Author Archives

John Irvine

Being Graded

Nov 9, 2015• 7

By MUNIA MITRA, MD

“Lawyers aren’t graded.”

“CEOs aren’t graded”

“How would you feel if I tracked every e-mail you sent and tracked how many people responded to them? You wouldn’t like that very much would you?”

“The people who make EMRs. Why aren’t they graded?”

If there’s one negative I hear time and time again from doctors when the subject of quality measurement comes up, it’s this one near-universal complaint. The world is unfair, the cards are stacked against us.

As a specialist at a busy urban medical center I hear the complaints almost every day from colleagues and peers at other hospitals. We’re being singled out for unfair treatment: They’re out to get us. It’s the world against the doctors.

Many of the so-called experts I’ve talked to at meetings around the country express disdain when the topic of physician resistance to quality improvement programs comes up.

But it shouldn’t be terribly surprising that the idea that one’s performance is being tracked can be seen as intrusive and threatening. The reaction is in many ways completely predictable.
Continue reading…

The Network You May Not Like

Nov 7, 2015• 1

BY PAUL LEVY

This has been my week to discuss networks (Internet and electricity), but I would be remiss if I didn’t spend a few moments on the networks that are most likely to rob us of personal choice and increase costs: Health care networks.

Wait, didn’t President Obama promise us that the new health care law would preserve choice for us? Didn’t he promise us lower costs? Well, in spite of much good that the law accomplished in terms of providing access to health insurance, these are two areas that have gone awry. For a variety of reasons–most of which have little to do with providing you with better care–the hospital world has grown more centralized. It’s done so to reduce competition and get better rates from insurance companies. It’s done so to create larger risk pools of patients under the “rate reform” that incorporates more bundled and capitated payments. It’s done so to keep you as a captive customer for your health care needs. It’s been aided and abetted by electronic health record companies that find a mutual advantage with their hospital colleagues in minimizing the ability of your EHR to be easily transferable to other health systems. As I’ve noted, we truly have created “business cost structures in search of revenue streams,” rather than a vibrantly competitive system focused on increasing quality and satisfaction and lowering costs.

Many people don’t even know they are part of a health care network until they discover its limitations. It might be that the insurance product they bought has different rates for in-network doctors and facilities from out-of-network doctors and facilities. It might be that their primary care physician subtly or not so subtly directs them to specialists in his or her network because they share in the financial reward of eliminating “leakage” to other systems. It might be that they discover that an MRI or other image taken in one health system cannot be transferred electronically to another, perhaps necessitating a second image and its accompanying cost.

The Doctor- Patient Relationship and the Outcomes Movement

Nov 4, 2015• 8

By MICHEL ACCAD, MD

In a recent Harvard Business Review article, authors Erin Sullivan and Andy Ellner take a stand against the “outcomes theory of value,” advanced by such economists as Michael Porter and Robert Kaplan who believe that in order to “properly manage value, both outcomes and cost must be measured at the patient level.”

In contrast, Sullivan and Ellner point out that medical care is first of all a matter of relationships:

With over 50% of primary care providers believing that efforts to measure quality-related outcomes actually make quality worse, it seems there may be something missing from the equation. Relationships may be the key…Kurt Stange, an expert in family medicine and health systems, calls relationships “the antidote to an increasingly fragmented and depersonalized health care system.”

In their article, Sullivan and Ellner describe three success stories of practice models where an emphasis on relationships led to better care.

But in describing these successes, do the authors undermine their own argument? For in order to identify the quality of the care provided, they point to improvements in patient satisfaction surveys in one case, decreased rates of readmission in another, and fewer ER visits and hospitalizations in the third. In other words…outcomes!

