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John Irvine

Building Healthy Communities 2.0

With its elegant homes, pleasant park and bustling stores, the Woodlawn section of Birmingham, Alabama was described in a 1950 news article as “a really great section of Birmingham…typical of the fine things in life.” Then came the racial unrest of the 1960s, disruption from urban renewal gone awry and white flight to Birmingham’s suburbs. Joblessness and poverty took root; the housing stock decayed. Today, median income in Woodlawn is just $21,000, less than half the level for Birmingham as a whole.But now Woodlawn is in the midst of a turnaround, aiming to become not just a neighborhood that prospers economically, but also one where people live healthier lives.

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Why Large Scale Government IT Projects Fail and What To Do About It

The volume of failed large-scale information technology (IT) projects in the public sector is troubling. These projects are failing at an alarming rate. The long history of public sector IT failures has seen billions of dollars lost, embarrassment, redundancy, waste, and a loss in public trust. In 2004, the U.S. Air Force (USAF) began work on the Expeditionary Combat Support System, a project designed to streamline and automate the USAF’s operations by consolidating over 200 legacy systems. The USAF contracted with Oracle and then Computer Sciences Corporation and by 2012, the project had spent $1.1 billion taxpayer dollars and was ultimately terminated. U.S. Senators Carl Levin and John McCain stated that this project was “one of the most egregious examples of mismanagement in recent memory.” The National Programme for IT in Great Britain has failed miserably after £12.7 billion was spent to create an online portal that would allow citizens access to their personal health information; the project will arrive four years late in 2015. In Victoria, Australia, a smartcard ticketing system for public transportation was started in 2005 and was flawed from conception. Eventually, the project was implemented years late, marred by various missteps, and went $500 million over budget.

Even though leaders are familiar with past failures, many in the public sector have failed to learn from these mistakes. Bent Flyvberg and his colleagues dubbed this phenomena the “megafailures paradox” where there is continued investment in IT projects while failing to understand the causes of failures.

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Interoperability via Direct Exchange: A Brief Update Mid-2015

Over the past three years it has been my good fortune to work with talented individuals and organizations dedicated to making sharing of health information ubiquitous, secure, inexpensive, and easy to use. Quietly and without much fanfare, they have built both technical and trust infrastructures that reach almost 40,000 health care organizations, interoperably connecting users of over 200 EHRs and PHRs from different vendors. What follows is a brief update of the current status of interoperability in health IT via Direct exchange.

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Health Data – It’s a “Thing!”

This year’s Datapalooza conference, June 1-3, in Washington, D.C. takes place as health data edges close to becoming “a thing” in the cultural landscape.  Consumers may not know it yet, but all that fitbiting, medical social networking, and test result accessing through patient portals could soon swell into a full-fledged consumer movement.    

You can almost hear it now:  “Hey man, did you upload your stats after your knee surgery—you know, how much you’re walking, your pain levels, and all that?”   

Or, to a newly diagnosed cancer patient:  “Be sure to track your treatment experience online.  It’s kind of cool to do and helps researchers figure out what works and doesn’t.”   

Or:  “Check this app out—you can enroll in a clinical trial in, like, 5 minutes.”   

This is, of course, what many health data heads have forecast for years.  It’s also now crystal clear that the use of big data to improve health care is no longer a research backwater.  To be sure, there’s hype around the potential to dramatically alter physician and consumer behavior via big data analytics.  We are still dealing with human beings, folks.  As well, concern about privacy continues to vex health data entrepreneurs, researchers, and consumers. 

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If You Can Read My Note, The Patient Was Sick

When my junior year in medical school started in September of 1971, my classmates and I entered daily notes in patients’ hospital charts, loose leaf notebooks that documented their medical progress – or not – over the course of their hospitalizations. The notes were official, legal – and largely useless. About half of what was entered by faculty and consultants on any single day was so illegible that the medical alphabet more resembled cuneiform than English. The possibility of a note being misread was not lost on one of our senior professors, who mumbled: “If you can read my note, you know the patient was sick,” as he slowly wrote a note on a patient who qualified as “sick”.

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Physician Burnout Presents Differently in Male and Female Doctors

Burnout is a chronic epidemic in physicians and a major threat to patient satisfaction and quality care. Recent research is showing that women and men experience burnout differently.

