Author Archives

John Irvine

A Declaration of Data Independence Through the Lens of the Patient

This weekend is not only independence day in the US, it’s the culmination of a patient-led uprising to demand that providers hand over their medical data. To that end I & THCB are supporting Health Data Independence Day. Sign the petition at and please use and encourage others to use the free tool from the associated Vocatus Project to request your data from your doctors and hospitals. I’ll be taking up the cudgels in the continuing story of my son’s “Search for Intr-Aero-Bili-Ty” but for now we’re thrilled to publish this amazing piece from Health IT expert and very recent cardiac patient, Brian Ahier–Matthew Holt
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Data Liberación is our battle cry…

Six years ago I wrote a blog on Independence Day. In 1776 the 56 citizens of the 13 British colonies signed their names to a document declaring that the King was abusing the colonies and violating the basic principles of human decency bestowed by God. So they declared independence from Great Britain and birthed the United States of America.

Abraham Lincoln said in a speech during his Senate race against Stephen A. Douglas of the Declaration of Independence, “This was their majestic interpretation of the economy of the Universe. This was their lofty, and wise, and noble understanding of the justice of the Creator to His creatures.”

We are blessed to live in the greatest country in the world. We have had many struggles and challenges and have had to to overcome the sins of the past, but the Founders wisely put in place a constitutional framework that allows for transformation changes to occur, generally without bloodshed. The Republic is alive and well and actually improves every generation. I wish all of you a peaceful, safe, and joyous Fourth of July celebrating with family, friends, and neighbors. I also hope that you will participate in the first Data Independence Day.

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It’s a Bird. It’s a Plane. No, It’s SCOTUS!!

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In a 6:3 decision, SCOTUS rescued Obamacare once again. Obamacare, untouched by Donald Trump and the Anti-Death Panelists, was almost brought to its knees by a single word; a lowly, miserable, reclusive preposition – “by”.

A brief summary.

Obamacare helps low income families buy health insurance through subsidies doled out by the Internal Revenue Service (IRS). Health insurance is sold at online marketplaces called exchanges. The online exchanges have been created by the state or the federal government. The statutes say that subsidies are available for insurance bought “through an exchange established by the state.”

The plaintiffs in King v. Burwell alleged that the IRS was illegally subsidizing people in over thirty states where the federal government, not the state, established the online exchanges.

The administration claimed that the subsidies applied in all states. That the language was admittedly sloppy and “by the state” also meant “by the federal government.” The country is now so polarized that even prepositions must take sides.

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The ABIM Controversy: A Brief History of Board Certification and MOC

Bob WachterWhat’s up with the ABIM?” “I just got a note about an alternative board. Should I join it?” “Aren’t you glad to be off the Board?”

These days, I get these questions from friends and colleagues regularly. When I first joined the board of directors of the American Board of Internal Medicine (ABIM) in 2004, the organization was a well-respected pillar of American medicine. Today the organization finds itself in a fight for its life, being painted as everything from out of touch to money-hungry to, more recently, corrupt.

I just completed my decade-long service to the ABIM and, more recently, the ABIM Foundation. I’ve waited until now to write this because I wanted to be clear that I am not speaking for ABIM or its leadership. I am also well aware that there is a vocal group of critics who feel passionately about this matter, whose minds are made up, and who are approaching this fight with a take-no-prisoners zeal. By adding my voice, I am likely to become a target for their anger.

So be it. With the help of social media and a journalist who has turned this matter into a cause célèbre with an unfortunate mixture of half-truths and innuendo, the critics have managed to control the debate, and people who believe in the values of the Board have been cowed into silence. It feels vaguely McCarthyish, and there comes a time when silence is immoral. This feels like such a time.Continue reading…

King vs. Burwell: Chalk One Up For Common Sense

Screen Shot 2015-06-26 at 8.33.49 AMThe Supreme Court yesterday decided that Congress meant what it said when it enacted the Affordable Care Act (ACA). The ACA requires people in all 50 states to carry health insurance and provided tax credits to help them afford it. To have offered such credits only in the dozen states that set up their own exchanges would have been cruel and unsustainable because premiums for many people would have been unaffordable.

But the law said that such credits could be paid in exchanges ‘established by a state,’ which led some to claim that the credits could not be paid to people enrolled by the federally operated exchange. In his opinion, Chief Justice Roberts euphemistically calls that wording ‘inartful.’ Six Supreme Court justices decided that, read in its entirety, the law provides tax credits in every state, whether the state manages the exchange itself or lets the federal government do it for them.

That decision is unsurprising. More surprising is that the Court agreed to hear the case. When it did so, cases on the same issue were making their ways through four federal circuits. In only one of the four circuits was there a standing decision, and it found that tax credits were available everywhere.

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Quantifying the Art of Medicine

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Historically, placebos have been defined as a sugar pill or inert substance used as a control variable in experimental studies. Placebo effects were considered a nuisance. Researchers and clinicians have paid little attention to the fact that placebos seem to produce their own health impacts.

