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Month: May 2013

Hacking Healthcare

• 6

By Fred Trotter

There are two definitions of the word “Hacker”. One is an original and authentic term that the geekdom uses with respect. This is a cherished label in the technical community, which might read something like:

“A person adept at solving technical problems in clever and delightful ways”

While the one portrayed by popular culture is what real hackers call “crackers”

“Someone who breaks into other people computers and causes havok on the Internet”

People who aspire to be hackers, like me, resent it when other people use the term in a demeaning and co-opted manner.  Or at least, that is what I used to think. For years, I have had a growing unease about the “split” between these two definitions. The original Hackers at the MIT AI lab did spend time breaking into computer resources… it is not an accident that the word has come to mean two things.. It is from observing e-patients, who I consider to be the hackers of the healthcare world, that I have come to understand a higher level definition that encompasses both of these terms.

Hacking is the act of using clever and delightful technical workarounds to reject the morality embedded default settings embedded in a given system.

This puts “Hacking” more on the footing with “Protesting”. This is why crackers give real Hackers a bad name. While crackers might technically be engaged in Hacking, they are doing so in a base and ethically bankrupt manner. Martin Luther King Jr. certainly deserves the moniker of “protester” and this is not made any less noble because Westboro Baptist Church members are labeled protesters too.

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Top THCB Blog Posts of the Last Two Weeks

• 2

The E-mail I Want to Send to Our Tech Guys But Keep Deleting (40)

By Shirie Leng, MD

It really shouldn’t be this hard. This doesn’t seem like rocket science, but you keep telling us it is. What’s the deal with the passwords? Why can’t computers at different hospitals talk to each other? What’s the story with the obsession with mindless data entry? Have you ever tried using one of these things? Harvard’s Shirie Leng speaks for a growing chorus of annoyed EMR users.

The Rest of the Story About Hospital Pricing (26)

By David Dranove

Nobody would argue that opening up hospital prices is a bad idea. After all, it’s pretty hard to shop around when you don’t know how much what you’re shopping for costs. So opening up hospital price lists is a logical thing to do. But people who argue that giving the public access to this information without context will change anything are guilty of deeply flawed magical thinking, argues David Dranove.

Medicine in Denial (51)

By Leslie Kernisan, MD

Larry and Lincoln Weed’s 2011 exhaustive study on the problems facing the healthcare system and the ways technology might be able to help solve them did not exactly get the attention many more talked-about and hyped titles on health reform and the business of healthcare do. A pity that their sensible and timely book has largely been ignored by critics, writes THCB contributor Leslie Kernisan. Many of the ideas the Weeds discuss, such as the Problem Oriented Medical Record (POMR) and the need for a better way for physicians to manage their decision-making, are well worth our time.

Misunderstanding Oregon (31)

By Ashish Jha, MD

Critics looking at this months Oregon study are getting a bit carried away in their rush to weigh on the unbelievable significance of what it all means, writes Harvard’s Ashish Jha. The initial reaction served as a “Rorschach test,” reflecting critics’ view on Medicaid” which shouldn’t really have surprised anybody. The reality is a little more complicated. Actually, make that a lot more complicated.

Evidence That Health Does Not Equal Health Care?

Early Results From the Oregon Experiment Are In (4)

By Mike Miesen

Nonsense, writes THCB contributor Mike Miesen. The Oregon experiment may turn out to be the most important public health study in decades, if not in history. “Get ready for bombastic claims and scorching heat as opposed to illuminating light.” We finally have solid data that lets us understand what’s happening. And that’s a very good thing.

I Was Told There Would Be No Math (5)

By Shirie Leng, MD

You heard it here first. Doctors are going to need all sorts of special skills to survive in the future. A growing number of medical schools are experimenting with novel approaches designed to attract brilliant candidates with experience outside of the traditional science focused areas.

A Tale of Two Births (42)

By David Overton

Ezra and Silas. Two births. Two very different stories. After their obstetrician pushed for an early delivery when David Overton’s wife was pregnant with the couple’s son Ezra, the healthcare insider began asking questions. When their son Silas was born, they took the opposite approach, hiring a midwife to help them through the process using an all-natural, all “granola approach.” The two experiences could not have been more different. What was happening here?

