Month: February 2015

How Technology Will Disrupt Your Doctor’s Monopoly

Feb 10, 2015• 13

By ALAN PITT, MD

Although you may not realize it, your doctor is a monopoly. Yes, you can see someone else, but not without difficulty. And if you wanted a second opinion, how far would you go? In part, through insurance coverage, in part based on a desire for convenience, healthcare is generally a local monopoly. However, that may be about to change.

I’m a radiologist, an expert in medical imaging. When I started my career in 1997, I’d show up for work and it was just me and my films. The exams presented to me were a mix of imaging- CT, MRI, ultrasound, plain X-Rays- all captured, presented and stored on film. By 2000, the film was gone. Just about everything I did was done on a computer.

I was an early proponent for this technology (also know as PACS for Picture Archiving and Communications Systems). It allowed my group to work faster and smarter. However through a series of steps (consolidation, specialization and finally commoditization/globalization) technology broke up the local monopoly many radiology groups enjoyed. Similar to Instagram, PACS allowed medical images to be seen instantly by anyone anywhere. And now, based on improvements in technology, I’m expecting similar changes for the rest of healthcare.

Consolidation

Tele-radiology first emerged in hospitals when computers began to be used to optimize the daily workload. At the beginning of my career, several doctors divided work for the day into piles. Each person did his or her allotment with no real help from peers. With the transition to digital, work became a common pile that was shared among physicians in the same hospital. Faster doctors filled downtime gaps reading more cases, resulting in improved overall efficiency.

False Positives and Real Dollars: Why $88 won’t effectively screen for lung cancer

Feb 9, 2015• 11

By MATT HAWKINS, MD

Let me be clear. I think lung cancer screening is a good thing. The National Lung Cancer Screening Trial (NLST) had air-tight design and was impeccably performed. Those who have paid attention know that the NLST demonstrated a 20% relative reduction in mortality from low-dose CT screening (as opposed to chest x-ray). Plus, the all-cause rate of death in the low-dose CT group was 6.7% lower than the radiography cohort.

But the details reveal concerns – those with financial and geographic-specific implications that have, until now, mostly escaped public debate. The fanfare that accompanied the glorious NLST quest has supplied perverse financial incentives for entrepreneurial types – and has put patients in places such as the Ohio River Valley at potentially increased risk from exploitation of our interminable fear of cancer. It has also given providers in these regions the unenviable and perhaps impossible task of balancing costs, patient expectations, and disease prevalence.

The Histo-belt

I took this picture while driving along a rural southern Indiana highway during a recent trip to visit family. Southern Indiana (and neighboring northern Kentucky) are known for blue-collar shipping industries, steamboats, and high school basketball. They also rest squarely in what is colloquially known as the “Histo-belt.” Histoplasma capsulatum is a fungus endemic to the Ohio and Mississippi River Valleys. It is everywhere. You get it by breathing. Prior studies suggest that >80% of those living in these regions have contracted the fungus. The majority of people with histo don’t get sick. But – they get lung nodules. Lots of them. The nodules are benign but often indistinguishable on imaging from “early” lung cancer. Continue reading…

Halamka Speaks: athenahealth & the Future of AMCs as Tech Innovators

Feb 9, 2015• 4

By MATTHEW HOLT

It’s always interesting to talk with John Halamka, and last week–after athenahealth bought the IP but apparently not the actual code of the Beth Israel Deaconess Medical Center (BIDMC) web-based EHR he’s been shepherding for the past 18 years–I got him on the record for a few minutes. We started on the new deal but given that had already been covered pretty well elsewhere we didn’t really stay there. More fun that way–Matthew Holt

Matthew Holt: The guys across town (Partners) ripped out all the stuff they’ve been building and integrating for the last 30 years and they decided to pay Judy Faulkner over a billion dollars. And you took all the stuff that you’ve been building for the past 15 to 20 years and sold it to Jonathan Bush for money. Does that make you a better businessman than they are?

