Month: October 2013

Target Demographic

Oct 11, 2013• 9

By Rob Lamberts, MD

He seemed a bit grumpy when he came into the office. I am used to the picture: male in his early to mid-forties, with wife by his side leading him into the office to “finally get taken care of” by the doctor. Usually the woman has a disgusted expression on her face as he looks like a boy forced to spend his afternoon in a fabric store with his mother. My office is the last place he wants to be.

He let himself down on the couch across from my desk with a wince, belying the back pain that brought him here. He looks around at my office, which is not only a place he didn’t expect to be, but not what he expects a doctor’s office to look like. First there’s the sofa he is sitting on, which is where my patients spend most of their time during their visits. Then there is my guitar just behind me. He and his wife comment on how their daughter would love the fact that I have a guitar, as she is into acoustic guitar music. Then there’s me, wearing jeans and an untucked button-up shirt, sitting back in my chair and chatting like an ordinary person. He seems intrigued.

He owns a business, which is a service type business like mine. Like me, he and his wife choose to do things differently, charging less for folks who can’t afford it. I chat with him about the stress and strain of owning and running a small business, pointing out how his choice is similar to mine.

He had actually suggested coming to me after he had seen me on television, but obviously had initial doubts as to the accuracy of the report. Spin happens. But as we talk, there is much to find in common, and he warms up. His shoulders relax, he sits back on the couch, and forgets he’s in the doctor’s office.

Healthcare’s Tech Disconnect: Why Aren’t We Building the Products Patients Really Need?

Oct 11, 2013• 8

By Leslie R. Schover

Having been supported by several small business grants from the National Cancer Institute to create online interventions for cancer patients, I have been learning gradually about commercialization models to get our work out to the public. I am dismayed about the major disconnect between eHealth entrepreneurs and eHealth intervention researchers (my personal reference group).

Last year I attended Stanford Medicine X and last week I did a demo of one of our web sites at Health 2.0 in Santa Clara. Both times, I was struck by the assumption in the IT developer and consumer community that giving people realtime feedback about their health will automatically result in major positive changes in behavior, not to mention cost savings for insurers.

The Connected Patient movement seems particularly naïve to me. Psychologists have been using self-monitoring, i.e. recording behaviors such as smoking, eating, and exercise, for at least 30 years to promote behavior change. First we used paper-and-pencil diaries, but researchers like Saul Schiffman quickly adapted the first handheld computers to prompt people to record their behaviors in realtime, greatly increasing the accuracy and power of self-monitoring.

As technology has advanced, so have our means of self-monitoring. Overall, however, the technology matters far less than the procedure itself. For most people, tracking their smoking, calories, mood, or steps does change unhealthy behaviors somewhat, for a limited period of time. A small group of highly educated, motivated people is more successful in using self-monitoring to make larger, more lasting changes.

I was reminded of this last year in a seminar on tracking at Stanford Medicine X, when a concierge physician from San Francisco and several of his patients talked about being empowered to change their health by using feedback from various types of sensors. One had paid out of pocket for a continuous blood glucose monitor since his insurance would not cover the costs to use it for his Type II diabetes.

Another doggedly demanded access to the data from his cardiac defibrillator. They believed their experiences heralded a sea change in health care in the United States. I am all for empowering patients with knowledge, tracking tools, and social support.

However, if knowledge and feedback was all it took to change unhealthy behaviors, psychologists would be superfluous in the world.

My Return to American Health Care

Oct 10, 2013• 41

By Beth Arnold

A year and a half ago, my husband, James Morgan, and I moved back to the U.S. after living 10 years in France.

We returned more or less kicking and screaming. We had been away long enough to lose some of our American culture and to prefer the European way of life, despite our squabbles with it–and every American abroad has some squabbles. I had discovered I was a born expat, something I’d suspected my entire adult life — from my first trip to Europe when I was 19 years old–but hadn’t arranged to test until my younger daughter graduated from high school. Jim and I are both writers, and I’d thought of a book idea for him (Chasing Matisse) that would take us to France, and my intention was for us to stay there.

But there were things we’d left undone for the 10 years we’d been away that needing tending to — life was calling us back. And if the truth be known, I felt France was falling behind in the world, and her inability to change was grating. Paris was stuck in her perpetual stupendous, effervescent beauty, while nothing new happened there at all. This city I love more than any other had long since lost the artistic dynamism that had propelled it forward with Picasso, Matisse, and the other artists that the Lost Generation had adopted and promoted in the early part of the 20th century, when Malcolm Cowley wrote his classic Exile’s Return.