Numerous studies have shown that an average of 1 in 3 practicing physicians are suffering from symptomatic burnout on any given office day … worldwide, regardless of specialty. There is good evidence to believe the physician burnout rate is higher in the USA than in other world markets simply because of the uncertain political and payment environment and the massive merger and acquisition activities across the country. As evidence, the 2015 Medscape Physician’s Lifestyle Survey showed a 46% burnout rate, 16% higher than the same survey in 2013.

The three classic signs and symptoms of burnout are measured by a standardized evaluation; the Maslach Burnout Inventory (MBI) developed by Christina Maslach and her team at the University of San Francisco in the 1970’s.

Here is Maslach’s description of the experience of burnout: “… an erosion of the soul caused by a deterioration of one’s values, dignity, spirit and will.” The three symptoms of the MBI are.

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Did Dr. Virginia Apgar worry about work-life balance?

Dr. Margaret Wood, who chairs the Department of Anesthesiology at Columbia University Medical Center, has published a wonderful article titled “Women in Medicine:  Then and Now“, in the journal Anesthesia and Analgesia.

I think I speak for many of us in admitting that Anesthesia and Analgesia doesn’t occupy a prominent place on my bedside table. Many readers may have missed Dr. Wood’s article. That’s a shame, because it isn’t just about anesthesiology, and speaks to issues in medicine independent of specialty or gender. Here are some of my favorite passages about lessons she learned over the course of her long and successful career:

“1. It is important to have a passion for what you do if you strive for excellence. If you have that passion, then the efforts do not feel like a sacrifice and “burnout” is not an issue. I cannot imagine that Virginia Apgar spent a single moment talking, thinking, or worrying about burnout.

2. The current fashion to complain about “life balance” can be self-destructive; however, pacing oneself is critical. You can have it all, just not all at once. The Chairman of Anatomy gave the inaugural lecture to my incoming class of medical students. His thesis was that as a physician/medical student you could have (i) an active time-consuming social life, (ii) a family, and (iii) a career, but to be successful you should have no more than two of these at the same time. I believe this to be true and have followed this advice since.

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Fear-based Medicine: Using Scare Tactics in the Clinical Encounter

flying cadeuciiHow often do doctors say something like this to patients?  “It’s really important for you to do this; if you don’t you might … have a stroke, go blind, lose a leg, die or (insert a scary outcome here).”  There are no solid data to answer this question, though patients report that conversations containing such direct threats are common in clinical encounters. The more important question is, do scare tactics work?

Fear-based messages in clinical encounters

Health communication experts call these types of messages fear-based appeals. Fear appeals create an emotional reaction to some “threat” of disease, disability or death, which in turn, is thought to motivate behavior change. Doctors may use fear-based messages when counseling patients about chronic disease self-management or prevention, especially when faced with a patient we believe to be unmotivated or non-adherent.  In such situations, using fear as a tool is appealing because it is easy, doesn’t take much time and we know intuitively that fear can be a powerful motivator.   Yet despite decades of research on the subject, there is no consensus on whether or how fear can be used effectively to motivate long-term behavior change.

Research supporting the effectiveness of fear appeals is generally from public health campaigns, where frightening facts or images can quickly capture the audience’s attention.  This makes sense when a message sender is competing for audience attention among many billboards, advertisements and other messages. But it rarely makes sense when a doctor is alone in an exam room with a patient. For many patients, the 15 minutes they have with their doctor will be the 15 most important minutes of their day.

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A Classic Non-Reaction Reaction From Screening Proponents

Is it just me or has there been a deafening silence from the wellness proponents of forced HRA/biometric screening since Dr. Atul Gawande’s article Overkill appeared?

Two salient quotes from the article capture the issue. The first about over screening and testing in general, not specific to wellness but applicable:

“Often, these are fishing expeditions, and since no one is perfectly normal you tend to find a lot of fish. If you look closely and often enough, almost everyone will have a little nodule that can’t be completely explained, a lab result that is a bit off, a heart tracing that doesn’t look quite right.”

Now, read the article and Dr. Gawande’s story of how he treated a patient who’d been diagnosed with thyroid cancer. Please-read it, this is what overscreening leads to and can do to your employees. It is not an academic issue, real people are impacted. His quote here is especially impactful

“All the same, she thanked me profusely for relieving her anxiety. I couldn’t help reflect on how that anxiety had been created. The medical system had done what it so often does: perform tests, unnecessarily, to reveal problems that aren’t quite problems to then be fixed, unnecessarily, at great expense and no little risk…An entire health care system has been devoted to this game.”

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