(Update Note 2/11/15: While I’ve heard from public & private sources that the cost of the Partners project will be between $700m and $1.4 billion, Carl Dvorak at Epic asked me to point out less than 10% of the cost goes to Epic for their fees/license. The rest I assume is external and internal salaries for implementation costs, and of course it’s possible that many of those costs would exist even if Partners kept its previous IT systems).

John Halamka: Well, that is hard to say, but I can tell you that smart people in Boston created all these very early systems back in the 1980s. On one hand, the John Glaser group created a client server front end. I joined Beth Israel Deaconess in 1996 and we created an entirely web-based front end. We have common roots but a different path.

It wasn’t so much that I did this because of a business deal. As I wrote in my blog, there is no benefit to me or to my staff. There are no royalty streams or anything like that. But sure, Beth Israel Deaconess receives a cash payment from Athena. But important to me is that the idea of a cloud-hosted service which is what we’ve been running at Beth Israel Deaconess since the late ’90s hopefully will now spread to more organizations across the country. And what better honor for a Harvard faculty member than to see the work of the team go to more people across the country?

MH: There’s been a lot of debate about the concept of developing for the new world of healthcare using client server technology that has been changed to “sort of” fit the integrated delivery systems over the last 10 years, primarily by Epic but also Cerner and others. In particular how open those systems are and how able they are to migrate to new technology. You’ve obviously seen both sides, you’re obviously been building a different version than that. And a lot of this is obviously about plugging in other tools, other technologies to do things that were never really envisaged back in 1998. You’ve come down pretty strongly on the web-based side of this, but what’s your sense for how likely it is that what has happened over the last five or ten years in most other systems including the one across the street we just mentioned is going to change to something more that looks more like what you had at Beth Israel Deaconess?Continue reading…

Anthem Was Right Not to Encrypt

Feb 9, 2015• 53

By FRED TROTTER

The Internet is abuzz criticizing Anthem for not encrypting its patient records. Anthem has been hacked, for those not paying attention.

Anthem was right, and the Internet is wrong. Or at least, Anthem should be “presumed innocent” on the issue. More importantly, by creating buzz around this issue, reporters are missing the real story: that multinational hacking forces are targeting large healthcare institutions.

Most lay people, clinicians and apparently, reporters, simply do not understand when encryption is helpful. They presume that encrypted records are always more secure than unencrypted records, which is simplistic and untrue.

Encryption is a mechanism that ensures that data is useless without a key, much in the same way that your car is made useless without a car key. Given this analogy, what has apparently happened to Anthem is the security equivalent to a car-jacking.

When someone uses a gun to threaten a person into handing over both the car and the car keys needed to make that care useless, no one says “well that car manufacturer needs to invest in more secure keys”.

In general, systems that rely on keys to protect assets are useless once the bad guy gets ahold of the keys. Apparently, whoever hacked Anthem was able to crack the system open enough to gain “programmer access”. Without knowing precisely what that means, it is fair to assume that even in a given system implementing “encryption-at-rest”, the programmers have the keys. Typically it is the programmer that hands out the keys.

Most of the time, hackers seek to “go around” encryption. Suggesting that we use more encryption or suggesting that we should use it differently is only useful when “going around it” is not simple. In this case, that is what happened.

NATE: Making Choices Easier

Feb 9, 2015• 3

By AARON SEIB

You have the choice to get your health information anywhere and any way you want –according to the Office of Civil Rights with some limitations. Today, more and more uses of health information are being presented to consumers as innovators recognize our demand for health related applications. Unfortunately, there is a dilemma. Over the past ten years a lot of things have changed – more and more providers are using technology to improve how they deliver care and, once that care is delivered, how they share information with other caregivers that see the patient. Sadly, other things are still pretty much as they were in the 19th Century, including how patients get access to information about themselves held by their provider.

The release of the National Association for Trusted Exchange’s (NATE) Blue Button for Consumers (NBB4C) Trust Bundle is aimed at simplifying interoperability between the healthcare delivery system and the consumer, enabling you to decide how to use your health information.