A Proposal to Increase the Transparency and Quality of Electronic Health Records

Nov 2, 2015• 12

By HAYWARD ZWERLING, MD

The electronic health record (EHR) is now used by the majority of physicians during every patient encounter. The EHR has become the most important tool in our “black bag” and precisely for that reason, the EHR must be highly accurate and free of bias. As our most heavily utilized tool, the EHR must also be flexible and highly optimized so as to ensure it does not adversely impact the delivery of healthcare. Unfortunately, numerous surveys have found widespread physician dissatisfaction with EHR design.

The fact that EHR programming code is shielded from objective scrutiny by independent evaluators increases the risk that the EHR will contain errors and bias which could adversely impact our patient’s health, hinder our ability to deliver healthcare, “warp” the design of the healthcare system and drain financial resources from our patients and society.

EHR “errors” are well documented in the literature and are referred to as “e-iatrogenesis” or “technology induced” errors. “Bias” in EHR programming code is not discussed in the literature.

Sex, Lies and Cheeseburgers

Oct 28, 2015• 16

By AL LEWIS

Number of deaths attributable to eating processed meat, according to the World Health Organization (WHO): 34,000

Number of people struck by lightning annually: 240,000

And yet the WHO generated a huge headline by saying that eating red and processed meat could increase your risk of colon cancer by 18%.

Let us assume that they are right. (And we will let the trade associations debate them on the scientific merits of that 34,000 figure.) Even if they are right, this is a perfect example of confusing an increase in relative risk of one disease with absolute risk of dying. To use the lightning example, you probably have a 1-in-a-billion chance of being struck by lightning if a thunderclap is audible but the sky above is clear.

Some states close public pools when that happens. If the sky above is clear but you can see lightning in the distance, your odds of getting struck may jump to 1-in-100,000,000. That’s a 10-times relative increase, but only a 9-in-a-billion absolute increase. So these states inconvenience parents and fidgety kids for basically no reason other than misunderstanding relative and absolute risk.

To make matters worse, the WHO conflates the risk of smoking and asbestos with red meat. Both the former cause perhaps something like an 18% increase in age-adjusted death rates in total, not an 18% increase in one form of cancer. The difference? Probably about a thousand times in total, unvarnished, absolute risk.

Yes, I know it’s not always about me (my ex-wife was quite clear on this) but this is exactly what Quizzify teaches. Newscasters who had taken the Quizzify quiz (and relative-vs-absolute risk is in the advanced level…but they are newscasters so they should get to that level) would have led with the headline: “WHO Demonstrates No Understanding of Health” instead of “You Could Die from Eating Red Meat”.

Healthcare’s Deadly Data Problem

Oct 26, 2015• 7

By LEONARD D’AVOLIO

I have read with interest the ongoing conversation about the ProPublica Surgeon Scorecard in THCB and beyond, not because I believe this latest effort at measuring quality will have a significant effect on patient care, but because behind the latest public metric debate – in fact behind all healthcare metric debates – is a major systemic problem. This problem somehow always seems to remain unseen. We acknowledge that measuring healthcare quality is difficult and that using medical data is challenging, but I’m not convinced that people completely understand why or how measurement and data are so difficult in healthcare…nor am I certain that everyone understands the repercussions of those challenges.

As I wrote here, the most promising recent development in medicine is the emphasis on learning from our data. We are finally digitizing records of clinician and patient interactions via the adoption of EMRs. Data warehousing technologies are connecting healthcare’s disparate systems and making data accessible to decision makers. Data will be the foundation for healthcare improvement. However, it is dangerous to assume that accessing raw data is equivalent to accessing relevant information.

All of today’s widely adopted EMR systems were designed to fulfill three purposes: financial reimbursement, narrative communication among clinicians, and legal protection. Now, we aim to use that data for very different purposes: the improvement of health and the discovery of process efficiencies. The impact of the resulting inconsistencies between design and use cannot be overstated, and yet no one else seems to be stating those impacts at all.

Defining Interoperability: An Interview with Grahame Grieve

Oct 26, 2015• 2

By LEONARD KISH

Grahame Grieve is a long-time leader within HL7 and one of the key drivers behind FHIR. He chats with Leonard Kish about what’s been happening and what’s ahead for interoperability.

