Author Archives

John Irvine

Love and Measurement

Jan 30, 2016• 7

By WESTBY FISHER, MD

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Many of us recall the final scene of Mad Men where Machiavellian dealmaker, philanderer, and ad mogul Dan Draper sits in lotus position finding either true inner peace or the next cynical direction from which to profit. This scene came to mind as I read another apparent conversion experience by Robert M. Wachter, MD in his recent opinion piece in the New York Times on how the metric measurement business fails physicians and teachers.

Remarkably, Dr. Wachter, once the Chairman of the American Board of Internal Medicine (ABIM) that is responsible for “continuously” measuring, re-testing, and re-certifying US physicians, seemed to pivot from his former self by quoting a few of Avedis Donabedian’s words on quality assessment suggesting “the secret of quality is love.” Unfortunately, Dr. Wachter conspicuously failed to acknowledge the full context of Donabedian’s words.

“I think that commercialization of care is a big mistake. Health care is a sacred mission. It is a moral enterprise and a scientific enterprise but not fundamentally a commercial one. We are not selling a product. We don’t have a consumer who understands everything and makes rational choices — and I include myself here. Doctors and nurses are stewards of something precious. Their work is a kind of vocation rather than simply a job; commercial values don’t really capture what they do for patients and for society as a whole.

“Systems awareness and systems design are important for health professionals but are not enough. They are enabling mechanisms only. It is the ethical dimension of individuals that is essential to a system’s success. Ultimately, the secret of quality is love. You have to love your patient, you have to love your profession, you have to love your God. If you have love, you can then work backward to monitor and improve the system. Commercialism should not be a principal force in the system. That people should make money by investing in health care without actually being providers of health care seems somewhat perverse, like a kind of racketeering.” – Avedis Donabedian

Guideline-Centered Care

Jan 30, 2016• 2

By JOHNATHON TOMLINSON, MD

flying cadeucii Doreen, Ahmed and Henry have recently had their medication changed in response to a new guideline for prescribing Statins, cholesterol-lowering drugs.

None of them came to ask for a change in their medication. In each case the change was recommended by a clinician in response to a new guideline against which our practice will be judged and financially rewarded or penalised.

Here are the NICE guidelines 2015:

The NICE guideline on lipid modification recommends that the decision whether to start statin therapy should be made after an informed discussion between the clinician and the person about the risks and benefits of statin treatment, taking into account additional factors such as potential benefits from lifestyle modifications, informed patient preference, comorbidities, polypharmacy, general frailty and life expectancy.

and

NICE recommends that statin treatment for people with CVD [Cardio–vascular disease] (secondary prevention) should usually start with atorvastatin 80 mg daily.

It is very easy to judge whether or not people with CVD are on Atorvastatin 80mg, but almost impossible to judge whether the decision to start therapy has been made as a result of thoughtful deliberation between the patient and the clinician. Thoughtful deliberation is at the heart of patient-centered care – not doing whatever the patient wants, as is often confusingly assumed.

Data Socialism

Jan 26, 2016• 4

By SAURABH JHA, MD

In an unusually candid editorial in the NEJM, Longo and Drazen say that data sharing may be problematic because some researchers fear that the data could be used to by others to disprove their results. The editors predicted a new class of researchers who use data created by other researchers without ever taking the trouble to generate data themselves – research parasites.

With this editorial, the NEJM has firmly established itself as descriptive (the way the world is), rather than normative (the way the world ought to be). I, for one, find this move rather refreshing. I have been pumped to a diabetic state by the saccharine naivety of the hopey-changey, “we need this and that” brigade. The editors merely said what some researchers secretly think, and how many actually behave.

FHIR: The Last, Best Chance to Achieve Interoperability?

Jan 20, 2016• 3

By DAVID SHAYWITZ, MD

Can an impassioned band of savvy, battle-tested techno-optimists save our healthcare system from its worst instincts, and deliver at least a soupcon of real interoperability?

