Categories

Author Archives

lauramontini

Delivering Progress. Choosing Wisely.

Last April, the ABIM Foundation, with Consumer Reports and other partners, drew national attention to overuse of ineffective and harmful practices across the health care system with their Choosing Wisely campaign. As part of the campaign, professional medical societies identified practices within their own specialties that patients should avoid or question carefully. Today, the American Congress of Obstetricians and Gynecologists (ACOG) and the American Association of Family Physicians (AAFP) have joined the campaign, drawing national attention to the overuse and misuse of induction of labor. ACOG and AAFP are telling women and their maternity care providers:

1. Don’t schedule elective, non-medically indicated inductions of labor or cesarean deliveries before 39 weeks 0 days gestational age.

2. Don’t schedule elective, non-medically indicated inductions of labor between 39 weeks 0 days and 41 weeks 0 days unless the cervix is deemed favorable.

(“Favorable” means the cervix is already thinned out and beginning to dilate, and the baby is settling into the pelvis. Another word for this is “ripe,” and doctors and midwives use a tool called the Bishop Score to give an objective measurement of ripeness. Although ACOG and AAFP do not define “favorable,” studies show cesarean risk is elevated with a Bishop Score of 8 or lower in a woman having her first birth and 6 or lower in women who have already given birth vaginally.)

Much work has already been done to spread the first message. Although ACOG has long advised against early elective deliveries, the practice has persisted. But a confluence of recent reforms has made it increasingly difficult for providers to perform elective deliveries before 39 weeks. Quality collaboratives have supported hospitals to implement “hard stops” that prevent these deliveries. Payers have used carrots and sticks to disincentivize them. CMS has funded a national public awareness campaign to reduce consumer demand.

Continue reading…

Rick Scott’s Privatization Experiment in Florida

A million Floridians will now be eligible for Medicaid––the Obama administration is happy about that.

Republican Rick Scott gets to do it his way––in an almost entirely private market.

This from today’s Tampa Bay Times:

His [Scott’s] endorsement of the expansion came hours after the federal government agreed to grant Florida a conditional waiver to privatize Medicaid statewide for the state’s more than 3 million current recipients, more than half of which are children or people under age 21.

Scott has agreed to only a three year trial expansion and the legislature must vote in favor of it––not a certainty. And, the Obama administration is taking some big risks––a five county trial of Scott’s privatization program has had lots of problems.

In prior posts I have said that Republican governors, so adamantly opposed to “Obamacare,” ought to go to Washington and negotiate a deal on Medicaid expansion. If they believe they can manage Medicaid better than the traditional federal route, which is what they claim every time they demand block grants, then they should put a deal on the table. Ultimately, the feds will pay 90% of costs and the state will pay 10% of the cost of the expansion. The Republican governors don’t believe they can save 10% if given more flexibility?

Continue reading…

Investors Are from Mars. Entrepreneurs Are from Venus


Last year was a banner year for digital health, as the market saw significant growth in funding, bigger deals and new investors entering the space. So what’s in store for 2013? According to a survey of nearly 140 digital health entrepreneurs and over 50 health care information technology venture investors, conducted by my venture capital firm InterWest Partners, we are in for another exciting ride this year. In the survey, we asked which sectors will see the most love from investors in 2013; which companies (if any) will see a $1 billion valuation; where they are having trouble recruiting; and which digital health entrepreneur would win “Survivor: HCIT Island” The answers? Well, it all depends who you ask.

Continue reading…

Killed by The New York Times?

Readers know that I am skeptical of medical practices that defy logic, or as we say in the business, evidence. Among the most controversial issues that beguile all of us (patients and docs) is this business about the PSA test.

A loyal reader sent me a doctor-written column with the provocative headline “My Patient, Killed by The New York Times.”

First, keep in mind that the website that posted this, Mediaite, is all about the media covering (really fawning and dishing) itself. The purpose of this story, with its provocative headline, sad outcome, and mea culpa tone, is to generate “buzz.”

Then understand that this is a story of one patient who made an informed decision to forego PSA testing, based on the fact that he was an intelligent person without symptoms who’d read the literature (or at least responsible press coverage of said evidence). He did not want to open the Pandora’s Box (literally: crapshoot) that is PSA screening.

Yes, he wound up with advanced prostate cancer and subsequently died. Had he had his prostate removed or radiation to ablate his cancer, and wound up with horrible side effects (impotence, incontinence) would he value the trade-off?

I offer you the counter-anecdote of Ted, who in a discussion with me, insisted that he get a PSA test because his heroes Joe Torre and Norman Schwarzkopf told him to. When it came back at 4.10 ng/dL (threshold 4.00), he went for biopsy (what else to do?) which showed low grade, gland-confined prostate cancer. Fearful of the “C” word, he couldn’t live with the idea of doing nothing (“watchful waiting”) about his cancer. So he chose external beam radiation, with the hope that it would be less damaging than radical surgery.

Continue reading…

The Four Things You Should Absolutely, Positively Do For Somebody at Risk of Developing Alzheimer’s

Do they need a PET scan to confirm the presence or absence of amyloid plaque?

More importantly, would doing such PET scans make meaningful impacts on patients’ health?

Those are the questions that a Medicare expert panel recently considered, and their impression, after carefully reviewing lots of high-quality research, is that we don’t yet have evidence supporting the benefit of using the PET scans. Unsurprisingly, some experts disagree, including a working group convened by the Alzheimer’s Association. This group of experts reviewed the evidence and common clinical scenarios, and concluded that in certain select situations, use of the PET scan would be appropriate. (See their guidelines here.)

As someone who evaluates many memory complaints, I’m certainly interested in Medicare’s inquiry, and in whether they’ll decide to cover the scan. (The NYT’s New Old Age Blog has a nice summary of the debate; a good read if you haven’t seen it yet, esp the comments.)

Also, I blogged last fall about how I thought the new scan could and wouldn’t help clinicians like myself evaluating cognitive complaints, especially in those who likely have early dementia. In particular, I commented on the difficult period of uncertainty that we often go through, as we wait to see if subtle problems progress or not.

Would the PET scan meaningfully help with that period of uncertainty? Hard to say, and it hasn’t yet been tested. I myself think that this period of uncertainty can be pretty hard on families, but measuring this burden is tricky. (Much easier to measure hospitalizations and utilization!)

I also suspect that it’ll be hard to prove benefit from “knowing earlier,” in large part because our healthcare system is currently so poorly equipped to meaningfully help people with a new dementia diagnosis.

Which brings me to the part of this story that has me annoyed.

Continue reading…

A Call for Apps at the HDI Forum IV: Health Datapalooza

We are excited to announce that the Health Data Initiative (HDI) Forum IV: Health Datapalooza will be held on June 3 and 4, 2013 at the OMNI Shoreham Hotel in Washington, DC. Last year, HDI had over 1,400 of the world’s leaders in health care featuring speakers and attendees in data science, software development, management, policy and technology.

The event will highlight the latest trends in efforts to liberate health data and effectively use it, through keynote presentations, code-a-thons, interactive panels and an “Apps Expo.” The “Apps Expo” is an exciting opportunity to collaborate with innovative developers and designers who are changing the health care landscape.

HDI IV is looking for great apps that are dedicated to meaningful use of health care data. The apps’ developers and data experts will interact with attendees who are looking for new tools to grow their business. If you’re interested in featuring your product in the “Apps Expo” or if you would like to present or exhibit at Healthdatapalooza please submit your idea here. Apps will be judged on the following criteria:

Continue reading…

When Patients Can Obtain Their Own EKG

With the announcement that the FDA granted 510(k) approval for the AliveCor EKG case for the iPhone 4/4s, the device became available to “licensed U.S. medical professionals and prescribed patients to record, display, store, and transfer single-channel electrocardiogram (ECG) rhythms.”

While this sounds nice, how, exactly, does one become a “prescribed patient?”  Once a doctor “prescribes” such a device, what are his responsibilities?  Does this obligate the physician to 24/7/365 availability for EKG interpretations?  How are HIPAA-compliant tracings sent between doctor and patient?  How are the tracings and medical care documented in the (electronic) medical record?  What are the legal risks to the doctor if the patient transmits OTHER patient’s EKG’s to OTHER people, non-securely?

At this point, no one knows.  We are entering into new, uncharted medicolegal territory.

But the legal risks for prescribing a device to a patient are, sadly, probably real, especially since the FDA has now officially sanctioned this little iPhone case as a real, “live” medical device.  But I must say, I am not a legal expert in this area and would defer to others with more legal expertise to comment on these thorny issues.

This issue came up because a patient saw the device demonstrated in my office and wanted me to prescribe it for them.  So I sent AliveCor’s Dr. Dave Alpert a tweet and later received this “how to” e-mail response from their support team:

Continue reading…

Is Interoperability Possible in HIT? And if it Is, Do We Even Want it?

Anyone who understands the importance of continuity of care knows that health information exchange is essential. How are we supposed to cut waste and duplication from the healthcare system and truly focus on patient welfare if doctor B has no idea what tests doctor A conducted, or what the results were?

The predominant proprietary HIT vendors know this, yet have engaged in prolonged foot-dragging on interoperability and even basic data interfacing. Yes healthcare IT is their business, but interoperability is not in their nature.

As we’ve seen before, the problem is with the business model.

The proprietary business model makes the vendor the single source of HIT for hospital clients. Complexity and dependence are baked into both solutions and client relationships, creating a “vendor lock” scenario in which changing systems seems almost inconceivable.

In the proprietary world, interfacing with third-party products is a revenue generation strategy and technical challenge; the latter, though unnecessary, justifies the former. When we go looking for the reasons that healthcare is a laggard compared with other industries, this single-source model—the obstacle to much-needed competition and innovation—is a primary culprit.

To be fair, provider organizations, with little if any incentive to exchange patient data before the advent of Meaningful Use, haven’t shown much collaborative spirit either. In the fee-for-service model, why would a healthcare organization let patients slip from their grasp? Health reform is finally mandating needed change, but when will proprietary vendors actually enable the interoperability hospitals and practices soon have to demonstrate?

Recent rumblings from Washington, DC, suggest the feds are losing patience.

Continue reading…

The Rise of the Non-Physician Expert

I remember when one of my patients with coronary artery disease suggested that he be given a course of an antibiotic to lower his future risk of a heart attack. The patient had done his homework, quoting literature that pointed to a possible infectious link to atherosclerosis. He also was aware of the theory that aspirin’s benefit had less to do with blood thinning than reducing underlying inflammation.

Fast forward to the Feb 2-8 Economist that has an editorial pointing out that U.S. legal expertise may not require the completion of three years of law school. Why not, it asks, cut the requirement back to two years or, even better, skip the school requirement entirely and license anyone who can pass the bar exam?

And then there’s the Feb. 11 Wall Street Journal, where “Notable and Quotable” refers to the “BA Bubble.” Charles Murray argues that a looming oversupply of college graduates may portend a decline in the employment value of a liberal education. Work careers may consist of serving as “apprentices” and “journeymen” before becoming “craftsmen.”

All of which makes me wonder if the vaunted Doctor of Medicine degree may be vulnerable.

Why should physician education be immune from a perfect storm of over-priced graduate education, “alternative” web-enabled learning with on-the-job-training? The declining value of the formal credential may be less about the university degree and more about competency, turbocharged by flexible licensing and a discerning consumer.

Non-physician health care professionals are arguing that their expertise is enough to enable them to deliver babies, administer anesthesia, prescribe drugs and perform surgery. My traditionalist colleagues argue that patient safety is at stake and that lay persons may not be able to discern all of the possible risks, benefits and alternatives. When things go occasionally wrong in the delivery suit, operating room or with a drug, they say a credentialed and experienced doc can make the difference between life and death.

Continue reading…

When is a Health Care Facility not a Health Care Facility?

There are 900,000 people in the United States who reside in assisted living settings, at an average age of nearly 87. On average, these individuals pay privately between $3,000-$6,000 per month for services that often include room and board, medication delivery and pill box set-up, supervision, and assistance with activities of daily living. Assisted living facilities are an integral part of the health care delivery system for many of our nation’s frailest older adults.  Despite the high quality care that is often provided, the assisted living environment can often leave healthcare providers scratching their heads about what they can and cannot order for their patients.  My recent experience with such a facility involving a patient with possible influenza illustrates the complex middle ground these facilities occupy.

A phone call from an assisted living facility in town interrupted me from my afternoon schedule. The facility’s nurse introduced herself and began to give me a report about my 85-year-old patient with dementia.

“Mr. Smith has a fever to 102 and is coughing up some ugly looking sputum.  I’d like to order some labs and perhaps a chest X-ray. We might also want to consider an antibiotic.”

I asked the nurse a series of questions. Was my patient’s blood pressure unstable? Was he short of breath? Was he confused or disoriented?”

In each case, she told me, “no.”

“He is sitting quite comfortably watching a talk show on television. His only complaint is the occasional cough.”

I asked a few more questions and was reassured that he was otherwise fine. I told her that her initial request for blood work and a chest X-ray sounded like a good idea. We would wait on the antibiotic until the results came back.

“I’ll call you later today with the results,” she said.

Continue reading…

Registration

Forgotten Password?