LK: First tell me how you got into standards… it’s kind of an odd business to get into. Why have you chosen this and why are you excited about it?

G: It happened by accident. I was working for a vendor and we were tasked with getting some exchanges and I wanted them to be right the first time. That was the philosophy of the vendor. If we did it right the first time, then we wouldn’t have to keep revisiting and that meant that using the standards correctly. The more I got involved, the more I discovered that it wasn’t obvious how to do that…and that the standards themselves weren’t good. I felt personally that we need really good standards in healthcare. So it became a personal mission and I got more involved through the company I was working for and eventually I left so I could continue doing what I wanted doing with the standards – I enjoy the community aspect of the standards and feel very strongly that it’s worth investing time in and I had the opportunity to build a business out of it, which not many people do. So now I freelance in standards development and standards implementation.

LK: There’s a lot of talk in Congress about the lack of interoperability and everyone probably has their own definition. Do you have a working definition of interoperability or is there a good definition you like for interoperability?

G: The IEEE definition to get data from one place to another and use it correctly is pretty widely used. I guess when you’re living and breathing interoperability you’re kind of beyond asking about definitions.

LK: Are there ways to measure it then? Some people talk about different levels; data interoperability, functional interoperability, semantic interoperability. Are there different levels and are there different ways to measure interoperability?

G: We don’t have really have enough metrics. It’s actually relatively easy to move data around. What you’ve got to do is consider the costs of moving it, the fragility of the solution, and whether the solution meets the user’s needs around appropriateness, availability, security, and consent. Given the complexity of healthcare and business policy, it’s pretty hard to get a handle on those things. One thing that is key is that interoperability of data is neither here nor there in the end because if providers continue with their current work practices, the availability of data is basically irrelevant, because they treat themselves as an island. They don’t know how depend on each other. So I think the big open area is clinical interoperability.

LK: Interoperability in other verticals mostly works. We hear talk about Silicon Valley and open APIs. There’s perhaps less commotion about standards, maybe because there are less conflicting business interests than in healthcare. Why is healthcare different?

G: First of all – from an international perspective, I don’t think other countries are by and large better off or different (where incentives are different). They all have the same issues and even though they don’t have the business competition or the funding insanity that you do in the US, they still have the same fundamental problems. So I hear a lot of stuff from the US media about that and I think it’s overblown. The problem is more around micro level transactions and motivations for them and fundamentally the same problem around getting people to provide integrated clinical care when the system works against them doing that.

LK: So can you give me an example of how things are maybe the same with NHS or another country vs. the US in terms of people not wanting to exchange clinical data?

G: In Australia, there’s a properly funded medical health care system where the system is overwhelmed by the volume of work to be provided. No one get’s any business benefit from not sharing content with other people. Still, because you have to invest time up ahead to exchange data and other people get the benefits later, there’s very low participation rates for any kind of voluntary data sharing schemes that you set up. There’s scandalously low adoption rates. And that’s not because it’s not a good business idea to get involved but it’s because the incentives are misaligned at the individual level (and the costs are up front).

LK: Right, so it’s maybe it’s also a lack of consumer drive? It’s there data and you’d expect the incentives to align behind them, but they don’t ask and don’t get, maybe because we (or our providers) only access your record when we really need them. It’s not like banking or email or other things we use on a daily basis?

G: Probably that’s part of it, but from a consumer’s point of view, what does it do for them getting access to their data? Continue reading…

Why Health Care Providers Should Publish Physician Ratings

Oct 24, 2015• 3

By ASHISH JHA, MD

Early efforts to publish performance data about doctors and hospitals usually required a strong external force, such as pressure from a state department of health. But that’s changing. Some leading health care systems are now publishing ratings of their physicians on their own websites, not just ceding that activity to consumer outlets. This development may seem small, but if the trend grows, it will drive improvements in the quality of care. To envision that potential transformation, you first have to understand some of the origins of physician and hospital ratings.

