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Can Facebook Save Us?

• 12

By JAMES SALWITZ, MD


At some point, this gets to be ridiculous. Online, I can buy any item from anywhere at any price, pay any bill, watch any movie, listen to any song, order dinner, schedule car repair or read about any subject on Wikipedia.  I can determine the weather in Rio, sport scores of Barcelona, Parisian traffic or by GPS the location of my kids, just down the block.  However, I absolutely cannot learn anything at all of the health history of the flesh and blood cancer patient sitting right in front of me.

Today, I am seeing long-term patient, Thomas R.  Father of three and a really nice guy, Tom is a medical challenge.

He is immunocompromised and status post 20 years of complex chemotherapy, radiotherapy, a bone marrow transplant and several bizarre complications, we barely understand.  In the last two months, since his last visit with me, he has seen an internist, a dermatologist, a podiatrist, a neurologist, a dentist and an infectious disease specialist.  These doctors ordered X-rays, lab tests, blood cultures, an EMG, a skin biopsy and several new medicines.

These are confusing tests resulting in confusing diagnoses with confusing therapy in a confusing patient.

What records do I have of all this new complexity? Nada. None.  Moreover, based on our files, all these other physicians have none of ours.

Continue reading…

How Doctors Think About New Technologies

• 20

By Leslie Kernisan, MD

“Hey doctor, what do you think about this product/solution/service?”

These days, I look at a lot of websites describing some kind of product or solution related to the healthcare of older adults. Sometimes it’s because I have a clinical problem I’m trying to solve. (Can any of these sleep gadgets provide data — sleep latency, nighttime awakenings, total sleep time — on my elderly patient’s sleep complaints?)

In other cases, it’s because a family caregiver asks me if they should purchase some gizmo or sensor system they heard about. (“Do you think this will help keep my mom safe at home?”)

And increasingly, it’s because an entrepreneur asks me to check out his or her product.

So far, it’s been a bit of a bear to try to check out products. Part of it is that there are often too many choices, and there’s not yet a lot of help sifting through them. (And research has shown that choices create anxiety, decision-fatigue, and dissatisfaction with one’s ultimate pick.)

But even when I’m just considering a single product and trying to decide what to think of it, I find myself a bit stumped by most websites. And let’s face it, if I visit a website and it doesn’t speak to my needs and concerns fairly quickly, I’m going to bail. (Only in exceptional cases will I call or email for more information.)

So I thought it might be interesting to try to articulate what would help me more thoughtfully consider a product or service that is related to the healthcare of older adults.

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Why Obamacare Helps Small Business – And What That Means For the Rest of Us

• 23

By JAAN SIDOROV, MD

It wasn’t until I had read this Jan. 30 Wall Street Journal opinion piece that I realized that my “nano” corporate” status was packed with such futuristic potential. According to the editorialist, American companies should follow my lead and be “protean” by dropping old fashioned W-2 employees and substituting 1099 contract relationships.  That way, everyone – including a single person “nano” – can enjoy the upsides of being a corporation and stay below Obamacare’s 50 employee pay-or-play $2000 penalty threshold.

Since I formed my own corporation more than 5 years ago, it has certainly participated in “protean” business relationships.

Once things get underway, I’ve discovered that of the many prominent organizations that it does business with really consist of a small core office populated by a few owner-founders, a single administrative aide and one or two payroll folks who oversee the outsourcing of everything else.  While the term “protean” is certainly novel,  distributed, adaptable and organic business networks have been around for years.

But the WSJ editorial opens a window into an underappreciated consequence of Obamacare and the underlying assumptions of the central planners who run Washington DC.  I doesn’t necessarily think it’s bad, but it sure is interesting.

Read on.

While the Affordable Care Act (ACA) was intended to link employment and health insurance, what it has really done is handed many small nimble interlocked businesses another leg-up against their large traditional mainframe competitors. For example, one colleague pointed out to the  that “new” pharma companies are really marketing departments that outsource manufacturing that, in turn, outsources supply management that outsources I.T. that outsources its cloud services. It’s the only way they can compete.

