Author Archives

John Irvine

A Care Coordination Innovation Intervention

Jul 20, 2016• 4

By JOHN HALAMKA, MD

John Halamka Would you buy an iPhone if the only apps that ran on it were written by Apple? Maybe, but the functionality would not be very diverse.

The same can be said of EHRs. Athena, Cerner, Epic, Meditech, and self developed EHRs such as BIDMC’s webOMR are purpose-built transaction engines for capturing data. However, it is impossible for any single vendor to provide all the innovation required by the marketplace to support new models of care I’m a strong believer in the concept of third party modules that layer on top of traditional EHRs in the same way that apps run in the iPhone ecosystem.

There are 3 such companies doing important care coordination work in Massachusetts and we’re expecting a wide rollout of their cloud hosted modules that tightly couple with EHRs, but are not authored by EHR companies.

The Doctors Club

Jul 19, 2016• 22

By ANISH KOKA, MD

Vatsal Thakkar, a psychiatrist, recently wrote of the perks doctors are afforded in everyone’s favorite instrument of social justice – the New York Times. Dr. Thakkar speaks effectively and correctly about a broken health care system navigated best by pulling the ‘doctor’ card. Some on the progressive left have seized on this blatant disregard for egalitarianism as yet another example of a broken healthcare system, despite the fact that a two tiered system is exactly what they have been building over the last eight years.

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To be clear, there has always been special treatment accorded fellow doctors and nurses – it has just become more obvious as the gulf between the haves and the have nots in health care has grown. Make no mistake – this is absolutely a function of multiple strategies that have created winners and losers in the healthcare space. The problem, of course, is that patients and physicians have ended up on the losing side of this equation.

Hope, Statistics and the Overtreatment of Cancer

Jul 16, 2016• 19

BY SAURABH JHA, MD

flying cadeucii When diagnosed with abdominal mesothelioma, a rare cancer with a blighted future, evolutionary biologist and writer, Stephen Jay Gould, turned his attention to the statistics; specifically, the central tendency of survival with the tumor. The central tendency – mean (average), median and mode – project like skyscrapers in a populated city and are the summary statements of a statistical distribution.

The “average” is both meaningful and meaningless. The average utility of average is zero. Consider a gamble – fair coin toss where you get $50 if it lands heads and lose $50 if it lands tails. The average (net) gains of this coin toss, if the coin is thrown hundreds of time, is zero. But no one gets nothing – you either get $50 or lose $50. The average is twice wrong – it over estimates for some and under estimates for others. But the average of this gamble has important information. It helps you decide if you could profit from making people play this gamble – you wouldn’t profit unless you charged a small fee to play the gamble.

The Illness of Work Incapacity

Jul 15, 2016• 3

By NORTIN HADLER, MD

Nortin Hadler Etiology, pathogenesis and translational science beat drums to which modern medicine marches – with escalating cadence. Yes, there is cacophony on occasion and missteps, but we all wait for the next insight to trigger a wave of enthusiasm at the bench and beyond. “Disease” is no longer an elusive monster in the swamp of ignorance; “disease” is prey. It can be defined, parsed, deduced, and sometimes defeated.

Little of this pertains to “health.” Health does not objectify itself. Nor is it simply the absence of disease. Health has temporal and geographic dimensions. Health is inseparable from the context in which it is experienced. Health has a narrative laced with peculiar, often idiosyncratic idioms. Furthermore, there is a crucial difference between the health of a person and the health of the people.

Science has limitations when it comes to studying health. For one, the studying becomes a component of the experience of health. Nonetheless, we have accumulated a great deal of substantive information that serves to define the boundaries of healthfulness and offers options with salutary potential. Much of this reflects a century of considering the personal ramifications of gainful employment. Much of this falls under the purview of occupational medicine and should be a source of pride.

Oh, Those Evil Law Suits!

Jul 14, 2016• 10

By JIM PURCELL

flying cadeucii My wife of 47 years likes to tell of her travails after having married me. She claims she had no inkling that I would specialize in despised career choices. Right after we were married, I served as an infantry airborne officer in Viet Nam, a then despised profession. Then I became a trial lawyer. A very despised profession. And then in 2004, I became the CEO of a health insurer, the pinnacle of my career in despised professions. At one point she stopped reading the Providence Journal and listening to local talk radio. When asked if she were my wife, she’d often reply, “Why do you want to know?”

So I have some perspective on emotional reactions of people in varied contexts. Here we will discuss the hyper-emotionalism that lawsuits engender, because they indeed cause people to act in ways that are confounding. Of course, an individual plaintiff in a medical malpractice lawsuit is hyper-emotionally involved. But more to the point of this article, so is the defendant physician.

Why is that? For the plaintiff, that’s easy to understand. They believe (or were convinced) that the physician harmed them through negligent conduct, and that they should be compensated (and perhaps apologized to). Their world often starts to revolve around the lawsuit as if nothing else mattered. It consumes them, and the outcome is rarely satisfying.

The physician reacts almost equally emotionally when sued. While that is counterproductive, they typically can’t help themselves because it is a direct and personal attack going to the heart of who and what they are professionally and as human beings. Heavy stuff.