In 2005, the Centers for Medicare and Medicaid Services (CMS) launched Hospital Compare, which publicized data on hospitals’ compliance with process-of-care metrics (for instance, whether a patient with pneumonia received the correct type of antibiotic, according to the medical evidence). The CMS system now also reports clinical outcomes, infection and rehospitalization rates, and other data. But all the evidence suggests that consumers are not using that information to make health care choices, mainly because the reports are hard to digest and often don’t convey information that matters to patients.

Given the limitations of public reporting, several companies have jumped into the ratings business. U.S. News & World Reporthas long been publishing its America’s best hospitals list, and experienced consumer outlets such as Yelp, Consumer Reports, Leapfrog, and Healthgrades now offer up user-friendly ratings of physicians and hospitals. It’s tough to gauge how extensively consumers use this information, but the number of outlets that rate physicians by name is clearly growing. Even if providers and policymakers resist the trend, the market is making it happen.Continue reading…

Stop Calling Them Patients!

Oct 23, 2015• 32

BY JIM PURCELL

We have a healthcare system that is provider-centric indeed. Why else would we call the consumers of their services “patients?” Perhaps because they have to be patient. Patient because they have to wait long after their appointed hour to be seen. Patient while waiting in the Emergency Room. Patient because the healthcare system is rigidly resistent to change. Patient because even the most advanced providers measure quality based on “best practices” rather than outcomes. Do you care about whether your physician employed best practices if your outcome was bad? Ummm, nooo.

So let’s rename patients right now. How about “consumers?” For sure they are, although in today’s dysfunctional healthcare “system,” they rarely pay the providers whose care they consume. But let us not hesitate over that anomalie, which may be slowly changing. Up to now, we as consumers of healthcare rarely even choose our providers. They are chosen for us by other providers. And if we want to be good shoppers and choose ourselves? How do we do that when we cannot determine how much a provider costs or how good he or she is?

Oliver Wyman’s Tom Main and Adrian Slywotzky got it right when they opened their superb article with the following observation:

“For many people, the word “consumer” sounds out of place in a discussion of healthcare. And indeed some of the woes of our system arise precisely from our (mostly ineffective) effort to keep commerce away from medicine. We thought we were protecting the autonomy of physicians, but inadvertently we created a system that rewards waste and failure and makes it difficult to deliver optimal care. Continue reading…

Why Does the FDA Approve Cancer Drugs That Don’t Work?

Oct 22, 2015• 5

By BRIAN KLEPPER

A new study in JAMA Internal Medicine finds that two-thirds of cancer drugs considered by the US Food and Drug Administration (FDA) over the past five years were approved without evidence that they improve health outcomes or length of life. (This study closely corroborates and acknowledges the findings published last year by John Fauber of The Milwaukee Journal Sentinel and Elbert Chu of MedPage Today.) Follow-up studies showed that 86 percent of the drugs approved with surrogate endpoints (or measures) and more than half (57%) of the cancer drugs approved by the FDA “have unknown effects on overall survival or fail to show gains in survival.” In other words, the authors write, “most cancer drug approvals have not been shown to, or do not, improve clinically relevant end points.”

The use of surrogate endpoints in the approval process is at the heart of this issue. Drug companies argue that these alternative measures permit smaller, cheaper and faster clinical trials, allowing desperately needed drugs to get to market faster. Demonstrating efficacy with “harder” measures like overall survival – whether someone actually lives longer as a result of the drug – is a higher bar that requires more time and resources.

Many drug company representatives argue that the shortcut is not only acceptable but desirable. A 2011 Genentech white paper on oncology endpoints opens with this headline:

“…such surrogate endpoints as objective response rate and progression-free survival have been employed because they can be reached faster and may offer important benefits in evaluating therapies.”Continue reading…