But in a July 2 New England Journal of Medicine Perspectives piece , Ted Kaptchuk of Harvard Medical School and Franklin G. Miller from the Department of Bioethics at the National Institutes of Health, show us that there’s more to placebos than we originally thought.

For example, in a study of patients with irritable bowel syndrome, patients experienced adequate symptom relief when given a placebo, compared to those who didn’t receive a placebo. That’s a common enough finding. But what’s most interesting is that relief was even greater when the placebo was coupled with more engaged positive interactions with a provider, such as attentive listening and thoughtful conversation. In another study, when given morphine directly by a doctor or nurse through a syringe, patients experienced more pain relief than when it was administered through an IV. Seeing it administered increased the effectiveness of the medication.

This evidence leads the authors to argue that placebo effects are not the products of dummy treatments but actually the effects of immersion in a health care environment with all its cues and signals. Continue reading…

No MUwithoutMe: Here’s What Happened When I Requested My Medical Records

NayerAs an innovator, restless entrepreneur, and national award winner for consumer engagement, I was intrigued with the stories I was reading about accessing the patient portal for data, basically the looking glass into “my data.” For those who are not familiar with health data, here’s a quick history.

As part of the Great Transformation in health care, HHS, CMS, and ONC (which is the Office of the National Coordinator for Health Information Technology), and others regularly update rules on health data, privacy, HIPAA and meaningful use. Meaningful use—otherwise known as MU—is a term that describes how the stakeholders, starting with the patient, provider (doc, hospital, etc.) and plan can and should be using the data, because it provides historical and patient-centric context. Meaningful use as a measure of quality improvement was launched to describe the kinds of health IT [HIT] improvements that would be developed over the course of several years.

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An Anatomy of Chairs

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R had been my patient for over a year. She was referred to me by a colleague. She had 38 symptoms. All tests and imaging studies failed to find any demonstrable medical disease; I considered her to have “symptoms of unknown origin”.

I had little information on R’s personal and family history. I did know she was 43 years old and was 7 years into her second marriage. Her first marriage ended in divorce from a severe alcoholic husband. She had no children. She dwelled on her many symptoms and avoided all my attempts to gather more personal or social information.

Before I can share my full experience with R, I need to provide some back ground on my clinical thinking.

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FTC Files First Ever Complaint Against a Kickstarter Project …

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Crowdfunding platforms like Kickstarter have exploded in popularity over the past few years. As the number of funded projects has grown so have the number of projects that never deliver on their stated goals. The Federal Trade Commission (FTC) recently filed its first ever complaint with a Kickstarter project that did not provide its stated rewards to backers.

The complaint charges Erik Chevalier with misusing the $122,874 in pledges he received for a board game called The Doom That Came to Atlantic City, which features characters from the works of H.P. Lovecraft on a Monopoly-style board. Chevalier agreed to a settle with the FTC that includes a fine of $111,793.71. Kickstarter’s Terms of Use states that a funded project must either deliver the promised rewards to its backers or refund their money, but the website does not rigorously enforce the policy. Although Kickstarter claims that its projects have an excellent record of delivering on their promises, a lack of transparency could scare potential backers away from the website.Continue reading…

How Might Crushes Right In Healthcare

Richard Gunderman goodDr. Melos is a gastroenterologist in solo practice in a medium-sized Midwestern city.  One day she hears a knock on her door.  When she answers, she finds two representatives of Athenian Health System, who request a few minutes of her time.  She invites them to take a seat in her office.

After exchanging pleasantries, the visitors get down to business.  They extend Dr. Melos an offer to join the ranks of Athenian’s employed physicians.  If she declines, they say, they will hire their own gastroenterologist, whose practice will grow rapidly on referrals from their large network.

The representatives of the health system are remarkably candid.  “We will not take up your time with arguments about the appropriateness of what we are doing.  What we have here is a large imbalance of power, and as a business matter, you really have no choice.”

Dr. Melos replies that she has always worked amicably with Athenian Health, using many of its diagnostic testing services and admitting her patients to its facilities, so the health system has no need to deliver such an ultimatum.

The representatives respond that, if they allowed Dr. Melos to maintain her practice in the form she is accustomed to, it would make Athenian Health, which is seeking to consolidate its market position in the area, look weak. 

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Disruptive Regulation

The latest salvo in the interoperability and information-blocking debate comes from two academic experts in the field of informatics, and was recently published in JAMIA. In the brief article, Sittig and Wright are endeavoring to describe the prerequisites for classifying an EHR as “open” or interoperable. I believe the term “open” is a much better fit here, and if the EHR software happens to come from a business dependent on revenues, as opposed to grant funding from the government, bankrupt may be a more accurate description. Since innovation in the EHR market seems to lack any disruptive effects, perhaps a bit of disruptive regulation would help push everything over the edge.

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