Proposed Drug and Device Laws Should Be Pushed to 2017

Jul 14, 2016• 1

By PAUL BROWN, TRACY RUPP, and STEVEN FINDLAY

flying cadeucii Senate leaders now say they won’t consider companion legislation to the House-passed 21st Century Cures Act until September, after months of delay. Lawmakers would then have to reconcile the differing House and Senate versions, presumably by year’s end during a lame-duck Congress.

We believe the summer delay is a good thing, and that Congress should actually extend consideration of the complex legislation into 2017 when must-pass FDA funding through industry user-fees will be on the congressional calendar. That way, lawmakers can debate the implications of the proposed bills in the context of the resources FDA needs.

Why further delay? Because the legislation—which makes substantial changes to the way the Food and Drug Administration (FDA) approves drugs and devices—is flawed. As currently crafted, it lowers standards for drug and device approvals and safety, and risks adding to the rising cost of prescription drugs.
The ostensible rationale for the legislation—being pushed by drug and device companies—is that the FDA stifles innovation and advances in treatment by approving drugs and devices too slowly compared with other countries.

From Takeoff to Touchdown, It’s About Engaging the Patient

Jul 14, 2016

By CHRIS ZANT

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Screen Shot 2016-07-16 at 12.50.25 PM In my personal time away from my role at Deloitte, I am a private pilot and passionate volunteer for a charity that facilitates free air transportation for children and adults with medical conditions who need to get to treatment far from home. In my interactions with these patients I hear how important communication is to their well-being. I also hear how outreach from life sciences companies enables improvements in their lives and puts them back at the center of the health ecosystem.

It is not controversial to say that patients must be at the center of the current and the future healthcare ecosystem; however, it may be to admit that today they are not well served by this ecosystem. The need to enable and effectively support care coordination across health care professionals (HCPs), providers, and other care team members to drive effective and appropriate use of pharmaceutical products is something I hear my clients in health care asking for on a daily basis. My clients ask for strategies that will enable them to build loyalty through extraordinary execution of their patient engagement programs, and through that loyalty drive adherence and better health outcomes. This ability to deliver consistent, high-quality, reliable service across all channels of engagement is a game changer. Recently Deloitte Consulting leaders discussed this subject on a webinar for our clients.

Risk-Factor Based-Medicine and Its Discontents

Jul 12, 2016• 6

By MICHEL ACCAD, MD

Screen Shot 2016-07-12 at 12.02.36 PM If concepts could get awards, then “risk factor” would surely be a Nobel prize winner. Barely over 50 years of age, it enjoys such an important place in medicine that I suspect most of us doctors could hardly imagine practicing without it. Yet, clearly, the concept is not native to our profession nor is its success entirely justified.

A few years ago, on the occasion of the risk factor’s fiftieth anniversary, my colleague Herb Fred and I published an editorial highlighting some of the problem with the use of this concept. I will summarize here some of those points.

The risk factor concept was developed in the first decades of the twentieth century from within the life insurance industry as it began to systematically apply statistical methods in order to optimize actuarial predictions. The idea was to identify which baseline characteristics held by individuals would correlate with future risk of death.

The Framingham investigators imported this idea into the public health sphere and introduced the term risk factor in the medical literature in 1961. From then on, the concept and term have enjoyed an unmitigated success.

So Much Talk, So Little Walk on Quality

Jul 11, 2016• 3

By CECI CONNOLLY

Ceci Connolly Quality is all the rage in health care these days. It rolls off the presidential tongue and is at the heart of robust targets set by Health and Human Services Secretary Sylvia Burwell. (No less than half of all Medicare payments to be quality based by the end of 2018!)

“We’re moving Medicare toward a payment model that rewards quality of care instead of quantity of care,” President Obama declared at a March 2015 summit dedicated to alternative payment models that move away from volume-based, fee-for-service payment

Industry is on the rhetorical bandwagon too. A quick search for the word quality on THCB turns up 277 entries – including “Zen and the Quest for Quality,” “An F for Quality” and the very earliest entry dated Aug. 18, 2003, “Performance-based pay in health care?”

Don’t get me wrong. We at the Alliance of Community Health Plans (ACHP) were into quality way before quality was cool. (We were there at the creation of today’s HEDIS quality measures.) So perhaps that’s why it’s a little disheartening to see policymakers slow to match the speeches with action by fixing a glitch in the pay-for-quality movement.

Dear Mr. Slavitt, Please Come Visit My Office

Jul 11, 2016• 26

By NIRAN AL-AGBA, MD

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Andy, if you want to fix primary care you must do some field research. Come spend one day, or even a week at my office or another small primary care physicians’ office. You need to see what we do on a daily basis and actually understand the view from a small practice perspective. This knowledge deficit is at the core of CMS’s problem. You cannot repair what you do not comprehend.

Once you understand what we are capable of doing, how we do it, and how it actually SAVES money in the long run, while still providing high quality, then you are ready to tackle Focusing on Primary Care for Better Health. The bottom line: you must pay us more for what we are doing if you want to increase our overhead expenses. Tasking us with additional administrative burden in order to earn extra money is not actually paying us any more for our work. We would be working harder, not smarter. Do you understand that?