The World Wars had crippled France for a time, and she had gotten back on her feet. But what the French do so very well is the past — not the present or future — and this is even truer in our digital global society. The French refusal to change defines the Gallic nation in every way imaginable, and the centuries-long celebration of their grand culture is what we love about them — and is also placing them in the rear of the international pack.

Except for this — their Number One in the World (as determined by the World Health Organization) health care system.

One of the things I most dreaded about returning to America was having to deal with a health care system that was an embarrassing national wreck.

What Covered California Got Right–And What Other States Did Better

Oct 10, 2013• 1

By Dan Diamond

On the day that Covered California went live — the very moment that Executive Director Peter Lee declared the exchange “open for business” — staff debuted a video celebrating the launch.

The video features photos of cheerful, ethnically diverse people — spliced between scenes of California — holding up signs written in English, Farsi, Korean and other languages that all translate to “open.” (You can watch Lee unveil the video, beginning at the 10:40 mark.)

One week later, Covered California brought the video back; once again, clips of grinning men and women toting signs that read “Ya abrimos” filled time before a webinar on Tuesday where officials shared updates on the exchange’s progress.

The smiling faces and multilingual message illustrate one of California’s major challenges in rolling out the ACA: The state is arguably the most geographically and demographically diverse in the union. Expanding health coverage to seven million uninsured residents will take time and a unique strategy.

But you can also forgive Covered California officials for wanting to remind the public that their exchange is live. During much of the first week, the site often sent a different message.

What Went Wrong
Covered California’s launch was supposed to be different. The state had spent years gearing up for the exchange’s rollout on Oct. 1. It had enlisted dozens of groups to help perform outreach. It had equipped some staffers with “Keep calm and go live” t-shirts.

But a triumphant debut turned out to be an oft-frustrating one. In California, like in most of the nation, most launch day stories didn’t center on the people signing up for coverage through the new exchanges, but on all the people who couldn’t.

Australia’s Prisoners’ Dilemma: Incentives Matter in Health Care

Oct 10, 2013• 4

By Chris Denoia

The shortcomings of the Fee For Service (FFS) model are widely known.

During the 1800s, the British empire shipped prisoners to newly formed penal colonies in Australia (technically, these were British prisoners, but that doesn’t make a catchy title). Ship captains were compensated for each prisoner who boarded the ship. The financial incentive ruled over decency, each captain stuffed as many prisoners on to the ship as it could handle. Of course, the prisoner survival rate lingered at a precarious 50%, while those who managed to survive the journey often arrived beaten, sick or starving.

Attempts were made to improve the survival rates, through what might be considered early wellness programs. Captains were mandated to bring citrus to combat scurvy, a 19th century wellness program. Doctors were required on each ship carrying prisoners, improved access ala concierge medicine. I’m sure someone may have proposed it’s the prisoners responsibility to survive the trip and they ought to engage in their own survival. Nevertheless, requiring lemons and limes and placing physicians on the ships proved equally ineffective.

In 1862, economist Edwin Chadwick suggested a change to the incentive structure. Ship captains were no longer compensated for each prisoner who boarded in England, but, instead, received payment for every living prisoner who got off the ship in Australia. The first pay for outcomes program in healthcare. The survival rate on ensuing trips jumped from 50% to 98%.

The moral of the story is that incentives matter.

Primary care physicians are the ship captains of the 21st century.
American patients are prisoners of the US healthcare system.
Misaligned incentives are the root cause for what ails the system.

Christopher DeNoia is the Vice President of Business Development at Amplify Health, where this post originally appeared.

The Government Shutdown: Why the Pipeline Matters

Oct 9, 2013• 5

By Suzanne M. Rivera

Much attention has been paid to the government shutdown that started last week. Many of us heard heart-tugging stories on public radio about the NIH closing down new subject enrollment at its “House of Hope,” the clinical trial hospital on the NIH main campus. These stories gave many people the impression that clinical research halted around the country when the federal government failed to approve a Continuing Resolution.

