Author Archives

John Irvine

The Black List: Features Which Should Be In Most EMRs/EHRs (But For Some Reason Aren’t)

Jun 9, 2016• 12

By HAYWARD ZWERLING, MD

flying cadeucii I have been in the health information technology field since 1990 when I began creating ComChart EMR. It was a labor of love which ultimately evolved into a small business. From 2004 until 2012, ComChart EMR had amongst the highest KLAS rating of all EMRs in the small ambulatory care group. From 2011 until 2015, ComChart EMR was certified by the ONC for Meaningful Use Stage I. Unfortunately, the technical requirements arising from Meaningful Use mandates and changes in market conditions required that I stop selling ComChart EMR in 2015.

As a result of the 2.5 decades I spent creating ComChart EMR, I have learned a lot about which features are useful in the exam room and how to design an EMR so that it facilitates the user ability to provide medical care to their patient. As Judy Faulkner, Founder and CEO of Epic said, “Good software is art.” To this, I would add that it is only possible to create a well designed EMR if a practicing physician is intimately involved in both design and programming of the EMR.

Men, Women and Health Care Pricing Theory: Speaking Different Languages

Jun 9, 2016• 20

By JEANNE PINDER

flying cadeucii Men and women in the United States think very differently about health care costs. When I talk about the topic, it’s common for me to see half of my listeners zoning out — the male half. Why? Well, because women make or influence 90 percent of the health care decisions in this country, according to a study by the American Academy of Family Physicians. Of course, men go to the doctor. But they make fewer health care decisions, and they don’t think about pricing the same way women do.

Women are more in touch with health care pricing and more affected by it than men. Women own reproductive health. Women make pediatricians’ appointments and run elder care. Women nag their spouses, be those spouses husbands or wives or none of the above, to get their cholesterol checked, to pick up a prescription, to go to that physical therapy appointment.

So when we talk about shopping for health care, about our business, we’ve grown accustomed to having dudes say “Hm, interesting, can we talk about wearable devices?” or “We have some big data, we’re not really interested in the prices.” At the same time, women tell us how excited they are that we’re attacking opacity in health care pricing.

The Cab Ride

Jun 8, 2016• 7

By ROBERT MCNUTT, MD

flying cadeucii I usually walk from the University of Illinois, campus to Union Station at the end of my workday. But, that day it was raining. So, I hailed a cab. The cab driver was not in a mood to talk so I had time to relax and look around at the traffic. To my right was a recent model Mercedes sedan. I watched it for a moment and then pivoted to peer to the left. An old Toyota Corolla with the rear view mirror attached with duct tape was neck-in-neck slowed on the road with the cab and the Mercedes.

This image struck me; three impressively different cars depicting, perhaps, personal preferences and different opportunities of individuals, despite the differences, were driving on the same road.

So, this piece is about civil rights. Everyone who gets ill deserves the same road to drive on, but presently, some get better, or different roads than others. The “road” in the potentially obscure metaphor is the road that allows every individual the equal and omnipresent rights to information that will allow them to make an informed decision.

The Five Year Plan

Jun 7, 2016• 9

By JOHN HALAMKA

John Halamka When my father died 3 years ago, my comments at his funeral noted that the greatest aspiration any of us can have is to make a difference in the world. My father’s life made a difference.

I’m always self critical and analyzing my own life. I moved to Boston 20 years ago this month. In those 20 years of service to BIDMC, Harvard, numerous federal organizations, international governments, and industry, I’m hopeful that I’ve laid a foundation for 20 more years of trying to make a difference. It’s hard to forecast the best path to have an impact on the healthcare ecosystem, but I can try.

The past 5 years belonged to government – with $34 billion spent on healthcare IT as a result of HITECH, the Meaningful Use program accomplished the goal of moving clinician practices and hospitals from paper to digital systems. Although many challenges remain – improving workflow, enhancing quality/safety, and ensuring usability, the basic platform on which we can build future innovation has been created.

The government will continue to be very a important actor, especially CMS, setting payment policy that will impact the behavior of all stakeholders. However, I believe the era of prescriptive government direction of the IT agenda has ended. Provider organizations are begging for an outcomes focus, instead of a process focus.

Consumer Groups Weigh in on EHRs Under MACRA

Jun 7, 2016• 2

By STEVEN FINDLAY

One of the things that needs to happen as physician payment reform and EHR interoperability (post-meaningful use) evolve under MACRA is this: CMS and ONC need to promote, measure and significantly enhance consumers’ access to their health information and/or interaction with EHRs.

Stated another way: after spending $30 billion to compel the adoption of EHRs, the federal government needs to get its act together to assure that consumers and patients are directly—and not just indirectly—benefiting. That was, after all, part of the original vision way back in the George W. Bush administration. Simply stated: Electronically stored and continually updated information and records on you should be available to you. And without a lot of trouble. Continue reading…

Fame and Fentanyl

Jun 7, 2016• 1

By KAREN SIBERT, MD

flying cadeucii A fentanyl overdose led to the recent death of musician and singer Prince, according to the medical examiner’s report released June 2. The drug seems likely to become as notorious as propofol did after the death of Michael Jackson in 2009.

