Year: 2014

The Non-Physician’s Guide to Hacking the Healthcare System

Jul 30, 2014• 4

By DAVID DO, MD and CRAIG MONSEN, MD

We are residents and a software developers. Before starting residency, we spent time as software developers in the startup community. We were witness to tremendous enthusiasm directed at solving problems and engaging people in their health. The number of startups trying to disrupt healthcare using data and technology has grown dramatically and every day established healthcare companies appear eager to feed this frenzy through App and Design Competitions.

When we started residency, the restrictiveness of data and reliance on decades-old technology was grossly apparent. Culturally, hospitals are an environment of budgets and deadlines that are better suited towards maintaining the status quo than promoting the creative process. Hospital IT departments harbor a deep cover-your-rear-end mentality and are incentivized for two things: first, keep systems running, and second, prevent security breaches. Perhaps rightly so–privacy and security need to be prioritized–but this environment has delayed them from facing the inevitable challenges of effectively using their own data and investing in new tools, including ones that could improve the triple aim of greater quality care with greater patient satisfaction and lower cost.

In the future, as hospitals and health systems become more accountable for the long term outcome of patients, we are optimistic that they will innovate as much out of cost-cutting necessity as for providing a better product to patients. We have little evidence that established players can power innovation solely on their own engines and expect many of the solutions will come from problem-solvers outside medicine. Doctors and patients will choose from an arsenal of apps to interact with the health information in EMRs. These healthcare apps come in three major categories: education, workflow, and decision support.

A Challenge to Control Blood Pressure Using HIT

Jul 30, 2014• 22

By KAREN DeSALVO, MD and JANET WRIGHT, MD

Heart disease and stroke are two of the leading causes of death in the United States. To combat these threats, the Department of Health and Human Services (co-led by Centers for Disease Control and Prevention [CDC] and the Centers for Medicare & Medicaid Services [CMS]) has joined with private and non-profit organizations such as the American Heart Association, American Pharmacists Association and the YMCA, to launch Million Hearts®, a national initiative to prevent one million heart attacks and strokes by 2017. The initiative is working to encourage clinicians nationwide to improve the quality of care through use of the ABCS strategies – Aspirin when appropriate,Blood pressure control, Cholesterol management and Smoking cessation.

On July 7th, as we marked the halfway point in this ambitious drive to improve America’s health, the Office of the National Coordinator for Health Information Technology (ONC), in collaboration with the CDC, launched the EHR Innovations for Improving Hypertension Challenge to accelerate improvement on the Million Hearts® “B” strategy – Blood Pressure Control. The goal is to show how professionals are using health IT to improve patients’ cardiovascular health. Evidence-based treatment protocols are an essential tool for providers to use in improving blood pressure control.

What makes this ONC challenge unique? First, it taps the expertise of clinicians who care for patients with hypertension and are using health IT to improve their control. Second, the challenge is designed to promote the scalability of critical tools for maximum impact and reach.Continue reading…

Many More Halbigs to Come

Jul 30, 2014• 41

By SAURABH JHA, MD

“Then you should say what you mean,” the March Hare went on.

“I do,” Alice hastily replied; “at least–at least I mean what I say–that’s the same thing, you know.”

“Not the same thing a bit!” said the Hatter. “You might just as well say that “I see what I eat” is the same thing as “I eat what I see”!”

Alice in Wonderland. A Mad Tea Party. Lewis Carroll.

The brilliant Carroll had a field day with logical fallacies in the fictional mad world of hyper rationalism. Alice in Wonderland still passes for children’s fiction. The verdict in Halbig versus Burwell is a Tea Party no less. Alice from Dickensian London, if magically teleported to present day might have believed she had fallen in to a rabbit hole.

The DC Court of Appeals ruled in a narrow 2-1 decision that citizens who bought insurance in the individual marketplace in states where the Federal government runs the exchange do not qualify for subsidies. But in states with state-run exchanges they do qualify for subsidies. The IRS’s subsidies are unlawful in the former but perfectly lawful in the latter.

