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John Irvine

Technologic Decline in Health Care


The Disease Management Care Blog has been delighting in the geopolitical lessons of George Friedman’s book The Next Decade: Where We’ve Been . . . and Where We’re Going. While most of Dr. Friedman’s work deals with foreign policy (for example, a better relationship with Argentina can serve as an important counterweight to the emerging power of Brazil and its threats to sea lanes in the south Atlantic), there were two unexpected healthcare insights toward the end of the book.

They are 1) U.S. technology innovation is in decline and will stay that way for years, and 2) the next area of innovation will be “robotics.”

First, the technology.

The United States’ twin health care challenges are demography and technology. Most DMCB readers understand the demography: there is an aging baby-boomer population that is well on its way to living long enough to develop degenerative diseases that will sap the available labor pool and cause consumption of expensive services to soar. Yet, the problem with the parallel issue of technology, according to Dr. Friedman isn’t cost. It’s that technology occurs in waves of innovation that have crested and is now in decline just when we need it.

Technological “waves,” you ask? Looking back, Dr. Friedman argues that the first great wave in the 80’s and 90’s was characterized by the advent of increasingly powerful computers, microprocessors and robust data storage. Think Microsoft. The second was this decade’s massive data transmission and communication. Think the Internet. Unfortunately, both technology waves ended with an emphasis on expanding capacity and finding new applications for the existing technology. In the 90’s, personal computers plateaued and Microsoft’s business model focused on protecting its business models. While today’s Internet is still being rocked by Facebook and Twitter, the fundamentals of “many to many” communication haven’t really changed for years. Productivity gains from technology have peaked and the rest is, in the author’s words, a matter of rearranging the deck chairs.

Despite our investment in medical research, that pales compared to the benefits from military research spending. Ironically, that, not the Institutes of Health, has been the most powerful impetus to new waves of health care innovation, from penicillin to MASH units to remote robotic surgery. All that is now in decline, thanks to the U.S. focus on applying current technologies (the exception being remotely piloted drones) to a limited style of infantry-based land warfare. Another impediment is America’s budget woes combined with the unwillingness of the private financial markets to commit capital to anything other than safe bets. Add it all up and Dr. Friedman argues that it is unlikely that another technological innovation wave is going to occur before 2020.

Now…. robotics.

Dr. Friedman points out that there aren’t enough people to care for all the aging boomers. He says that the answer will be devices that he says “change reality,” but could be better termed as capable of manipulating the environment. When the DMCB thinks about this, aren’t all those blue toothed glucose meters, remote blood pressure monitors, telephonic heart devices and other “input” devices merely “half” of what is ultimately needed? The other half will be “output” devices that administer medicine, generate a treatment, give advice or trigger other responses from the health care system. They may not “look” like “robots” with a pair of flashing eyes or waving arms, but they will definitely “speak” to their masters and will probably be mobile.

They will need even higher levels of computing power as well as more powerful batteries. We don’t have that yet.

It’s no accident that the military seems to be leading the way on the robotics. Ironically, the DMCB has a new appreciation for that technology and is now cheering it on. That’s because until they come on line, the only answers we have are 1) drugs that may delay the onset of the diseases plaguing the boomers along with 2) providing palliative services. Neither options seem to be very attractive.

2020 is about when the DMCB and the spouse are going to be in their 60s.

Jaan Sidorov, MD, is a primary care internist and former Medical Director at Geisinger Health Plan with over 20 years experience in primary care, disease management and population-based care coordination. He shares his knowledge and insights at Disease Management Care Blog, where this post first appeared.

Value-based Interoperability: Less is more

flying cadeuciiInteroperability in health care is all the rage now. After publishing a ten year interoperability plan, which according to the Federal Trade Commission (FTC) is well positioned to protect us from wanton market competition and heretic innovations, the Office of the National Coordinator for Health Information Technology (ONC) published the obligatory J’accuse report on information blocking, chockfull of vague anecdotal innuendos and not much else. Nowadays, every health care conversation with every expert, every representative, every lobbyist and every stakeholder, is bound to turn to the lamentable lack of interoperability, which is single handedly responsible for killing people, escalating costs of care, physician burnout, poverty, inequality, disparities, and whatever else seems inadequate in our Babylonian health care system.

When you ask the people genuinely upset at this utter lack of interoperability, what exactly they feel is lacking, the answer is invariably that EHRs should be able to talk to each other, and there is no excuse in this 21st iCentury for such massive failure in communications. The whole thing needs to be rebooted, it seems. After pouring tens of billions of dollars into building the infrastructure for interoperability, we are discovering to our dismay that those pesky EHRs are basically antisocial and are totally incapable or unwilling to engage in interoperability. The suggested solutions range from beating the EHRs into submission to just throwing the whole lackluster lot out and starting fresh to the tune of hundreds of billions of dollars more. When it comes to sacred interoperability, money is not an object. It’s about saving lives.