Testing Wisely (20)

By Rob Lamberts, MD

In American society more is generally considered better. The result: health care costs more than anywhere else in the world. There is a better a way. And doctors have it in their power to do something about it. THCB contributor Rob Lamberts offers his house rules for winning the “war against more.” Never order a test that doesn’t help you decide something important. Never send a patient to a specialist, unless they need. Never prescribe a drug without telling the patient. And, well, if you want to know how the story ends you’ll have to read the whole thing for yourself…

Massively Open Online Medicine (6)

By David Harlow

Playing Games(MMORPGS), Massively Open Online Courses (MOOCs) like the Khan Academy have become one of the latest obsessions in the tech industry. That led Eric Topol to playfully suggest that the time may be right for Massively Open Online Medicine.(MOOM). That may not be a good thing.

Open Data Advocate Joins Patient Privacy Rights Group

as Chief Technology Officer (8)

By Adrian Gropper, MD

The news the Patient Privacy Rights Coalition had appointed a chief technology officer caused a minor stir. After all, the Austin-based non-profit organization has a long history of challenging the tech industry at almost every turn, raising awkward (read highly annoying) questions about the EMR vendor practices, companies privacy policies and questionable use of data. In a THCB commentary, CTO Adrian Gropper talks about what it all means. Could a thaw be coming. Does the news signify that new era of peace, love and understanding is at hand? Probably not.
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The DIY Electronic Medical Record

• 17

By Rob Lamberts, MD

There was a hole in the wall of our bathroom that was a painful reminder of a bad encounter with a plumber.  Yes, that hole has been there about a year, and it has been on my to-d0 list for the duration, daring me to show if I inherited any of the fix-it genes I got from my father.  Why not hire someone to come fix it?  I also got (as I mentioned in my last post) dutch genes, which scream at me whenever I reach for my wallet.  So this hole was giving me shame in surround-sound.

I attempted to fix it the hole last year, even going to the degree of asking for  a router table for my birthday.  Since there was previously no way to get to this all-important access to the shower fixture without cutting through the sheetrock, I decided I would take a board, cut it larger than the hole, then use the router to make a rabbet cut so the panel would fit snuggly.  Up until then, I thought a rabbet cut was a surgery to keep the family pet population under control, but my vocabulary was suddenly expanded to include words like rabbet, roundover, chamfer, dado and round nose. Unfortunately, my success only came in the realm of vocabulary, as I was not able to successfully master the rabbet cut without making the wood become a classic example of the early american gouge woodworking style.

I am not sure why, but something inside me told me today was the day to give this another shot, and to my shock (and that of my family), I was successful!

This home project is actually a late comer to the DIY party I’ve been holding for the past few months.

  • Don’t like your practice?  Build your own from scratch!
  • Don’t like the health care system, build a new one!

My latest DIY venture is in an area I swore I’d not go: I’m building my own record system.

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Into the Extrapolation Machine

• 3

By Les Funtleyder

The Kaiser Family Foundation (KFF) recently released a study that showed that 42% of Americans are unaware that Obamacare (the Affordable Care Act) remains the “law of the land.” News like this seems to us, to act as a Rorschach test on how observers feel about the law. Considering 50% of Americans can’t identify New York on a map we tend not to read too much into these polls. However, according to the logic of extrapolation, since we know that the ACA remains law, we are in the elite 58% (it’s about time we made it into the elite of something).

In almost parallel to the KFF news, the New England Journal of Medicine published a follow-up study of the “Oregon experiment.” For those who haven’t been following closely, the study found that previously uninsured people who were enrolled in Medicaid did not see an improvement in clinical measures when compared to those who remained uninsured. The study did seem to show a reduction in the amount of financial distress for the insured however.

Another contentious study, another Rorschach test (example, example). The problem we see with the polarity of views is that both sides seem to be cranking up the extrapolation machine and use single studies/data points to draw broad conclusions to gin up opinions about ACA’s success or lack thereof. In light of the fact that for most practical matters ACA doesn’t really get going until 2014, use of the extrapolation noise generator approach smacks of a lack of analytical rigor in our view. We will know soon enough how the program is doing… exchanges start enrolling on 10/1.

As investors, we should state upfront that we tend to give more weight to financial returns than what the philosopher-kings might call the political context. So what caught our eye in the Oregon study was that Medicaid recipients had higher healthcare utilization rates (and associated costs) than the uninsured. The connection between gaining insured status and healthcare utilization should not come as a surprise since there is a very extensive literature elucidating this connection.