The statutory language in the Affordable Care Act (ACA) states that subsidies are available to those “enrolled in an exchange established by the state…”

Personally, I can’t see the issue. What’s the difference, in principle, between subsidizing citizens in exchanges established BY the states and citizens in exchanges established FOR the states by the Federal government?

Is this the first war between prepositions in human history?

The argument is that we must follow the rule of the law as it is written. Section 1401 (rules on who can get subsidy) applies to Section 1311 (the one about how exchanges are set up) not Section 1321 (the one about Federal government running the state exchanges when states don’t).

Kaiser Permanente Chairman and CEO to Keynote Health 2.0

Jul 29, 2014• 8

Announcing Wearables Health Tech Runway Show and New Companies, Panels, Sessions and Speakers!

Health 2.0 announces Bernard J. Tyson, Chairman and CEO of Kaiser Permanente, as a keynote alongside visionary physicians Eric Topol, Patrick Soon-Shiong, and Samsung’s President Young Sohn at the Health 2.0 8th Annual Fall Conference this coming Sept. 21-24 in Santa Clara, CA. This year, Health 2.0 is set to host the very first Wearable Tech Fashion Runway as a part of the larger session on Consumer Tech & Wearables: Powering Healthy Lifestyles. The panel will also showcase data utility layer platforms from tech giants such as Intel, Qualcomm, WebMD, and Walgreens, which are working with these trackers to provide a complete consumer health solution. Once again,Health 2.0 leads the industry with never before seen technologies, panels, and discussions based on industry classifications of patient-provider communication, consumer facing products, professional facing products, and data analytics.

Health 2.0 8th Annual Fall Conference highlights include:

Consumer Tech & Wearables: The newest addition to the Health 2.0 agenda is The Wearable Tech Fashion Runway which features a multitude of wearable health tech in addition to data utility layer platforms from giants such as Samsung, Intel, Qualcomm, WebMD and Walgreens.

Big Names, Big Issues, Big Solutions: Notable Industry leaders and companies bring their solutions and knowledge to tackle some of the most pressing issues within health care. Newly added to the agenda are Ryan Howard (Practice Fusion), Mike & Albert Lee (myfitnesspal), Kent Bradley (Safeway), Jonathan Bush (athenahealth), Girish Navani (eClinicalWorks), Andy Krackov (California Healthcare Foundation), Jacob Reider (ONC), Rajni Aneja (Humana), andDena Bravata, (Castlight Health). A special bonus feature includes ademo of the latest Samsung Electronics platform and product–SAMI and the SIMBand–with President Young Sohn interviewed by Indu Subaiya (Health 2.0).

Health care Data Analytics: This topic covers the volume, velocity, variety, veracity, and value of health care data and analytics. Highlights include genomics, non-invasive diagnosis tools, and integrated data collection to uncover new discoveries, personalize medicine, and develop new care protocols with speakers from IBM Watson, Merck, Predilytics, and many more.

Start-Ups, Entrepreneurship & Investors: This year, Health 2.0 is poised to offer new opportunities for start-ups and entrepreneurs during the fall conference. Traction: Health 2.0’s Start-Up Championship is the inaugural pitch contest enabling series A-ready start-ups to showcase their business plan in front of a judging panel of renowned venture capitalists. The Bootstrapped Basecamp will put the most innovative seed stage start-ups inside the Health 2.0 Exhibit Hall to be found by potential partners, investors and customers.

The 8th Annual Health 2.0 Conference showcases over 200 LIVE demos, 150+ speakers, and 50+ sessions across four full days with an extensive audience of 2,100+ health care professionals, health care and health tech executives, thought leaders, policy makers, and entrepreneurs. A multitude of never before seen technologies will be presented on stage,while the conference offers ground-breaking insights into the policy, tools, and solutions of new health care technology.

Registration information is available here. Prices for the conference are set to increase on Wed. 30th, July. The full agenda of speakers and companies can be found on the main conference website here.

