its health.  We’ve got all sorts of tests, treatments, and pills for it, with more on the way all the time.

However, there has been increasing awareness of the impact our microbiota has on our health, and I think modern medicine is reaching the point classical physics did when quantum physics came along.  

Image credit: E. Edwards/JQI

Classical physics pictured the atom as kind of a miniature solar system, with well-defined particles revolving in definite orbits around the solid nucleus.  In quantum physics, though, particles don’t have specific positions or exact orbits, combine/recombine, get entangled, and pop in and out of existence.  At the quantum level everything is kind of fuzzy, but quantum theory itself is astoundingly predictive.  We’re fooled into thinking our macro view of the universe is true, but our perceptions are wrong.   

So it may be with modern medicine.  Our microbiota (including both the microbiome and mycobiome) both provide the fuzziness and dictate a significant portion of our health.   

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Consumer Weight Loss Platform Noom Heads for Digital Health | Saeju Jeong, CEO, Noom

By JESSICA DAMASSA

Popular weight management app Noom is officially stepping into the world of digital health and digital therapeutics. CEO & co-founder, Saeju Jeong, shares some of the impressive stats that the behavior change platform has been able to help users achieve — including an average 7.5% reduction in body weight in 6 months. With more than 1 million (!) users around the world already, Noom is expanding globally and is venturing further into the healthcare space as a result of their successful pilot with Novo-Nordisk, which saw Noom as a ‘wrap around’ support to the drug company’s diabetes medication. On tap next, Saeju tells us he’s headed further into diabetes management, hypertension, kidney failure, and various cardiac conditions.

Filmed at Frontiers Health in Berlin, Germany, November 2019.

Strategic Interests and the ONC Annual Meeting

By ADRIAN GROPPER, MD

The HHS Office of National Coordinator (ONC) hosted a well-attended Annual Meeting this week. It’s a critical time for HHS because regulations authorized under the almost unanimous bi-partisan 21stC Cures Act, three and a half years in the making, are now facing intense political pressure for further delay or outright nullification. HHS pulled out all of the stops to promote their as yet unseen work product.

Myself and other patient advocates benefited from the all-out push by ONC. We were given prominent spots on the plenary panels, for which we are grateful to ONC. This post summarizes my impressions on three topics discussed both on-stage and off:

  • Patient Matching and Unique Patient Identifiers (UPI)
  • Reaction to Judy Faulkner’s Threats
  • Consumer App Access and Safety

Each of these represents a different aspect of the strategic interests at work to sideline patient-centered practices that might threaten the current $Trillion of waste. 

The patient ID plenary panel opened the meeting. It was a well designed opportunity for experts to present their perspectives on a seemingly endless debate. Here’s a brief report. My comments were a privacy perspective on patient matching, UPI, and the potential role of self-sovereign identity (SSI) as a new UPI technology. The questions and Twitter about my comments after the panel showed specific interest in:

  • The similarity of “enhanced” surveillance for patient matching to the Chinese social credit scoring system.
  • The suggestion that we already have very useful UPIs in the form of email address and mobile phone numbers that could have been adopted in the marketplace, but are not, for what I euphemistically called “strategic interests”.
  • The promise of SSI as better and more privacy preserving UPIs that might still be ignored by the same strategic interests.
  • The observation that a consent-based health information exchange does not need either patient matching or UPIs.
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