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The Bounce Back Effect

• 5

By Anubhav Kaul, MD and Sindhu Kubenderan

Critically ill Medicare patients, who are battling for stable health at the end of life, are victims of repeated hospitalizations, especially after being discharged to a skilled nursing facility (SNF).  The cycle of hospitalizations is an indicator of poor care coordination and discharge planning – causing the patient to get sicker after every “bounce back” to the hospital.  Total spending for SNF care was approximately $31 billion in 2011; with an estimated one in four patients being re-hospitalized within thirty days of discharge to a SNF.[1]

Each readmission leads to further test and treatments, higher health care costs, and most importantly, patient suffering.  It is hard to imagine that patients would prefer to spend their last few months of life shuttling from one healthcare setting to another and receiving aggressive interventions that have little benefit to their quality and longevity of life.  The heroic potential of medical care should not compromise the patient’s opportunity to die with dignity.   A hospital is not a place to die.

Medicare beneficiaries are eligible to receive post-acute care at SNFs, after a three day hospital admission stay.  SNFs provide skilled services such as post-medical or post-surgical rehabilitation, wound care, intravenous medication and necessities that support basic activities of daily living.  Medicare Part A covers the cost of SNF services for a maximum of 100 days, with a co-payment of $148/day assessed to the patient after the 20th day.  If a patient stops receiving skilled care for more than 30 days, then a new three day hospital stay is required to qualify for the allotted SNF care days that remain on the original 100 day benefit.  However, if the patient stops receiving care for at least 60 days in a row, then the patient is eligible for a new 100 day benefit period after the required three day hospital admission.[1]  It is evident that the eligibility for the Medicare SNF benefit is dependent on hospitalizations – many of which may be a formality and a source of unnecessary costs.

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The Bedside Manifesto

• 2

By Jeff Kane, MD

“Most of us went into medicine because we love spending time with patients,” said Johns Hopkins Hospital’s Leonard Feldman, MD.

Dr. Feldman is co-author of an article published April 18 in the Journal of General Internal Medicine which reveals that medical interns spend only 12% of their time examining and talking with patients, and more than 40% of their time on computer tasks. 

“Our systems have squeezed [patient contact] out of medical training,” said Dr. Feldman.“ All of us think that interns spend too much time behind the computer. It’s not an easy problem to solve.”

For three weeks a year ago, investigators observed 29 interns at two Johns Hopkins University internal medicine residency programs for a total of 873 hours. Direct patient care accounted for only 12.3% of interns’ time, and computer use for 40%. The paucity of direct interaction may explain previous studies’ findings that only 10% of hospitalized patients know which resident physicians are responsible for their care. “I think we can do better,” said Dr. Feldman.

He’s right. Unless we want healthcare to devolve ultimately into a system of vending machines, we need to restore its traditional personal intimacy. But medical sages have been chanting that mantra since the 1920s. What holds it up?
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The Problem-Oriented Medical Record

• 10

By Leslie Kernisan, MD

[This post is Part 2 of a commentary on “Medicine in Denial,”(2011) by Dr. Lawrence Weed and Lincoln Weed. You can read Part 1 here.]

An excellent chapter in “Medicine in Denial” discusses the problem-oriented medical record (POMR), a comprehensive charting approach that Dr. Larry Weed began developing in the late 1950s.

The Weeds begin by detailing what a good health care record should allow clinicians, and the healthcare system to do. In other words, they start by clearly defining the needs of patients, the purpose of the medical record, and the kind of health care it should support.

Specifically, the Weeds make the following points:

  • Managing chronic illness often involves multiple interventions that require adjustment over time, rather than a single treatment that results in cure/resolution. This requires tracking of physiologic variables and medical interventions over time.
  • Chronic care of medically complex patients, especially those with multimorbidity, requires coordination of care among multiple clinicians at multiple sites over time.
  • For the many people suffering from multi-morbidity, chronic medical problems and their associated interventions often interact. This makes it particularly important that care be individualized, and carefully tracked over time.
  • Enabling patient awareness, participation, and commitment is essential, with the Weeds noting that “unavoidable complexity must somehow be made manageable by patients who need to cope with what is happening to their own bodies and minds.”
  • Patient care – and hence the charting of medical data — must be oriented towards a single purpose: individualized medical problem solving for unique patients.