Narrow Networking

Jul 29, 2014• 12

By DAVID DRANOVE and CRAIG GARTHWAITE

The Affordable Care Act is premised, at least in part, on the notion that competition can be harnessed to reduce healthcare costs and improve quality. This explains why insurance in the individual market has not been nationalized. Instead, consumers go to an online exchange where they customers can easily (at least in theory) compare plans offered by different firms. Unleashing competitive forces should result in lower premiums for these plans. And why not? Over the past two decades, competition has been one of the few success stories in the U.S. health economy. For example, when competition intensified in the 1990s, healthcare costs moderated. When competition weakened in the wake of provider mergers and the backlash to the narrow networks that were essential to cost containment, healthcare costs rose.

When most people think about the benefits of competition, they tend to think about prices. Monopolies charge high prices; competitors charge low prices. There is nothing wrong with this perspective, but it misses a more fundamental point. In the long run, the greatest benefit of competition is that it has the potential to fuel innovation. This is as true, in theory, for health insurers as it is for telecommunications and consumer electronics. It hasn’t always been true in practice; for several decades after the IRS made employer-sponsored health insurance tax deductible, insurers tended to offer the same costly indemnity products. But consumers eventually demanded lower premiums, and insurers responded with managed care. After the backlash, insurers developed high deductible health plans and value based insurance design. Insurers are now moving towards reference pricing. These plans offer consumers reimbursement up to a pre-specified level for treatments that can be easily broken into a treatment episode such as hip replacements or MRIs. Patients have the choice of any provider, but they bear the cost of choosing a more expensive facility.

High deductibles and reference pricing are fine, but do not always work in practice. Chronically ill patients quickly exhaust their deductibles, and reference pricing does not work well for chronic diseases. In order to complement these tactics, some insurers are once again offering narrow network plans. We commented in earlier blog posts that the ACA would catalyze the return of these narrow networks and also warned that this might fuel another backlash. Unfortunately, a recent New York Times article shows, the backlash is well underway.

Hyping Cancer Genotyping

Jul 28, 2014• 13

By NORTIN HADLER, MD

It was 1970. I was in my laboratory at the NIH sequencing a murine myeloma protein in order to define the structure of its antibody combining region. Studies of protein conformation were at the cutting edge of science then; enthusiasm abounded. But it was clear to me that this work, in all its scientific elegance, had little to do with treating myeloma or anything else in mice or man. The reason for all the painstaking effort was the joy of pushing back the frontier of ignorance, even if only a bit. No one could foresee clinical utility then, nor would any become apparent for decades. Today such monoclonal antibodies are widely used to treat many diseases, sometimes with efficacy that justifies the costliness.

Genomics is in a bigger hurry.

Thanks to 40 years of breakthroughs, many earning Nobel Prizes, the chromosome carrying the defective gene underlying a genetic disease, Huntington’s disease, was identified in 1983 and the gene sequenced a decade later. In short order, defective genes underlying a number of single-gene diseases were defined: cystic fibrosis, hemophilia, and others. We all wait with baited breath for these elegant insights to transform into primary treatments for single allele genetic diseases. Attempts to transfect patients with normal genes are encouraging but barely so; it has proved difficult to get the right gene to stay in the right cells. Likewise, directly modifying the abnormal genetic apparatus is still largely just promising. The fallback remains working downstream from the genetic apparatus, replacing or modifying the defective products of many of these pathogenetic genes. Nonetheless, optimism regarding modifying the genetic apparatus itself is rational as is ever more boldness on the part of molecular biologists.

Using Big Data to Manage Medical Expectations

Jul 28, 2014• 4

By CYNTHIA RUDIN

x axis = time since prostatectomy, the y axis = predicted sexual function level,
scaled by the sexual function level. Young patients (below 55 years) reporting
poor sexual function prior to treatment

For all the advances in both medicine and technology, patients still face a bewildering array of advice and information when trying to weigh the possible consequences of certain medical treatments. But a hands-on, data-driven tool I have developed with some colleagues can now help patients obtain personalized predictions for their recovery from surgery. This tool can help patients better manage their expectations about their speed of recovery and long-term effects of the procedure.