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The Healthy Crowd

• 3

By Esther Dyson

BERLIN – I recently attended the JP Morgan health-care conference, the Davos of the medical world. And, like the World Economic Forum’s annual gathering of business leaders, the JP Morgan conference is a Rorschach blot: you find in it what you are looking for.

Personally, I am interested in how health-care business models are changing – not in a smooth trend line, but one example at a time. The change has less to do with health-care “reform” than it does with improved access to information beyond the traditional sources of clinical trials and medical billing systems. Now we can find out more about each individual patient (and ultimately aggregate data), about the use and performance of drugs and treatments out in the market (not just during testing), and even about outcomes.

In search of this theme, I met with a variety of start-up companies on the fringes of the event. (The formal program was mostly publicly traded companies talking about their earnings outlooks, with one section reserved for privately held companies.)

First, there was Andrew Brandeis of SharePractice, a doctor who used to run a high-end medical service called CarePractice in San Francisco, but saw a need for doctors to share information about how they treat patients. The industry standard for such information, Epocrates, offers a mobile app with information about pretty much every drug on the market, but neglects other kinds of treatments. (Brandeis also asserts that there is too much advertiser influence; in fact, only Epocrates’ educational content and sponsor messages are driven by ads. Make of that what you will.)

Brandeis’s idea is crowd-sourced information: Doctors will record for one another what treatments they actually use. He showed me his own cellphone contact list; most of the people on it are other doctors. He shares with them already; SharePractice will make it easy.

But will they want to share this kind of information? Yes, says Brandeis, because they already do, via text, email, and phone: “It’s a cumbersome process, the data are totally unstructured, and doctors wind up repeating themselves, because searching through six months of text messages makes no sense.”

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OpenNotes: Drilling Down to Assure a Healthy Evolution

• 14

By Tom Delbanco, MD and Jan Walker, RN

As the instigators of the OpenNotes initiative, we are thrilled that OpenNotes is being adopted by the VA. Prompted by Dr. Kernisan’s thoughtful post , the ensuing lively discussion, and our experiment with 100 primary care physicians and 20,000 of their patients ), we thought it useful to offer some observations drawing both on our experiences as clinicians and on ongoing conversations with clinicians and patients.

First and foremost, we don’t have “answers” for Dr. Kernisan. Our hope is to contribute to new approaches to these sticky questions over time. And, remember that patients’ right to review their records is by no means new. Since 1996, virtually all patients have had the right to access their full medical records. What’s new is that OpenNotes takes down barriers such as filling out forms and charging per page, while actively inviting far more patients to exercise this right in an easier and accessible way.

We think of open visit notes as a new medicine, designed like all therapies to help more than it hurts. But every medicine is inevitably accompanied by relative and absolute contraindications, and it’s useful to remember that it’s up to the medical and patient community to learn to take a medicine wisely as it becomes more widely available. A few specific thoughts:

Dementia and diminished physical capacity:

When a clinician notices symptoms or signs of dementia, chances are the patient and/or family has already been worrying about this for some time.  Is it safe for the patient to live alone?  What about driving? How and when could things get worse?  They may actually be relieved when the doctor brings up these topics and articulates the issues in a note. Moreover, their worst fears may prove unfounded, and reading that in a note can be reassuring. But we need to consider the words we write so we don’t rush to label a condition as “Alzheimer’s.”  Being descriptive is often better and more helpful than assigning one word definitions. In itself, OpenNotes reminds the health professional to choose words wisely.  That doesn’t have to mean more work, but we believe it can certainly mean better notes that can be more easily understood by the patient.  We urge colleagues to stay away from “The patient denies…,” or “refuses,” or “is SOB.”