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Keep Calm and Interoperate On

Following the recession, the Obama administration sought shovel-ready projects.

One unlikely shovel wielding aggregate demand was health information technology. The Health Information Technology for Economic and Clinical Health (HITECH) Act passed in 2009 directed 5 % of the stimulus towards digitizing medical records.

Computerization of medical records doesn’t induce the images of public works as building freeways during the Great Depression does, but the freeway is a metaphor for exchange of information between electronic health records with the implication that such an exchange is a public good and so government intervention is justified.

Robert Wachter, voted the most influential physician by Modern Healthcare, sums the optimism and frustration with the electronic health record (EHR) in Digital Doctor – which stands to be a classic.

It was Bush Jr., not Obama, who started the digitization. Seeking bipartisanship after the war in Iraq, Bush was inspired by his closest ally, Tony Blair, who was wiring the National Health Service (NHS) – a $16 billion initiative which has since failed, spectacularly.

Bush founded the Office of National Coordinator of Health Information Technology (ONC) and appointed David Brailer – a physician, quant and entrepreneur – as head. Brailer wanted interoperability so that hospitals shared information. It is because of interoperability that we can use our debit cards in New York and Singapore. The market must agree on a common language, such as the TCP/ IP for the internet, to achieve interoperability.

Patients suffer when systems can’t talk. Were patients, not a third party, bearing the full costs of care – a free market – they might have forced hospital information systems to talk. Rightly or not, healthcare is not a free market and hospitals have little motivation in making cross-talking simpler.

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A Second Look at the Two Midnight Rule

Anwar“You gotta change us to inpatient!”

Mrs. Mack’s daughter was referring to me changing her mother’s status from “inpatient” to “outpatient.” If Mrs. Mack was discharged as an outpatient, she wouldn’t be able to afford to go to the nursing home she needed to make a full recovery, and her daughter couldn’t care for her at home.

Physicians and hospital are all too familiar with this scenario.  When a patient stays inside a hospital building, they can be either an inpatient or an outpatient.  A patient can be either in an inpatient status or an outpatient status, yet stay in a hospital bed overnight and receive identical care.  The ‘2 Midnight Rule’ serves to put this determination of status in the hands of doctors, but somehow, physicians like those in the Society of Hospital Medicine and the American Hospital Association dislike this new responsibility.

When I work as an emergency physician or an internist, I used to have to explain to patient families that this status designation is not in my hands.

Mrs. Mack’s daughter was in a precarious situation, but not an uncommon one; I’ve heard similar requests from patients and their families, and with good reason.

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Why Cancer Patients and Clinicians Need a Decision Aid Upgrade

flying cadeucii

We have learned a lot about how to treat cancer in the past 30 years, yet patients still experience significant symptoms, pain, and stress from cancer and its treatments. And we are nowhere near curing patients of some of the most debilitating forms of this disease.

The outlook for lung cancer can be particularly poor because it is often diagnosed at a late stage, tends to occur in older people who often have other medical conditions, and remains one of the most difficult cancers to treat. The average survival has increased a few months with new treatment, but is still only to about a year – way too short.

However research has shown that palliative care – which addresses the emotional, physical, practical, and spiritual issues of serious illness – can help lung cancer patients live better, longer lives.

So, how do we incorporate palliative care into our conversations with patients and families who expect us to tell them about the latest treatment, downplay its side-effects and demonstrate the tenacity with which we will fight for them and with them against this scourge? It is especially tough when 70% of people (and some of their doctors) don’t know what palliative care is, or think of it just as “end of life care” or hospice.Continue reading…

Doctors Should Own Up to Creating the Mark Cuban Problem

Adams Dudley UCSF

Much has been made of Mark Cuban’s medical knowledge since he tweeted, “If you can afford to have your blood tested for everything available, do it quarterly so you have a baseline of your own personal health”.  Charles Ornstein shared the tweet and many physicians and others, myself included, weighed in on the costs and potential for harm from unnecessary testing.

I’ll admit that, when I tweeted to him, I expected Cuban to agree. But he didn’t. In fact, he grew increasingly resistant. I stopped responding when he announced that the opposition to his idea his had convinced him he needed to take his proselytizing to his TV show.

Instead of poking the sore, I began to wonder about the origins of Cuban’s conviction. I remembered that he is not alone in wanting tests that clinicians who worry about value, cost, and harm think he shouldn’t have.

But where do these attitudes come from? Is it possible that clinicians are contributing in any way to this situation? Quite the contrary: most Americans want tests, even when you tell them that nothing can be done with the information. Furthermore, Americans are more convinced of the benefits of tests like mammograms than people in other countries, and then go out and get more of them.

I think that we are. My team has studied why patients get so many electively placed coronary stents, when cardiologists readily admit that randomized trials have demonstrated that there are few situations in which such stents improve survival or reduce the risk of heart attacks.

Studies of the beliefs of patients who have just received an electively placed stent give a big clue: 80% thought stenting would reduce their risk of death, even though their cardiologists knew that this was not the case.