NATE is an association focused on enabling trusted exchange among organizations and individuals with differing regulatory environments and exchange preferences. With beginnings back in 2012, NATE emerged from a pilot project supported by the Office of the National Coordinator for Health Information Technology (ONC). NATE was incorporated as a not-for-profit organization on May 1, 2012 in the District of Columbia. NATE has been operating Trust Bundles in production since November 2012 and recently took over administration of the Blue Button Consumer Trust Bundles. Working with a broad set of stakeholders through multiple task forces, crowdsourcing and a call for public comment, NATE announced the first release of NATE’s Blue Button for Consumers (NBB4C) Trust Bundle February 4th at the ONC’s Annual meeting.Continue reading…

Will Getting More Granular Help Doctors Make Better Decisions?

Feb 7, 2015• 11

By MARC-DAVID MUNK

I’ve been thinking a lot about “big data” and how it is going to affect the practice of medicine. It’s not really my area of expertise– but here are a few thoughts on the tricky intersection of data mining and medicine.

First, some background: these days it’s rare to find companies that don’t use data-mining and predictive models to make business decisions. For example, financial firms regularly use analytic models to figure out if an applicant for credit will default; health insurance firms can predict downstream medical utilization based on historic healthcare visits; and the IRS can spot tax fraud by looking for fraudulent patterns in tax returns. The predictive analytic vendors are seeing an explosion of growth: Forbes recently noted that big data hardware/software and services will grow at a compound annual growth rate of 30% through 2018.

Big data isn’t rocket surgery. The key to each of these models is pattern recognition: correlating a particular variable with another and linking variables to a future result. More and better data typically leads to better predictions.

It seems that the unstated, and implicit belief in the world of big data is that when you add more variables and get deeper into the weeds, interpretation improves and the prediction become more accurate.Continue reading…

The Psephology of Early Diagnosis in Britain’s NHS

Feb 6, 2015• 17

By SAURABH JHA, MD

Consider this equation.

Early Diagnosis = Early Diagnosis + Overdiagnosis (1.1)

This sort of unequal algebra will fail high school mathematics. A new NHS initiative is arithmetic defying as well. Patients who think they have symptoms of cancer will be allowed to book medical imaging directly, without seeing their GP. This is to catch cancer early. The logic is impenetrable: early diagnosis of cancer saves lives.

Here is the problem. Cancer does not unequivocally announce its arrival. Early cancer presents with non-specific symptoms, such as an uncomfortable niggle in the back.

Tom

Let’s take Tom, who has advanced pancreatic cancer. He recalls that three years earlier he noticed a dull pain in his back during a misguided drinking binge. He would be correct in thinking that had he attended the emergency department and had a CAT scan of his abdomen, the cancer would have been smaller and would not have spread to other organs. He is right in contending that had the cancer been removed then, he would have a longer survival than presently.

The rationale has implications if extrapolated to everyone. To understand the consequences of extrapolation let’s visit a logical fallacy.

1) All Mr Smiths are over six feet tall.

2) He is above six feet tall so he must be Mr Smith.

This is affirming the consequent. Not all men above six feet in height are Mr Smiths. In fact, most are not.

3) Early pancreatic cancer presents with back pain.

4) All patients with back pain have early pancreatic cancer.

Similarly, (3) doesn’t imply (4).

Cancer often presents with non-specific symptoms, such as a vague discomfort, early on. But the majority of people with a vague discomfort do not have cancer. That is, the chance that someone with pancreatic cancer has dull back pain should not be confused with the chances that someone with dull back pain has pancreatic cancer. The chances of the latter are much lower than the former.

Computers Replacing Doctors, Innovation and the Quantified Self: An Interview with Atul Gawande

Feb 5, 2015• 49

By ROBERT WACHTER, MD

Atul Gawande is the preeminent physician-writer of this generation. His new book, Being Mortal, is a runaway bestseller, as have been his three prior books, Complications, Better, and The Checklist Manifesto.