In other words, the Weeds consider the longitudinal, comprehensive, person-centered, individualized, collaborative care of the medically complex patient to be a fundamental base scenario around which we should design healthcare, and healthcare information systems.

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The Rest of the Story About Hospital Pricing

• 30

By David Dranove

The recent Medicare report on variation in hospital “prices” is not exactly news. In fact, I wonder why anyone (including the NY Times and NPR) covered it, let alone make it a lead story.

As you probably know, Medicare reported that hospital charges for specific treatments, such as joint replacement surgery, greatly vary from one hospital to another. (This includes charges for all services during the hospitalization, including room charges, drugs, tests, therapy visits, etc.) Everyone in the healthcare business knows that charges do not equal the actual prices paid to hospitals, no more than automobile sticker prices equal the prices that car buyers actually pay. Except that for the past thirty years, the gap for hospitals greatly exceeds (in percentage terms) the gap for cars. This is not just a nonstory, it is an old nonstory.

So reporters tried to give it a new spin. One angle concerns the uninsured, who may have to pay full charges. I will write about this in a future blog. Another angle is that by publishing these charges, Medicare will encourage patients to shop around. That is the subject of this blog.

I suppose it is okay to tell patients that the amount they might have to pay out of their own pockets may vary from one hospital to the next. But the published charge data is useless for computing out of pocket payments; in fact, it may be worse than useless. As even the NY Times noted, insured patients make copayments based on prices that their insurers negotiate with hospitals. These prices are essentially uncorrelated with charges. So a patient who visits a hospital with low charges may well make higher out-of-pocket payments than a patient who visits a high charge hospital. It is a crap shoot.

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No Resident Left Behind

• 2

By Shirie Leng, MD

Yesterday at the faculty meeting, we learned that the first year residents in anesthesia will now have to take AND PASS a written exam at the end of their first year.  They will have a certain number of tries and if a resident can’t pass it by the third try they’re either out of the program or held back in some way.  Now, it used to be when I was a baby resident that the first year residents took the certification exam that the third years took, and it was graded on a curve based on year.  You didn’t have to pass it or get a certain grade; it was sort of a reality check, to see how you were doing.  I don’t know who’s brilliant idea this new test was, other than the people who administer and charge for the test.  It might be a solution in search of a problem, I have no idea.

Here’s the thing.  Testing freaks residents out.  They have been taking high-stakes tests their whole entire lives.  In high school they had to get As and score a 1400 on the SAT.  In college they still had to get As, but also had to ace the MCAT.  In med school the tests might have been pass/fail but USMLE Steps 1 and 2, both of which are taken during med school, certainly weren’t.  Results of those had bearing on what residency you got into.  The result of all this standardized testing is that every resident has PTSD about tests, and every resident has had years to figure out how he or she can most quickly cram in the amount of information necessary to do well on the test.  Residents are masters of this.  There is absolutely no reason to read the textbook, which is likely 8 years out of date anyway, when you can go straight to the review books and practice exams online.  Especially if the threat of expulsion or repetition, both of which are disasters on multiple foreign and domestic fronts, is held over their heads.

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Validating Mrs. X

• 1

By Ali Ansary

Mrs. X is a 46 year-old mother of two and wife to an Iraq war veteran. On this particular day she meets with her oncologist to follow up after treatment for skin cancer. Beyond her well-groomed hair, thick plastic framed glasses and coral-red manicured toes, she doesn’t have a clear agenda for her appointment and expectations have only been vaguely outlined. However, this will change.

Wired Magazine asked Mucca Design in 2010 to reimagine the blood test report and the result was an inspiring new way of communicating with patient. 2011 marked the launch of the Tricoder X-Prize worth $10 million supported by X-Prize Foundation and Qualcomm.  The goal is to bring to life the fictional Star Trek multifunctional handheld medical device that can scan, analyze and produce results with a goal to diagnose patients better than or equal to a panel of board certified physicians. And while 2012 launched a series of new medical innovations that leverage the power of the mobile device, 2013 will be a time to bring together these technologies into a web of interconnectedness.

In 2013, Mrs. X and her mobile device will have access to a digital medical record that gives access to prior appointment notes, recorded videos from remote mobile appointments with her team of physicians, and yesterday’s blood work results. New innovations in medicine will create a foundation for Mrs. X to have better access to care, translate her behavior into actionable data all being tied together to provide what is most important: validation.

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