Dudley Belief

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Wikipedia: Homeopathy and Evidence for Unpatentable Medications

flying cadeuciiRecently, I have had some interesting conversations with doctors and medical students of Naturopathic Medicine. I am slowly getting involved in editing Wikipedia medicine articles, and I was approached by several proponents of Naturopathic Medicine, who were upset about the following phrases from the Wikipedia article on Naturopathy:

Naturopathic philosophy is based on a belief in vitalism and self-healing, and practitioners often prefer methods of treatment that are not compatible with evidence-based medicine. Naturopathic medicine is replete with pseudoscientific, ineffective, unethical, and possibly dangerous practices.

Of course, they felt this was unfair. In their mind, the Wikipedia article was “wrong” and needed to be fixed and they were frustrated by the tendency for Wikipedia editors to thwart their efforts to “fix” the article.

This put me in an uncomfortable position. I had the option of remaining entirely silent, or informing these followers of Naturopathy of several issues:

  1. Wikipedia has become a “court for facts”. The Wikipedian community focuses on what has become verifiable scientific consensus.

  2. There is very little scientific consensus supporting Naturopathic methods while there is is a substantial amount of scientific consensus opposing some Naturopathic methods.

  3. Naturopathic methods tend to layer “placebo effects” (Ben Goldacre is the inevitable reference for how that works).

  4. These layered placebo effects tend to make the patients of naturopaths and the naturopaths themselves, believe that their methods are way more effective than they actually are.

  5. I have to admit that I fully expected to have a serving of Tim Minchin’s Storm. But what the hell. Why not?? So I jumped and put the basic issues forward.

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In Defense of Epic. No, Really!

flying cadeucii

Today THCB is delighted to feature an excerpt from Robert Wachter’s much-talked about new book “The Digital Doctor: Hope, Hype and Harm at the Dawn of Medicine’s Computer Age (McGraw Hill, 2015). If you enjoy this piece, be sure have a look at the director’s cut interviews Wachter did for the book with Atul Gawande: “Computers Replacing Doctors“,  and John Halamka: “Black Turtlenecks, Data Fiends & Code.” — John Irvine

That Epic would find itself labeled a monopoly is in itself an extraordinary turn of events. In 2000, after 21 years in business, the company had only 400 employees and 73 clients, and did not appear on a list of the top 20 hospital  EHR vendors. Its big break came in 2003, when the 8 million–member Kaiser Permanente system selected Epic over two far better known competitors, IBM and Cerner. The cost to build Kaiser’s electronic health record: $4 billion.

Today, Epic has 8,100 employees, 315 clients, and yearly revenues of approximately $2 billion. The system is now deployed in 9 of the US News & World Report’s “Top 10” hospitals. In 2014, the company estimated that 173 million people (54 percent of the U.S. population) had at least some medical information in an Epic electronic record.

Epic Founder and CEO Judy Faulkner’s vision, built on several central tenets, has been vindicated many times over. The first principle was that the winning EHR vendor would be the one that solved the most problems for its customers.

While Apple’s App Store has made a modular environment seem feasible and even desirable, most healthcare decision makers want a single product that does everything they need right out of the box (physician notes, nursing notes, drug ordering and dispensing, billing, compliance, and population health) and does those things everywhere, from the newborn nursery to the urology clinic to the ICU.

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The Case For the Exchanges

The Federal government will push forward to establish health insurance exchanges regardless of how the Supreme Court rules on the Affordable Care Act in the weeks to come, argues THCB contributor Maggie Mahar.  The only sensible conclusion?  The states should accept Washington’s help and open up the market for insurance online.

The Affordable Care Act (ACA) calls on the states to create health insurance exchanges – marketplaces where individuals and small businesses can shop for and compare health insurance plans. Beginning in 2014, insurers peddling policies on an exchange will have to meet the ACA’s standards by covering “essential benefits,” capping out-of-pocket expenses for individuals, and offering more transparent information about costs and benefits.

Best of all, insurers will not be able to turn down customers suffering from chronic diseases, or charge them higher premiums.

So far so good.

But some states are attempting to derail “Obamacare.” Florida, Louisiana and Alaska have openly declared that they will have nothing to do with setting up exchanges. Last week, reported that many others are stalling. The post quoted one consultant predicting that “between five and 10 states” will meet the 2014 deadline. The American Prospect confirmed the news, adding that some states that had begun making plans “have slowed down while awaiting the Supreme Court ruling on the health law.”

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The Boy Who Lived

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YouTube: Hundreds of thousands of Internet users downloaded a shockingly powerful viral YouTube clip made by an Austin teenager shortly before his death. Eighteen year old Ben Breedlove, who suffered from hypertrophic cardiomyopathy, died on Christmas day.

See Also: This Is My Story (Part 2) The second part of Ben’s story.

And: Los Angeles Times story on Breedlove, refutes charges video is a hoax.