That’s the question I found myself seriously contemplating after last week’s JP Morgan Healthcare Conference in San Francisco, and in particular after an inspiring data science roundtable discussion led by Aneesh Chopra (the first Chief Technology Officer of the United States, now at Hunch Analytics) and Claudia Williams, a senior advisor in the White House Office of Science and Technology Policy (OSTP).

The FHIR Engine

The (not so) secret sauce in question is the FHIR (pronounced “fire”) interoperability standard that has emerged from the non-profit HL7 organization, and functions as a universal adaptor, allowing some types of clinically-relevant data types to be shared easily and securely. Remarkably, most major electronic health record (EHR) vendors – including athenahealth ATHN +0.00%, Cerner CERN +0.00%, and yes, Epic — have signed onto this concept, and agreed to support an early effort at implementation, known as the Argonaut Project.

Ann Marie O’Callaghan and Perjeta

Jan 20, 2016• 11

By DAVID BELK, MD

Screen Shot 2016-01-20 at 5.10.39 PM A respected group of cancer specialists developed a chemotherapy program for a breast cancer patient. But then her insurance company denied the claim, so the cancer center stuck her with a bill three times as large as what they would have required from the insurance company.

In June of 2012 Ann Marie O’Callaghan got some of the most terrifying news a woman can get: she had breast cancer. Worse, Ann Marie was only 39 at the time and the oldest of her two children was about to go into kindergarten.

Cancers that strike young women can often be very aggressive, but fortunately there were proven treatments for her particular breast cancer. After six months of intensive chemotherapy her stage III tumor had shrunk to become a stage I tumor which could be removed by a simple lumpectomy. After she received local radiation treatment to her breast there was good reason to believe she might be cured.

Then, last summer, her cancer came back. It was only a small, locally recurring tumor, but any cancer that recurs is likely to be tougher to treat because it’s already learned to survive the original therapy. Ann Marie wanted to be able to raise her children, so she returned to the same specialists who had knocked her cancer back the first time.

Should Companies Invest In a Chief Health Officer?

Jan 20, 2016• 3

By JAAN SIDOROV, MD

flying cadeucii While employer-sponsored wellness, health promotion and disease prevention programs have been linked to “human capital,” talent recruitment and retention, improvements in employee morale, reductions in absenteeism, reductions in presenteeism and bending the curve of claims expense, should shareholders care?

After all, according to President Obama’s latest State of the Union Address, corporate America’s pursuit of profits have resulted in greater automation, less competition, loss of worker leverage and “less loyalty to their communities.” According to that narrative, employees are just another commodity on the road to total shareholder return.

Well, according to an expanding body of peer-reviewed scientific literature, shareholders should care.

The latest example of why is this publication by Ray Fabius and colleagues that appeared in the January issue of the Journal of Occupational and Environmental Medicine.

EHR Incentive Programs: Where We Go From Here

Jan 19, 2016• 16

By ANDY SLAVITT and KAREN DeSALVO, MD

Screen Shot 2016-01-19 at 8.34.45 AM As we mentioned in a speech last week, the Administration is working on an important transition for the Electronic Health Record (EHR) Incentive Program. We have been working side by side with physician organizations and have listened to the needs and concerns of many about how we can make improvements that will allow technology to best support clinicians and their patients. While we will be putting out additional details in the next few months, we wanted to provide an update today.

In 2009, the country embarked on an effort to bring technology that benefits us in the rest of our lives into the health care system. The great promise of technology is to bring information to our fingertips, connect us to one another, improve our productivity, and create a platform for a next generation of innovations that we can’t imagine today.

Not long ago, emergency rooms, doctor’s offices, and other facilities were sparsely wired. Even investing in technology seemed daunting. There was no common infrastructure. Physician offices often didn’t have the capital to get started and it was hard for many to see the benefit of automating silos when patient care was so dispersed. We’ve come a long way since then with more than 97 percent of hospitals and three quarters of physician offices now wired.