People need to be able to fully understand the possible effects of a medical procedure in a realistic and clear way. Seeking to develop a model for recovery curves, we developed a Bayesian modeling approach to recovery curve prediction in order to forecast sexual function levels after prostatectomy, based on the experiences of 300 UCLA clinic patients both before radical prostatectomy surgery and during the four years immediately following surgery. The resulting interactive tool is designed to be used before the patient has a prostatectomy in order to help the patient manage expectations. A central predicted recovery curve shows the patient’s average sexual function over time after the surgery. The tool also displays a range of lighter-colored curves illustrating the broader range of possible outcomes.

This model not only shows people what they can expect about their recovery on average, based on their own specific characteristics, but it also clarifies the uncertainty in the shape of the recovery curve. It shows a range of possible realistic outcomes. We want to help patients who are considering this particular surgery to understand what they could expect. We can’t tell them exactly what their recovery will look like, but at least we can now forecast a personalized recovery curve and show them an informed prediction of their possible outcomes. The model can be used in an interactive way. For example, patients could adjust their reported age or reported sexual function levels to see how their predicted recovery curves change.

No Mystery: Arizona Execution Lengthy Due to Drug Choice

Jul 26, 2014• 11

By KAREN SIBERT, MD

There’s no mystery about why the July 23 execution of Joseph Wood in Arizona took so long. From the anesthesiologist’s point of view, it doesn’t seem surprising that the combination of drugs used—midazolam and hydromorphone—might take nearly two hours to cause death.

Here’s why.

The convicted murderer didn’t receive one component of the usual mixture of drugs used in lethal injection: a muscle relaxant. The traditional cocktail includes a drug such as pancuronium or vecuronium, which paralyzes muscles and stops breathing. After anyone receives a large dose of one of these powerful muscle relaxants, it’s impossible to breathe at all. Death follows within minutes.

But for whatever reason, the Arizona authorities decided not to use a muscle-relaxant drug in Mr. Wood’s case. They used only drugs that produce sedation and depress breathing. Given enough of these medications, death will come in due time. But in the interim, the urge to breathe is a powerful and primitive reflex.

So-called “agonal” breathing, which precedes death, may go on for minutes to hours. The gasping or snoring that eyewitnesses described would be very typical. People who are unconscious after overdoses of heroin try to breathe in a similarly slow, ineffective way, before they finally stop breathing altogether or are rescued by emergency crews.

More about the drugs

Midazolam is a member of a class of drugs called benzodiazepines. The common “benzos” that many people take include Valium, Xanax, and Ativan. What these drugs have in common is that they produce relaxation and sleep. You might take a Xanax pill, for instance, to help you nap during a long flight.

In anesthesiology, we use benzodiazepines for another important reason: because they produce amnesia. There are stories of people taking a Valium to relax a little before they give an important talk, and the next day panicking because they can’t remember if they actually showed up and gave the talk.

Amnesia can be very helpful in my business. Many of my patients don’t want to remember coming into the operating room and seeing the bright lights and surgical instruments. After I inject one or two milligrams of midazolam into the IV, they’re often smiling and relaxed, and they have no memory later of coming into the operating room at all. The next thing they know, surgery is over and they’re waking up.

Half the Cost. Half the Jobs?

Jul 25, 2014• 58

By JOE FLOWER

Healthcare costs far too much. We can do it better for half the cost. But if we did cut the cost in half, we would cut the jobs in half, wipe out 9% of the economy and plunge the country into a depression.

Really? It’s that simple? Half the cost equals half the jobs? So we’re doomed either way?

Actually, no. It’s not that simple. We cannot of course forecast with any precision the economic consequences of doing healthcare for less. But a close examination of exactly how we get to a leaner, more effective healthcare system reveals a far more intricate and interrelated economic landscape.

