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Missive from the DMZ

Not everything about improving health care is breathlessly hanging on one high stakes decision.

The Supreme Court will rule soon enough on the constitutional challenges to the Affordable Care Act. Meanwhile, even amid the drama and bitter struggles, progress can occur in health care improvement—like the ever increasing adoption of health information technology. Believe it or not, there is broad agreement about using this technology in health care. Scott Gottlieb and J.D. Kleinke in a recent Wall Street Journal opinion said it well, “. . . promotion of health information technology is one of the only demilitarized zones in Washington—consistently attracting bipartisan support . . . .”

So, this rare consensus seems real and durable, but what is actually happening in the hallowed HIT ground where both sides have somewhat oddly come to a policy truce?

Since May of 2004 when President George W. Bush established the Office of the National Coordinator for Health Information Technology (ONC) we’ve witnessed a slow but relentless upturn in adoption. That progress dramatically accelerated with attention and funding in the American Reinvestment and Recovery Act in 2009. Since 2006, the Robert Wood Johnson Foundation (RWJF) in collaboration with ONC has supported an ongoing, independent effort to monitor the national adoption of the electronic health record.

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Finding a Good Doctor – A Doctor’s Notes

My in-laws are in town for my daughter’s graduation.

When I came home yesterday I was greeted with a big smile and vigorous handshake from my father-in-law.  ”I just want to thank you,” he said, standing up from his chair, “for finding us a good doctor.  The one you found for us is wonderful.”

My wife smiled at me warmly.  I just earned myself big points.  Yay!

Her parents and mine are both in their 80′s and are overall in remarkably good health.  When I called my father after he had a minor surgery over the summer, my mother told me he had a ladder and was “on a bee hunt.”  It’s a blessing to have them around, especially having them healthy.

My parents have a wonderful primary care physician, which takes a whole lot of pressure off of me to do family doctoring, and puts my mind at ease.  I’ve only personally contacted him once when my dad had a prolonged time of vague fatigue and body aches.  I try not to use the “I’m a doctor, so I am second-guessing you” card that I’ve had some patients’ children pull.  I called his doctor more as a son who wanted a clear story about what was going on than as a physician with thoughts on the situation.

“I first want to say that I am very grateful my parents have gotten such good care from you,” I said at the start of the conversation.  ”It’s nice to not have to wonder if they are getting good care.”Continue reading…

Why New Nurses Can’t Find Jobs (No, Really)

This month’s wretched jobs report tells a now-familiar tale: Employment has risen nicely in health care (a net gain of more than 340,000 jobs between May 2011 and May 2012). But almost every other sector has been flat or worse.

You might think that would mean that new-graduate nurses are having an easy time finding work. That’s still true in rural areas — but elsewhere, no.

In many U.S. cities, especially on the west coast, there’s real evidence of a nursing glut. The most recent survey conducted by the National Student Nurses’ Association found that more than 30 percent of recent graduates had failed to find jobs.

How is that possible?

While demand for nurses has been rising, it actually hasn’t risen as fast as most scholars had projected. Meanwhile, the supply of nurses has spiked unexpectedly, at both ends of the age scale: Older nurses have delayed retirement, often because the recession has thrown their spouses out of work. And people in their early twenties are earning nursing degrees at a rate not seen in decades. We’re now in the sixth year in which health-care employment has far outshone every other sector, and college students have read those tea leaves.

So what will happen next?

Here are crude sketches of two possible futures:

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FOO For Thought

Health Foo image via Paul Levy @Running A HospitalI cite this favorite quote from Max Planck in my book (and every chance I get):

A new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die, and a new generation grows up that is familiar with it.

I think this applies to all walks of life, not just science. Yet sometimes an argument so compelling comes along that, though reluctantly at first, one by one the old guard drop at its feet. This is what happened to me this weekend at the Health Foo Camp in Cambridge, MA.

First, what is Health Foo? Well that was my first question when I received an invitation to attend this strangely named meeting. A Foo Camp is something put together by O’Reilly, the pioneering digital media group. Started 12 years ago, these meetings are thematic gatherings of “Friends of O’Reilly,” hence “Foo,” intended to bring together a diversity of thought about a specific field. The camp that I attended was the second such gathering in the healthcare space, supported in part by the Robert Wood Johnson Foundation, and held at Microsoft’s New England Research and Development Center in Cambridge. How can I ever thank O’Reilly, RWJF and Microsoft for this mind-shifting event?

As I mentioned in my previous post, the attendee roster was so full of luminaries that I frankly wasn’t sure that the invitation had not ended up in my Inbox by mistake. But mistake or not, what a privilege to attend! I spent the weekend getting to know the faces and the substance behind such familiar names as Regina Holliday, Paul Levy, Alan Greene, Ted Eytan, Susannah Fox, Gilles Frydman and others. And what still has my mind spinning is my conversations with people I don’t normally interact with — computational scientists, game designers, food advocates and international public health movers and shakers.

The most risky aspect of this meeting was the very essence of its success: we were to free-range. No agenda was set; space, food and company were provided. The resulting sessions ran the gamut from the usual nerd porn of probability to such far-reaching topics as memory and the role of faith, poetry and the arts in medicine (my personal favorite, where I got to play in the sandbox of participatory painting led by Regina. Take that, left brain!)