The reality is both less dramatic in the short term and more concerning for the long term. For the most part, federally-funded projects at university campuses and hospitals are continuing as usual (or, the new “usual,” as reduced by sequestration), because the grants already awarded are like I.O.U.s from the government. By and large, university researchers will keep spending on their funded grants, with the knowledge that reimbursement will come once the government re-opens for business. The universities and hospitals are, in a sense, acting like banks that loan the government money while waiting for these expenses to be reimbursed.

Also, many clinical trials are funded by the pharmaceutical industry. So it is not the case that hospitals are closing their doors to research en masse. But the long-term effects of a shutdown will have lasting and compounding effects on our science pipeline. The U.S. federal government is the single largest funder of scientific research at American universities. Each month, thousands of grant proposals are sent to the various federal funding agencies for consideration.

These in turn are filtered and assigned to peer review committees. The whole process of review, scoring, and funding approval typically takes months, sometimes more than a year.

A Little Advice for the Next National Coordinator

Oct 9, 2013• 4

By John Halamka, MD

Over the next few months, Jacob Reider will serve as the interim National Coordinator for Healthcare IT while the search continues for Farzad Mostashari’s permanent replacement.

What advice would I give to the next national coordinator?

David Blumenthal led ONC during a period of remarkable regulatory change and expanding budgets. He was the right person for the “regulatory era.”

Farzad Mostashari led ONC during a period of implementation when resources peaked, grants were spent, and the industry ran marathons every day to keep up with the pace of change. He was the right person for the “implementation era”

The next coordinator will preside over the “consolidate our gains” era. Grants largely run out in January 2014. Budgets are likely to shrink because of sequestration and the impact of fiscal pressures (when the Federal government starts operating again). Many regulatory deadlines converge in the next coordinator’s term.

The right person for this next phase must listen to stakeholder challenges, adjust timelines, polish existing regulations, ensure the combined burden of regulations from many agencies in HHS do not break the camel’s back, and keep Congress informed every step of the way. I did not include parting the Red Sea, so maybe there is a mere human who could do this.

What tools does the coordinator have in an era of shrinking budgets?

At present, Meaningful Use Stage 2, ICD-10, the Affordable Care Act, HIPAA Omnibus Rule, and numerous CMS imperatives have overlapping timelines, making it nearly impossible for provider organizations to maintain operations while complying with all the new requirements.

Can resources be expanded?

Why Badly Designed iPad Apps Put Patients at Risk: EMS and ePCR

Oct 8, 2013• 7

By Jonathon S. Feit

Everyone who knows my writing can attest that I neither pull punches nor play politics. It may distress people, and hopefully it won’t harbinger my demise. But as CEO of a young firm bringing overdue innovations to the Fire and Emergency Medical Services industry, there are only four groups to whom I am duty-bound: our partner-clients, their patients, our team members, and our investors (in no specific order). To remain mum on topics that could affect the physical or financial health and wellbeing of any of these parties would be a disservice.

When I was in the magazine business, I often used the phrase “Respect the medium.” The meaning was simple: when every industry player surfing the waves of innovation is trying something new, how many are asking whether the form is appropriate to the intended function? What changes need to be made to magazine’s font so its text can be read clearly on a small, backlit screen? What interactivity can be embedded into a digitally delivered? How will the user’s experience change when network access is down? (In February 2012, I wrote about these topics for Electronic Design Magazine.)

Failure to ask these questions is often the downfall of the delivery method: either the medium changes or its use declines; rarely do customers acclimate. In the publishing world, if your readers ignore you, you go away—no lasting harm or foul. Not so in healthcare or public safety. Especially during emergencies, if a product fails to work as intended—or to work at all—it can mean lost productivity, mountainous legal fees, brain death, or loss of life, limb and property.

Healthcare IT offers outsized benefits to Emergency Response teams, which depend on speed, ease of training and use, data accuracy, and interoperability. But the stakes of failure or disruption are so high that one can say there are few areas of development with a more desperate need for criticism.

Still Demanding Medical Excellence

Oct 8, 2013• 21

By Michael L. Millenson

Forget for a moment the familiar scenes of action and outraged reaction that are playing out in our long-running national debate over how best to provide access to health care for every American. Instead, ask one simple question: what happens in the doctor’s office or hospital once access is achieved.

I set out to write a book addressing that question almost twenty years ago. I thought myself well qualified: I’d written about health care for a decade for the Chicago Tribune while receiving various awards and other recognition. But it didn’t take long for a painful realization to set in of how naïve I really was.