In a leaner healthcare, some types of tasks will disappear, diminish, or become less profitable. That’s what “leaner” means. But other tasks will have to expand. Those most likely to wane or go “poof” are different from those that will grow. At the same time, a sizable percentage of the money that we waste in healthcare is not money that funds healthcare jobs, it is simply profit being sucked into the Schwab accounts and ski boats of high income individuals and the shareholders of profitable corporations.

Let’s take a moment to walk through this: how we get to half, what disappears, what grows and what that might mean for jobs in healthcare.

Getting to half

How would this leaner Next Healthcare be different from today’s?

Waste disappears: Studies agree that some one third of all healthcare is simple waste. We do these unnecessary procedures and tests largely because in a fee-for-service system we can get paid to do them. If we pay for healthcare differently, this waste will tend to disappear.

Prices rationalize: As healthcare becomes something more like an actual market with real buyers and real prices, prices will rationalize close to today’s 25th percentile. The lowest prices in any given market are likely to rise somewhat, while the high-side outliers will drop like iron kites.

Internal costs drop: Under these pressures, healthcare providers will engage in serious, continual cost accounting and “lean manufacturing” protocols to get their internal costs down.

The gold mine in chronic: There is a gold mine at the center of healthcare in the prevention and control of chronic disease, getting acute costs down through close, trusted relationships between patients, caregivers, and clinicians.

Tech: Using “big data” internally to drive performance and cost control; externally to segment the market and target “super users;” as well as using widgets, dongles, and apps to maintain that key trusted relationship between the clinician and the patient/consumer/caregiver.

Consolidation: Real competition on price and quality, plus the difficulty of managing hybrid risk/fee-for-service systems, means that we will see wide variations in the market success of providers. Many will stumble or fail. This will drive continued consolidation in the industry, creating large regional and national networks of healthcare providers capable of driving cost efficiency and risk efficiency through the whole organization.

Are Patient Privacy Laws Being Abused to Protect Medical Centers?

Jul 24, 2014• 12

By CHARLES ORNSTEIN

This story was co-published with NPR’s “Shots” blog.

In the name of patient privacy, a security guard at a hospital in Springfield, Missouri, threatened a mother with jail for trying to take a photograph of her own son. In the name of patient privacy , a Daytona Beach, Florida, nursing home said it couldn’t cooperate with police investigating allegations of a possible rape against one of its residents.

In the name of patient privacy, the U.S. Department of Veterans Affairs allegedly threatened or retaliated against employees who were trying to blow the whistle on agency wrongdoing.When the federal Health Insurance Portability and Accountability Act passed in 1996, its laudable provisions included preventing patients’ medical information from being shared without their consent and other important privacy assurances.But as the litany of recent examples show, HIPAA, as the law is commonly known, is open to misinterpretation – and sometimes provides cover for health institutions that are protecting their own interests, not patients’.

“Sometimes it’s really hard to tell whether people are just genuinely confused or misinformed, or whether they’re intentionally obfuscating,” said Deven McGraw, partner in the healthcare practice of Manatt, Phelps & Phillips and former director of the Health Privacy Project at the Center for Democracy & Technology.For example, McGraw said, a frequent health privacy complaint to the U.S. Department of Health and Human Services Office of Civil Rights is that health providers have denied patients access to their medical records, citing HIPAA. In fact, this is one of the law’s signature guarantees.”Often they’re told [by hospitals that] HIPAA doesn’t allow you to have your records, when the exact opposite is true,” McGraw said.

I’ve seen firsthand how HIPAA can be incorrectly invoked.

In 2005, when I was a reporter at the Los Angeles Times, I was asked to help cover a train derailment in Glendale, California, by trying to talk to injured patients at local hospitals. Some hospitals refused to help arrange any interviews, citing federal patient privacy laws. Other hospitals were far more accommodating, offering to contact patients and ask if they were willing to talk to a reporter. Some did. It seemed to me that the hospitals that cited HIPAA simply didn’t want to ask patients for permission.