Bernie May Have a Point …

Jan 18, 2016• 52

BY ROGER COLLIER

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It doesn’t seem likely that Senator Bernie Sanders will be our next president, but the current primary election campaign is throwing some pretty startling curveballs. With substantial popular support for one candidate with a fondness for the bankruptcy courts, and another who believes the pyramids were grain silos, a “democratic socialist” can’t be counted out.

In this world of the politically unexpected, Senator Sanders’ “Medicare for All” proposal for restructuring our healthcare system seems like something we should take seriously.

It’s a great slogan – a lot zippier than “Patient Protection and Affordable Care Act” — although the specifics are a little hazy. Senator Sanders has been promising since July to provide more details, but so far has provided only some tantalizing sound bites, like this one from his spokesman a week ago: “At a time when we are the only major country on earth that does not guarantee health care for all and when we spend far more per person that any other country, the time is long overdue for us to pass a Medicare for All, single-payer program. Medicare for All would save the average family thousands of dollars a year in health care costs…”

Most liberals would agree that one of the disappointments of the Affordable Care Act is its failure to assure universal coverage. We still have millions of uninsured and, with coverage increasingly expensive and deductibles skyrocketing, the number seems more likely to grow than decrease. In comparison, a totally tax-supported (as Senator Sanders has proposed in the past) Medicare for All model would bring the United States into line with other nations and protect millions from healthcare financial crises.

However, the claim that “single-payer… Medicare for All would save the average family thousands of dollars a year” is a lot more questionable.

Risk Scoring and Value-based Payments Haven’t Worked: The Medicare Advantage Story

Jan 18, 2016• 5

By ANISH KOKA, MD

Mrs. Cassidy slowly walks into my office one busy afternoon. I see her out of the corner of my eye because she is hard to miss. Mrs. Cassidy has some serious style. She has a deep orange dress with a bright blue blazer on. There aren’t too many folks that can pull that outfit off, but she can. She has a wide slow smile, and she speaks with a slow southern drawl that belies her southern roots. This was supposed to be a routine follow up visit for a 67 year old woman with a history of a mechanical mitral valve replacement and coronary disease.

Unfortunately, she tells me a story that is concerning for angina. I think she needs a stress test. I slide over to the insurance tab on the EMR and I let out a somewhat audible groan. She has a Medicare Advantage (MA) plan. I explain to Mrs. Cassidy that we will need to go through an extra step to pre-certify her stress test. She expresses surprise and asks me what she should do. I will tell you what I told her, but first, let me tell you why.Continue reading…

Data Thinking In Health Care

Jan 15, 2016

By LEONARD D’AVOLIO

Clinicians have been on the receiving end of some pretty terrible practices when it comes to information technology. Instead of informed and shared decision making, clinicians experience an assault of mandates, metrics, buzzwords, and acronyms without clear explanation or expectations. Not surprisingly, the pages of THCB and beyond contain frustrated denunciations of EMRs, dares for Dr. Watson to replace them, and dismissals of “big data.” This whole “technologists are from mars, clinicians are from venus” vibe is understandable, but it isn’t productive.

Data is the building block of measurement and now that it’s finding its way into healthcare systematic use of it to measure, improve, and provision care isn’t likely to be dropped off the formulary any time soon. It would be helpful then to have a shared language to allow clinicians and technicians alike to cut through the fog of jargon and focus on using data productively.

Developed through trial and error (mostly error) is a simple heuristic that I have found useful for establishing a shared understanding around using data in healthcare. I’ll call it Data Thinking, if only to keep with the tech tradition of stealing working names from other products (in this case, Design Thinking).

Data Thinking is a simple way of coming to consensus, explaining the jobs to be done, and mapping buzzwords to function. Regardless of vendor, technology, or buzzword, making data useful falls into a few basic steps: