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Six Awkward Concerns in My OpenNotes

• 20

By Leslie Kernisan, MD

I found out this past weekend that the VA will be making clinician progress notes available for patients to view on the MyHealtheVet portal. In other words, the VA is going OpenNotes. (Note: I was a primary care provider in geriatrics clinic at the San Francisco VA from 2006-2010.)

My first reaction was to be impressed by this bold progressive move.

My next reaction was to feel mildly relieved that I’m no longer a PCP there.

Now, it’s not because I’m against transparency in healthcare, or am suspicious of patient engagement, or feel that patients shouldn’t see their health information without the assistance/gatekeeping/interference of a clinician. Far from it.

It’s because in my own VA practice caring for WWII vets, I used to frequently document certain concerns that would’ve been a bit, shall we say, awkward for the patient to see. Reading about these concerns would’ve quite possibly infuriated the patient, or the caregivers, or both.

So whew, I find myself relieved that I don’t have to figure out how to document (or not document?) these concerns.

Instead, I’ll get to see how my friends at the VA handle these issues.

Wondering what they are? Ok, I will tell you but shh … don’t tell my elderly patients that I may be considering these topics as I care for them.

Six awkward concerns in geriatric primary care practice

· Possible dementia. As a geriatrician, I focus on an age group that has a high incidence of dementia. Which means that when someone starts to tell me odd stories (concerns related to poison are a popular theme, as well as reports that someone is stealing things repeatedly), I start wondering about possible dementia. Ditto if he or she starts floundering with the medications, or starts having other difficulties with IADLs.

Why it’s awkward: Patients and families really hate it when I bring up the possibility that there might be dementia. Many find the possibility of a disease such as Alzheimer’s truly terrifying, both because it’s perceived as a terrible disease, and because they worry about having to leave their homes or otherwise losing their independence. Note that if I’m considering the possibility of dementia, I usually let the patient know during the visit.

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THCB Calendar: 2013 Harvard Business School Healthcare Conference

The 10th Annual Healthcare Conference at Harvard Business School is to be held Saturday, February 2, 2013. This year’s topic is Consumer-Centric Innovation.

Top 5 Reasons to Attend:

  • Network with over 700 students and professionals from Boston and beyond focused on healthcare
  • Hear from our keynotes: David Kirchhoff, President and CEO, Weight Watchers International; Nancy-Ann DeParle, Deputy Chief of Staff for Policy, Obama Administration; Kent Thiry, Chairman and CEO, DaVita Inc.; Tom Gentile, President and CEO, GE Healthcare Systems
  • Enjoy panel discussions across: pharma/ biotechnology, medical devices, diagnostics/ personalized medicine, healthcare financing, consumer health, payor/provider, IT, and emerging markets
  • Have a small group lunch with an industry leader of your choice
  • Attend our networking reception, with representatives from both established and emerging players

Please follow this link here to reserve your tickets. The current agenda and keynote speakers can be found at www.hbshealthcareconference.org

Obamacare’s Fiscal Cliff

• 10

By John Goodman

Did you notice that in the standoff over the fiscal cliff, all the discussion was about the Bush tax cuts? Which ones would be made permanent? And for whom? There was no discussion about the ObamaCare tax increases. I think that was a huge tactical mistake on the part of the Republicans.

Over and over again, President Obama claimed he was trying to protect the middle class from higher taxes. It was a claim that went unchallenged ― by the Republicans and by the mainstream media.

Yet five of the tax increases Americans are facing this month are new taxes created under the Affordable Care Act (ObamaCare). Three of the five will hit people who are solidly middle class.

Next year, things will get worse. The new tax on health insurance is about as regressive as a tax can be. It will total $100 billion over the next 10 years and very little of that amount will be paid by anyone who can be called “rich.”

  • The health insurance tax will fall on private sector Medicaid plans, which have about 70% of all Medicaid enrollees.
  • The tax will fall on Medicare Advantage plans whose enrollees have below average incomes and are disproportionately minority.
  • The tax will hit every small business and every individual who buys insurance in the commercial market place.
  • The tax will not fall on self-insured plans whose enrollees include the highest paid workers and the highest paid CEOs.

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Health Expert Insight for 2013: Jeff Goldsmith and Charlie Baker

• 5

By Alexandra Drane

We talk to people every day about the barriers, fears, and motivations they have around their health, and often have the luxury of funneling the insights we learn back into the larger healthcare ecosystem. So here’s a doozy:  recent Eliza survey data (from October 2012) suggests that 82% of people say they would like their health plan more if they were more proactive about covered health care benefits … and two-thirds of people believe that their health plan is not telling them enough about what’s going on with healthcare reform and how it will impact their care in the coming years.

Based on this data, we wanted to dig a bit deeper into what exactly we can tell people to expect on that front. So we engaged Jeff Goldsmith and Charlie Baker in a conversation on everything from whether or not the Affordable Care Act is implementable (2:50) to the readiness of state and federal exchanges (5:00) to how employers will be stepping up to fill in critical health components (10:15) to the impact of increasing consolidation (15:00) to how the physician realm can keep a semblance of competitive tension in the provider networks (25:25).

And finally, we asked them the question we should all be asking ourselves:  will the care you are going to get in 2015 be better than the care you got in 2009? [40:41]

Click here to listen to the Podcast.

The good news is that many of these trends can be addressed through strategies like a stronger consumer-focused angle; higher-touch yet lower-cost communication between healthcare organizations and the people they serve; and a deeper understanding of how to proactively encourage health in both traditional (preventive health) and not-so-traditional (patient advocacy) ways. All eminently doable, right?

So listen, learn, and enjoy… and most importantly, stay ferociously committed to a healthier 2013 for all of us.

Alexandra Drane is the Chief Visionary Officer of Eliza.

Connecting Medical Devices and Their Makers

• 7

By Peter Pronovost, MD

Today, an intensive care unit patient room contains anywhere from 50 to 100 pieces of medical equipment made by dozens of manufacturers, and these products rarely, if ever, talk to one another. This means that clinicians must painstakingly review and piece together information from individual devices—for instance, to make a diagnosis of sepsis or to recognize that a patient’s condition is plummeting. Such a system leaves too much room for error and requires clinicians to be heroes, rising above the flawed environment that they work in. We need a heath care system that partners with patients, their families and others to eliminate all harms, optimize patient outcomes and experience and reduce waste. Technology must enable clinicians to help achieve those goals. Technology could do so much more if it focused on achieving these goals and worked backwards from there.

This week marks a step that holds tremendous promise for patients and clinicians. On Monday the Masimo Foundation hosted the Patient Safety Science & Technology Summit in Laguna Niguel, California, an inaugural event to convene hospital administrators, medical technology companies, patient advocates and clinicians to identify solutions to some of today’s most pressing patient safety issues. In response to a call made by keynote speaker former President Bill Clinton, the leaders of nine leading medical device companies pledged to open their systems and share their data.

Lack of interoperability between medical devices plays no small role in the 200,000 American deaths caused by preventable patient harm each year, such as in the case of 11-year-old Leah Coufal. After undergoing elective surgery, Leah received narcotics intended to ease her pain.

When Leah received too much medication, it suppressed her breathing, eventually causing it to stop altogether. Had she been monitored, a device could have alerted clinicians when Leah’s breathing slowed to a dangerous level.

But as we know, clinicians are busy and unfortunately don’t always respond to alarms from bedside machines. If a machine measuring her breathing had been linked with the device delivering her medication, it could have automatically stopped the drugs from infusing into her blue, oxygen-deprived veins.

All of this is possible today; technology is not a barrier. Until now, the only thing that’s stood in the way is a lack of leadership and a lack of willingness for device manufacturers to cooperate.

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Welcome to Healthcare IT Live!

[youtube width=”475″ height=”300″]http://www.youtube.com/watch?v=9-2EkxSHPIg[/youtube]

This time the camera was turned on THCB’s Matthew Holt. Tim Cook of Healthcare IT Live! interviewed Matthew for the web show, which takes place weekly on Google+ Hangouts. Click for a list of the show’s upcoming guests.

Is Health Care about to Go the Way of the Dodo?

• 8

By Lucien Engelen

As the new year started, all kinds of predictions come to our attention, mostly of things that will enter our lives.

How about things that will dissolve from our lives ?

Of all species that became extinct the Dodo has become sort of synonymous with extinction. To “go the way the Dodo”means something is headed to go out of existence. (picture and quote source The Smithsonian)

So this goes not only for species but also stuff we use or things we do.

You might want to have a look at the extinction timeline and find things you did, ‘some’ time ago, and don’t anymore.

But what about health care? What will vanish, will the doctor due to all of this new technology disappear, or the nurse? Will we no longer go to a hospital or to the doctors office? I don’t think so.

We still will be needing professionals with compassion and care. However shift is happening and some things will start getting obsolete. In the following I am in no way going to try to be exhaustive, so feel free to add in comments or thought on what you think will disrupt from our lives in terms of health(care).

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Finally. Hard Evidence Against the Autism Epidemic?

• 12

By Neuroskeptic


No one disputes that diagnosed rates of autism have increased enormously over the past 15 years or so, around the world. However, other people write it off as essentially a cultural phenomenon: we’re getting better at detecting the disorder and more willing to label kids as having it.

I subscribe to the latter view, but there’s very little hard evidence for it. To prove that diagnostic changes have occurred, rather than a true increase in autism, you’d have to know what would have happened to today’s kids, say, 20 years ago. Would they have been diagnosed? We have no way of knowing. At least not until someone invents a time machine.

However, a new study just out offers a valuable new perspective on the debate: Spatial clusters of autism births and diagnoses point to contextual drivers of increased prevalence.

According to authors Soumya Mazumdar and colleagues, there’s a zone of high autism prevalence in California, areas where kids aged 0-4 years old are more likely to be diagnosed with the condition. The epicentre is L.A.; there’s actually three overlapping hotspots centred on Santa Monica, Alhambra and North Hollywood.

In these clusters, autism rates are between 2 and 6 times higher than the rest of the state.

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ONC Health IT Announces Ocular Imaging and SMART-Indivo App Challenge Winners

By Hemali Thakkar and Mel Meder

Technological solutions continue to create higher levels of efficacy and patient engagement in healthcare, as winning technologies from two recent innovation challenges demonstrate. Winners of the following challenges, which were sponsored by the Office of the National Coordinator for Health IT (ONC) in partnership with Health 2.0, have developed technologies to advance ophthalmologists’ imaging capabilities as well as expanded patient understanding of health data. ONC’s challenge program has covered topics ranging from care transitions to Blue Button, from cancer trial discovery to patient safety, resulting in the creation of new tools that benefit consumers and providers.

The Ocular Imaging Challenge asked applicants to create an application that would store and integrate imaging data from ophthalmology exams into existing electronic health record software systems. Such a system would resolve existing compatibility issues between different types of software in ophthalmology practices.

The winner, TSGiView from TSG Innovations Inc., has created a solution for eye care clinics that standardizes imaging data to DICOM specifications to ensure that databases can be accessed by applications such as electronic health records and billing systems. The Global Retinal Imager (GRI) suite by Estenda Solutions placed second and the EyeDoc Imaging application by Penn Medical Informatics Systems Inc. placed third.

The SMART-Indivo App Challenge tasked developers to build an Indivo application that provides value to patients using data distributed through the SMART API and its Indivo-specific extensions. Indivo is the original personal health platform, enabling an individual to own and manage a complete, secure, digital copy of her health and wellness information. Developers could, for example, build a medication manager, a health risk detector, a patient-friendly laboratory visualization tool, or an app that integrated external data sources (see http://www.healthdata.gov/) with patient records in real time.

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Why ACOs Are not HMOs and Other Important Questions

• 21

By Mohammad Al-Ubaydli, MD

Mohammad Al-Ubaydli: Let’s just start from the beginning. Tom, can you please give us an introduction about yourself and your background?

Thomas Tsang: I’m a general internist by training. I practiced internal medicine in New York City, first at a small community hospital where I predominantly worked with residents and medical students and mostly taught principles of outpatient medicine, ambulatory care and interviewing techniques.

Then I was recruited by the Charles B. Wang Community Health Center. That’s when I got to use some of the public health knowledge that I had acquired: I worked on various public health initiatives for the community in New York City. The health center itself served a predominantly Asian population. It had four sites and one of the things that I did in the beginning was implement an electronic health record. That work led to my involvement with the Board of Health of New York City, which, in turn led to my work in Congress.

I was then selected for the Robert Wood Johnson Foundation/IOM Health Policy Fellowship on the Committee on Ways and Means-Subcommittee on Health and worked on some of the policies that led to the creation of ACO’s, i.e., Value-Based Purchasing, Pay for Performance and so on. I was fortunate enough to actually help implement some of the policies that I worked on! It’s a long answer to your question, but that’s the route I took.

Mohammad: It’s perfect. It’s really interesting to learn. Among the many things under your belt, it sounds like you have a successful electronic health record deployment, which is good–so well done! Tell me and our readers a bit about Accountable Care Organizations. What is an ACO and what is the point of it?

Thomas: The ACO is not a very new concept. It was a term that was coined by Elliott Fisher from Dartmouth Medical School, who is the director of Center for Health Policy and Clinical Practice. I hate to use the word HMO, but in a way, it’s almost like an HMO. It’s not really an HMO because it is actually a provider-led organization, not an insurance-led one.

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