Abuse or diversion of drugs, possible substance abuse, or unhealthy alcohol use:

These subjects are always tough, and what to write down has been an issue for clinicians long before they worried about open records. Over the course of our experiment in primary care, we have heard stories from patients about changing their attitudes and behavior after reading a note and “seeing in black and white” what their doctors were most worried about. Though substance abuse may seem like a particularly sensitive topic, at least one doctor in our study is convinced that some of his patients in trouble with drugs or medications did better as a result of reading his notes. And while some patients may reject our spoken (or unspoken) thoughts that we document in notes, experience to date makes us believe that more patients will be helped than hurt, and that it is worth the tradeoff.

Continue reading…

Replacing Lance

• 4

By JAMES SALWITZ, MD

We need heroes.  Heroes show us light in the darkness, the way to the miraculous and ignite a fire in our soul to survive.  They prove what is truly possible, through the fog of the impossible.  We mourn the disgrace of Lance Armstrong because he seems to have achieved Pyrrhic victory.  Let us not doubt; whatever his frailty as a man, Armstrong vanquished a terrible foe; moreover the path blazed is not bare, for everywhere are cancer heroes.

– The 45 year old RN raising her children while she works full time in a pediatric intensive care unit, celebrates her eighth year in remission from pancreatic cancer, treated with surgery, chemotherapy and radiation.

– The grandmother who ignored a breast mass for two years so she could care for four disabled grandchildren, and when the tumor grew to be massive, continues to take care of the children while receiving chemotherapy.

– The hospital chaplain who has suffered from cancer, sits at the bedside holding a hand, sharing a smile, saying a prayer that is heard deep in the heart and to the heavens above.

– The 71 year old with four different cancers, treated with a bewildering mix of surgery, radiation and chemotherapy, whose primary worry is the cardiac care of her husband.

– The 64 year old rescue squad volunteer while receiving chemotherapy and radiation for extensive lung cancer, assists 150 people to flee from their homes and escape the wrath of Sandy.

– The national lymphoma expert, who could be wealthy in his own clinic, instead devotes his life to teaching and research, believing he can save more lives by consulting and advising oncologists in communities around the country.

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And With the Stroke of a Pen, Health Insurance Exchanges Become Health Insurance Marketplaces ….

• 6

By DAVID WILLIAMS

Thanks to David Kerrigan of the Massachusetts Health Connector for pointing out that the Obama Administration has suddenly switched terminology: health insurance exchanges are now health insurance marketplaces. I think it’s a great idea, which is why I wrote a blog post on this very topic on Friday. The Hill (Obama officials ditch ‘exchanges’ in rebranding of healthcare reform law) covers the story.

However, the Hill has a weird angle on this. The article heavily features an anti-ObamaCare activist, Dean Clancy who says:

“They could call them motherhood or apple pie, but it wouldn’t change our feelings about them… We’re encouraged that they’re showing signs of desperation. I think that it’s too late in the game to try to start calling this something different. And [we’re] not going to spend a lot of effort fighting over a word.”

Clancy’s website is called blockexchanges.com, so he may actually have more commitment to the word exchange than the Obama folks. Somehow blockmarketplaces.com just doesn’t have the same ring to it. (That domain is still available at this writing in case you want to grab it.) Blockexchanges also has some misleading information on its home page:

“Remember, without the state exchanges, ObamaCare cannot function.”

Actually, the federal government will step in if the states don’t.

Personally, I don’t sense desperation but rather a gradual wising up about what implementation will require. The term “marketplace” makes a good deal of sense for someone who is comparison shopping for health insurance. Here’s to more commonsense improvements as ObamaCare is rolled out.

David E. Williams is co-founder of MedPharma Partners LLC, strategy consultant in technology enabled health care services, pharma, biotech, and medical devices. Formerly with BCG and LEK. He writes regularly at Health Business Blog, where this post first appeared.

So, What Exactly Is a Health Insurance Exchange Anyway???

• 24

By David Williams


I’m a health care expert who follows health reform closely, so when I’m confused about something I know most people are.

When Massachusetts passed the universal coverage law in 2006 I didn’t understand exactly what the Connector was supposed to do. If they had called it a health insurance store or marketplace or comparison site I would have grasped the concept better. Once it’s explained it’s obvious, but why use the word “connector” in the first place?