One of the joys of my recent sabbatical in Boston was the opportunity to spend some time with Atul, getting to see what an inspirational leader and superb mentor he is, along with being a warm and menschy human being. In my continued series of interviews I conducted for The Digital Doctor, my forthcoming book on health IT, here are excerpts from my conversation with Atul Gawande on July 28, 2014 in Boston.

I began by asking him about his innovation incubator, Ariadne Labs, and how he decides which issues to focus on.

Gawande: Yeah, I’m in the innovation space, but in a funny way. Our goal is to create the most basic systems required for people to get marked improvements in the results of care. We’re working in surgery, childbirth, and end-of-life care.

The very first place we’ve gone is to non-technology innovations. Such as, what are the 19 critical things that have to happen when the patient comes in an operating room and goes under anesthesia? When the incision is made? Before the incision is made? Before the patient leaves the room? It’s like that early phase of the aviation world, when it was just a basic set of checklists.

In all of the cases, the most fundamental, most valuable, most critical innovations have nothing to do with technology. They have to do with asking some very simple, very basic questions that we never ask. Asking people who are near the end of life what their goals are. Or making sure that clinicians wash their hands.Continue reading…

Random Evil Policy Cancellations

Feb 5, 2015• 3

By THCBist

Suspicious in Michigan writes:

I am really upset. Our ACA coverage was cancelled without my knowledge or permission. When I contacted the help line I was informed that I had cancelled the policy myself, which is ridiculous! During a conference call with BCBSM and the marketplace, I was told that only a consumer could cancel a policy. Since neither myself nor my wife would have cancel I inquired what proof did they (the marketplace) have to verify it was in fact one of us that cancelled the policies. They don’t have that capability in their system. … The Market Place needs to be able to document who, when and where and the phone number used in canceling a policy. I can assure you we never had anything to do with effecting a policy cancelation. This needs to be investigated. Has anyone else experienced the Healthcare Marketplace canceling their policy especially with Blue Cross Blue Shield of Michigan? Please respond.

Where Does the ACA Go From Here?

Feb 5, 2015• 6

By DAVID DRANOVE and CRAIG GARTHWAITE

Barring a Republican landslide in 2016, it looks like the Affordable Care Act (ACA) is here to stay. By and large, we think that is a good thing. While there are many things in the ACA that we would like to see changed, the law has provided needed coverage for millions of Americans that found themselves (for a variety of reasons) shut out of the health insurance market.

That being said, since its passage the ACA has evolved and the rule makers in CMS continue to tinker around the edges. We are especially encouraged by CMS’ willingness to relax some of the restrictions on insurance design, but remain concerned about some of the rules governing employers and the definition of what is “insurance.” In the next few blogs we will examine some of the best, and worst, of the ongoing ACA saga.

We start with one of CMS’s best moves—encouraging reference pricing. The term reference pricing was first used in conjunction with European central government pricing of pharmaceuticals. Germany and other countries place drugs into therapeutic categories (such as statins or antipsychotics) and announce a “reference price” which insurers (either public or, in Germany, quasi-public) that insurers will reimburse for the drug. Patients may purchase more expensive drugs, but they were financially responsible for all costs above the references price. Research shows that reference pricing helps reduce drug spending both by encouraging price reductions (towards the reference price) and reducing purchases of higher priced drugs within a reference category. Other research has found suggestive evidence of similar results for reference pricing for medical services.

While the ACA does little to govern pricing in the pharma market, the concept of reference pricing can and should be extended other medical products and services. In particular, insurers can establish reference prices for bundled episodes of illness such as joint replacement surgery. Under the original ACA rules set forth by CMS, insurers were free to establish a fixed price for bundled episodes. They could even require enrollees to pay the full difference between the provider’s price and the reference price. But there was a catch. It wasn’t clear if any spending above the reference price would count to the enrollees by enrollees out of pocket limits (currently $6,600 for individual plans and $13,200 for family plans). Obviously, allowing the out of pocket limit to bind on reference pricing would limit the effectiveness of this cost control measure.