I have to say I spent a part of the weekend in a bit of a fog. What is gamification of medicine? What does “deep modularity” mean? But the full impact of such diversity of knowledge did not hit me until I was heading West on the Turnpike away from the meeting in the direction of home. It felt like a deep air pocket, and for a moment I couldn’t catch my breath.Continue reading…

June: A Big Month For ACO Watchers

As we trudge forward into various iterations of what and how ‘accountable care’ strategies can be sensibly configured and locally seeded for Medicare, Medicaid as well as commercial markets, attention is often focused on the ‘necessary’ but ‘not sufficient’ contribution(s) from health information technology (HIT). It is rare that a conversation centered on accountable care or ACOs in particular doesn’t shift to HIT, where EHRs, HIE’s (heath information exchanges) or other data banking or connectivity solutions aren’t a material part of the dialogue. Often posited as the central spine enabling the required coordination and integration essential to accountable care, the technology side of the challenge frequently preempts other issues including physician culture, clinical and financial risk management tolerance and sophistication, or the history of successful physician/hospital joint ventures, in the local market.

Yet in the paradigm shift from volume to value via accountability many are focused on the presumptive return expected from consumer empowerment and electronic health information connectivity. Whether couched as informed choice via up-leveled health literacy, e-patient activism, ‘data liquidity’ or the litany of supportive ‘apps’ including mhealth, wireless or other prevention and wellness oriented platforms, the consumer empowerment movement incentivized by HITECH and further challenged via the triple aim quest are energizing many entrepreneurs, healthcare providers and even regulators.

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The Lifesaving(?) Technology of Facebook

When most of us think about Facebook, the first phrase that comes to mind probably isn’t “good Samaritan.”  Facebook is an easy way to keep in touch with friends, and it can be a gigantic time-suck, for sure, but last week the site did something that could truly benefit a lot of people. On May 1, Facebook launched an initiative to encourage users to become organ donors, and within 24 hours there had been a spike in the number of people volunteering their body parts for the good of others.

California’s registry saw almost two months’ worth of people sign up within the first day after the Facebook put up the feature.

Organ transplantation is one of the miracles of modern medicine, but there simply aren’t enough organs to go around for all the patients who need them. According to the United Network for Organ Sharing (UNOS), there are 72,900 people on active lists waiting for an organ. Compare that number to the 2,263 transplants that took place between January 2011 – 2012. Last year, more than 6,000 people died waiting for an organ.Obviously, increasing the number of organ donors could have a huge impact on the number of transplants – and on the lives of thousands of people.

Why don’t more people become donors? Some object on religious grounds, but the biggest obstacle is inertia. Most of us who sign up to be organ donors (I’m one of them) do so when we renew our driver’s license, by checking a box on a form saying we want to donate our organs. If you don’t mark the form, it’s assumed you don’t want to donate. Most people only encounter this choice every few years, when their driver’s license is up for renewal, and it’s hard to think about such a decision while standing at a Department of Motor Vehicles counter.

Some countries, such as Spain, Australia and Germany, have opt-out systems. It’s assumed that you are willing to donate unless you’ve said you prefer not to. Rates of donation in those countries are sometimes higher than in the US, although some presumed-consent countries have much lower rates. (Factors other than the number of donors, like the availability of surgical facilities and transplant surgeons, can affect the number of actual transplants in different countries.)

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PlaceMe: A Creepy Model For Health Information?

Data, information, interpretation and decision-making are among the vital components of prevention, diagnosis, management and treatment.

The problem we have today is how to gather and manage the data that our bodies radiate.

In order to solve this problem, we have to surmount other problems – which are not just technological but also behavioral, cultural and financial.

But if you want an idea of what an extreme version of data-collection might look like, check out the application Placeme.

Now Placeme is *not* a Healthcare application. What Placeme does do, however, is to continually (in almost real-time) track the places that you visit. No check-ins; no need to enter and data – the application simply runs in the background and does its magic.

When you think about that (from the cultural perspective of today), that’s creepy.

And yet, this “creepy” model is the future. It represents the technological and cultural arc that social software is throwing us. We can fight it (and should in order to flesh out the nuances so we can ensure safety) but in the long-run we shall have to accept the trend and work accordingly.

So think of Placeme in terms of what the ‘Quantitative Self’ movement is attempting to achieve.

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The Republican Myth of Obama’s Entitlement Society

One of the few things Mitt Romney and Newt Gingrich agree on is that President Obama is turning America into “European-style welfare culture.”

In his standard stump speech Romney charges Obama with creating a nation of dependents. “Over the past three years Barack Obama has been replacing our merit-based society with an entitlement society.”

Gingrich calls Obama “the best food-stamp president in American history.”

What’s their evidence? Both rely on federal budget data showing direct payments to individuals shot up by almost $600 billion, a 32 percent increase, since the start of 2009.

They also point to Census data showing that 49 percent of Americans now live in homes where at least one person is collecting a federal benefit – Social Security, food stamps, unemployment insurance, worker’s compensation, or subsidized housing. That’s up from 44 percent in 2008.

Finally, they trumpet Social Security Administration figures showing that the number of people on Social Security disability jumped 10 percent in Obama’s first two years in office.

They argue our economic problems stem from this sharp rise in “dependency.” Get rid of these benefits and people will work harder.

 

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