The federal Affordable Care Act makes matters even worse. It calls these things health insurance “exchanges.”

That word has the wrong connotations. When I hear the word “exchange” I think of a stock exchange. That’s not somewhere I go to buy or compare products or services to use. Others think of “exchange” as what they do when they made a purchase that was the wrong size or received a gift they didn’t like.

Even for health wonks that fully grasp the concept, the word “exchange” is confusing, because the term is also used in the context of health information exchanges, which are used to exchange clinical data. I often hear people asking about the impact of the “exchange” –without specifying “insurance exchange” or “information exchange,” and I have to ask them which they mean.

There’s a simple solution to this: let’s dump the word “exchange” and use a term that’s more understandable and appropriate. How about:

  • Store
  • Marketplace
  • Comparison site
  • Supermarket

David E. Williams is co-founder of MedPharma Partners LLC, strategy consultant in technology enabled health care services, pharma, biotech, and medical devices. Formerly with BCG and LEK. He writes regularly at Health Business Blog, where this post first appeared.

Beyond the Fiscal Cliff? The Sea of Uncertainty …

• 12

By ROBERT LASZEWSKI

Last week’s deal to avert the “fiscal cliff” settled very little.

For those in the health care market, I will suggest the big takeaway is that we should expect very little will be settled in the coming months and we will continue to face a great deal of uncertainty for years to come.

Without an agreement to alter the course we are on, it is estimated that we will add more than $10 trillion to the national debt over the next ten years. Most experts agree that we need to reduce that amount by about half in order to put our nation’s fiscal course on a sustainable track. The Simpson-Bowles Debt Commission, for example, called for $4 trillion in deficit reduction––a fourth in new revenue and three-fourths in spending cuts.

We’ve heard lots of talk about a “Grand Bargain” between Republicans and Democrats to finally put our fiscal house in order. To be a grand bargain the two sides would have to agree to a deal that at least equaled the $4 trillion Simpson-Bowles proposal in its scope.

But Republicans and Democrats never came close to that kind of solution in the run-up to the recent fiscal cliff deal.

In the end, the two sides agreed to about $600 billion in tax increases. They also spent hundreds of billions more by agreeing to put off the sequester cuts for just two months, fix the Alternative Minimum Tax (AMT) problem, extend some business tax benefits, and extend unemployment benefits. They separately found $30 billion in Medicare savings, mostly from hospitals, to grant the Medicare doctors only a one-year delay in their 27% fee cuts.

Now, Obama says he wants $600 billion in more revenue by limiting tax breaks.

Continue reading…

Building a Better Health Care System: Patient-Friendly Orders

• 28

By RONI ZEIGER, MD

Here’s another technically easy and culturally hard product: Patient Friendly Orders.

My version of this idea was born when I was admitted to the hospital for pneumonia about 5 years ago.  Even though I had previously worked in that hospital, the quality of communication about my care between the patient and the medical team was poor.  This got me thinking…

There should be a touchscreen by my bed that lists all the current doctors’ orders.

They’re not hidden in the chart.  They’re not explained only in ephemeral conversations that occurred without me present.  And of course, if they’re in front of me, they’re going to have to get written in English.

Let’s organize the orders, too.  Imagine a loved one is hospitalized for a severe skin infection which also caused his diabetes to get way out of control.  He has difficulty sleeping in the hospital and also needs pain control.  All the orders — whether for diabetes, infection, sleep, or pain — are organized according to the problem they address.  (While doctors’notes are generally organized by problem, their orders are not.  I bet if we implemented Patient Friendly Orders, they’d be useful for doctors if only just for this reason.)

When the doctor or nurse or physical therapist comes in, the patient and family can have a conversation about the current plan, with that plan laid out in front of them.  They make a shared decision, and the doctor can update the plan on the same touchscreen.  “Sounds like a plan,” the patient says while actually looking at it.  When you visit your loved one, he can show you the plan, too.  If a question comes up about a given order, or why something is missing from the plan, you can make a note on the touchscreen so the medical team knows to address it when they next come by.Continue reading…

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