For all of us in anesthesiology who’ve been using fentanyl as a perfectly respectable anesthetic medication and pain reliever for as long as we can remember, it’s startling to see it become the cause of rising numbers of deaths from overdose. Fentanyl is a potent medication, useful in the operating room to cover the intense but short-lived stimulation of surgery. The onset of action is very fast, and the time that the drug effect lasts is relatively brief.

But fentanyl was never intended for casual use. Fentanyl is many times more potent than morphine; 100 micrograms, or 0.1 mg, of IV fentanyl is roughly equivalent to 10 mg of IV morphine. In March, the LA Times reported that 28 overdoses — six of them fatal — occurred in Sacramento over the course of just one week. The victims had taken pills that resembled Norco, a common pain reliever, but in fact the pills were laced with fentanyl. Even tiny amounts were enough to be lethal.

Like all opioids, fentanyl reduces the drive to breathe, and after a large enough dose a patient will stop breathing entirely. In addition to its effect on respiratory drive, fentanyl may also produce rigidity of the muscles in the chest and abdomen, severe enough to hamper attempts to ventilate or perform CPR.

10K Steps + Fitbit

Jun 6, 2016• 5

CECI CONNOLLY

Ceci Connolly Nearly every morning lately, as I make my daily dart to the metro station two blocks away, I pass a familiar face. She is one of about a dozen women who toil in the local nail salon. She does not live in my neighborhood, yet I see her early most mornings hiking up our hill, long before the salon opens.

Most days I wave and smile. But one recent morning I stopped and asked what she was doing. Her English is so-so and my Vietnamese is non-existent. But she managed to proudly convey, “Ten thousand steps!”

She’s not the only one. I myself have caught the walking bug, egged on by my better half and a Fitbit. For me, the rubber wristband has been revelatory. Given how active I am, I just assumed I was getting 10,000 steps every day. Far from it. Knowing your count – and how far you are from the daily goal – is an effective nudge to get off the metro one stop early or choose a lunch spot that’s a few blocks further away.

Sloppy Risk Adjustment and Attribution Guarantee MACRA Won’t Work

Jun 5, 2016• 6

By KIP SULLIVAN

flying cadeucii I just finished reading the 962-page MACRA rule CMS released late in April. I was prepared for the mind-numbing complexity of the document. What I was not prepared for was CMS’s glib treatment of two fundamental issues: The woeful inaccuracy of the scores CMS will use to punish and reward doctors, and the cost to doctors of participating in ACOs, “medical homes” and other “alternative payment models” (APMs)

These are not peripheral issues. If CMS dishes out financial rewards and punishments based on inaccurate data, MACRA will, at best, have no impact on cost and quality and may well have a negative effect. The second problem – the high cost of setting up and running APMs – may not be as lethal as the inaccurate-data problem, but at minimum it will reduce physician participation in APMs and, therefore, the already slim probability that APMs will reduce Medicare costs and improve quality.

In this comment and two more to come, I will review both of these problems and CMS’s what-me-worry attitude toward them. I begin with a jaw-dropping example of CMS’s reckless indifference to its inability to measure physician “merit” accurately.

About Hastert’s “Known Acts:” The Indifference Is As Disturbing as the Crime

Jun 4, 2016• 3

By DAVID INTROCASO

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This past April 8th federal prosecutors made known former Republican House Speaker, Denis Hastert, sexually molested at least four boys while employed as an Illinois high school wrestling coach beginning in the 1960s. Prosecutors said there was “no ambiguity” about these abuses. They were, they said, “known acts.”1 While the news was disturbing sexual and all other forms of child abuse is commonplace. According to the Centers for Disease Control’s (CDC) Adverse Childhood Experiences (ACE) study, one in four girls and one in six boys are sexually assaulted before they reach the age of eighteen.2 It cannot be a surprise therefore that even a member of Congress molested young boys.

Also not surprising is how frequently child abuse, if made known, is not revealed until many years later. Rumors about Hastert’s behavior persisted for years, for example, they were floated during 2006 when Congressman Mark Foley was forced to resign for forwarding soliciting e-mails and sexually suggestive instant messages to teenaged boys. It was not until last year Hastert’s actions nearly fifty years ago became known albeit accidentally. What banking officials and eventually the FBI wanted to learn, pursuant to the PATRIOT Act and other federal laws, was why Hastert made multiple $50,000 bank withdrawals over two years. Hastert initially told officials he was buying vintage cars and stocks. He then explained he did not think banks were safe and then argued he was the victim of extortion. None of these explanations were true. Eventually, the FBI learned Hastert was paying a victim for his silence.

Tech VC Answers ‘Will Computers Replace Doctors’ – I Mean VCs

Jun 4, 2016• 9

By DAVID SHAYWITZ, MD

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A constant frustration for many in healthcare is the cognitive dissonance between the elegant, highly anticipated promise of technology solutions and the messy, lived complexity of clinical practice.

In this context, I was fascinated–and feel compelled to share–this unexpectedly revealing excerpt from a recent (and, as always, captivating) a16z podcast, featuring a conversation a16z founder Marc Andreessen and board partner Balaji Srinivasan recorded at Stanford.

Following an extensive conversation about the factors associated with startup success and VC success, as well as about emerging (or re-, re-emerging) trends such as artificial intelligence (AI), an audience member asked whether AI might not select investments better than actual VCs–a VC version of the “will computers replace doctors?” gauntlet that tech VCs have thrown down before the medical establishment.