Digging through hundreds of studies, articles and other first-hand sources stretching back for decades, I was stunned to discover that repeated evidence of unsafe, ineffective, wasteful and downright random care had had no effect whatsoever on how doctors treated patients. Literally none. Moreover, the few professionals who understood this truth couldn’t talk about it in public without endangering their careers or engendering vitriol from peers.

Fortunately, I had no academic or clinical career to imperil. In the conclusion to Demanding Medical Excellence: Doctors and Accountability in the Information Age, I gave vent to anger and indignation. I wrote:

From ulcers to urinary tract infections, tonsils to organ transplants, back pain to breast cancer, asthma to arteriosclerosis, the evidence is irrefutable. Tens of thousands of patients have died or been injured year after year because readily available information was not used – and is not being used today – to guide their care. If one counts the lives lost to preventable medical mistakes, the toll reaches the hundreds of thousands.

The only barrier to saving these lives is the willingness of doctors and hospital administrators to change.

Demanding Medical Excellence came out in October, 1997. What progress has been made since then, and where we have fallen short? I address that question in a short article, “The Long Wait for Medical Excellence,” in the October, 2013 issue of Health Affairs. The purpose of this blog entry is to recap some of what’s said there (for you non-subscribers) and to add a few impolite observations that don’t jibe with the rules of a peer-reviewed journal.

HealthcareDIY: An Old Idea Made New

Oct 8, 2013• 1

By Jane Sarasohn-Kahn

My wisest and longest-time friend in health care, Jane Sarasohn-Kahn has a new project, new research and a new website called HealthcareDIY out today. I encourage all of you to look around her new site and consider the stories she is telling, as they matter to all of us.–Matthew Holt

We’re DIY’ing home renovations, photo development, music playlists, personal financial management, and travel reservations. Increasingly, we’re also DIY’ing health. Think: Maker Faire-Meets-Health.

My thinking about HealthcareDIY was first inspired by my mother Polly, who died 34 years ago this month. She was my first role model for an engaged patient. When she was diagnosed with Hodgkins lymphoma in 1971, there was no internet for her to tap into for a patient network, a clinical trial, or a directory of oncologists or centers of excellence that were Top Doctors for treating the condition.

Polly did, however, absorb the books of Adelle Davis and her Let’s Get Well series on nutrition and health. Polly’s good friend, a librarian with whom she worked, tapped into the Index Medicus on her behalf and retrieved abstracts of articles on blood cancers that he printed out from the microfiche. Polly partnered with her doctor, an internist with a keen interest in hematology, for her care. She also had a huge and diverse social network (offline, of course) that surrounded her with a whole lot of love. Her M.O. was informed by Dr. Bernie Siegel, who started Exceptional Cancer Patients in 1978 and evangelized about patient engagement, living fully with cancer, and dying in peace, which she did, in October 1979.

Among many legacies Polly left me was her can-do attitude when faced with a six-month-prognosis upon diagnosis with Hodgkin’s. Mom worked full-time until the last two years of her life, wore beautifully tailored clothes and put on lipstick every day, and project-managed her health through eight years of treatment: primarily, radiation and blood transfusions. Polly figured out how to take control where she could, and she did it with grace, humor and sheer human will.

She DIY’d her health given the resources she had at-hand between 1971 and 1979: books, cassette tapes, in-person support groups, medical journals in print, a specialist and internist, and lots of love.

In the three decades since Polly’s death, two seismic forces have structurally changed consumers in America: the Great Recession beginning in December 2007, and the near-universal use of the internet in health. Ogilvy’s report, Eyes Wide Open, Wallet Half Shut, found two countervailing forces re-shaping U.S. consumers: re-trenching and re-imagining. On the retrenching side of behavior, people began to do more binging: in media consumption, drinking, and eating.

On the re-imagining front, some people looked to re-invent themselves, reconnect with others, and re-train to re-tool careers. This group of people has sought to be more active and more deliberate, and accept more complexity in daily living. These people are more mindful, more frugal, and open to trading down. 9 in 10 use coupons, shop at discount stores, and buy more store brands and generics.

For this latter group, Ogilvy said, “Self Reliance is the new insurance policy,” with a group ethos believing that, “Americans need to be strong, get their house in order, and protect themselves,” per the report.

That’s where HealthcareDIY comes into play.Continue reading…