What: Join healthcare data journalist Fred Trotter‘s lecture on graph theory and find out how to translate healthcare issue into solvable graph problems.
When: Thursday, October 24th at 2pm PT/5pm ET (TODAY).
Where: Sign up here.
maithri
In Medicine, More May Not Be Better
The dull whir of the computer running in the background seemed to have gotten louder as the patient fell quiet. She was a young woman, a primary-care patient of mine, seeking a referral to yet another gastroenterologist. Her abdominal pain had already been checked out by two of the city’s most renowned gastroenterologists with invasive testing, CAT scans and endoscopic procedures.
But she wasn’t satisfied with her diagnosis — irritable bowel syndrome — or the recommended treatment and wanted a third opinion. I tried to reason with her but failed to convince her otherwise. Even when I acquiesced and gave her the referral, she walked out visibly unhappy. I sat there listening to the whirring, feeling disappointed.
Physicians love being liked. They also love doing their jobs well. With other incentives, such as monetary returns, dwindling, the elation we get from satisfying a patient as well as providing them good care is what still makes being a doctor special. But is keeping patients satisfied and delivering high-quality care the same thing? And more important, can patients tell if they are getting good care?
Policymakers certainly think so. In fact, under the Affordable Care Act, Medicare, and Medicaid hospital reimbursements are now being tied to patient satisfaction numbers.
But the association between patient satisfaction and the quality of care is far from straightforward, and its validity as a measure of quality is unclear.
In fact, a study published in April and conducted by surgeons at the Johns Hopkins School of Medicine showed that patient satisfaction was not related to the quality of surgical care. And a 2006 study found that patients’ perception of their care had no relationship to the actual technical quality of care they received. Furthermore, a 2012 UC Davis study found that patients with higher satisfaction scores are likely to have more physician visits, longer hospital stays and higher mortality. All this data may indicate that patients are equating more care with better care.
Although patients and their physicians generally have similar goals, that is not always the case. As a resident, who is not paid on a per-service basis, I have no incentive to order extra testing or additional procedures for my patients if they’re not warranted. But one study found that physicians who are paid on a fee-for-service basis and therefore have an incentive to deliver services — needed or not — are more likely to deliver these services (such as an MRI for routine back pain).
On top of that, as another study found, they also are more liked by their patients. It is no wonder then that the number of patients with back pain, one of the most common reasons for physician visits, are increasingly being overmanaged with MRIs and narcotic pain medications.
Darwinian Health IT: Only Well-Designed EHRs Will Survive
Remember the Ford Pinto and the AMC Pacer, aka the Pregnant Pinto?
Both serve as reminders of an in era in which the American auto industry lost its way and assumed drivers would buy whatever they put on the lot. Foreign competition, primarily from Japan, filled the void created by American apathy for quality and design, and the industry has never been the same.
Admittedly, the comparison of cars and EHRs is less than apt, but health IT also assumes healthcare will buy what we’re selling because the feds are paying them to. And, like the Pinto, what we’re selling inspires something less than awe. In short, we are failing our clinical users.
Why? Because we’re cramming for the exam, not trying to actually learn anything.
Myopic efforts to meet certification and compliance requirements have added functionality and effort tangential to the care of the patient. Clinicians feel like they are working for the system instead of it working for them. The best EHRs are focused on helping physicians take care of patients, with Meaningful Use and ICD-10 derivative of patient care and documentation.
I recently had dinner with a medical school colleague who gave me insight into what it’s like to practice in the new healthcare era. A urologist in a very busy Massachusetts private practice, he is privileged to use what most consider “the best EHR.”
Arriving from his office for a 7 PM dinner, he looked exhausted, explaining that he changed EHRs last year and it’s killing him. His day starts at 7 AM and he’s in surgery till noon. Often double or triple booked, he sees 24 patients in the afternoon, scribbling notes on paper throughout as he has no time for the EHR. After dinner he spends 1.5 to 2 hours going over patient charts, dictating and entering charges. What used to take 1 hour now requires much more with the need to enter Meaningful Use data and ICD coding into the EHR. He says he is “on a treadmill,” that it should be called “Meaningless Use,” and he can’t imagine what it will be like “when ICD-10 hits.”
My friend’s experience is representative, not anecdotal. A recent survey by the American College of Physicians and American EHR Partners provides insight into perceptions of Meaningful Use among clinicians.
According to the survey, between 2010 and 2012, general user satisfaction fell 12 percent and very dissatisfied users increased by 10 percent.
The Doctor Returns Bearing Data.
I have felt from the start that this practice model is far better than the one I had in my former life, including:
- Better experience for the doctor
- Better experience for the patient
- Better care quality
- Savings for the patient and for the system.
The last one on the list is the hardest to prove, and I am potentially getting someone to gather concrete numbers for patients who followed me from my old practice to see if their overall health expenditures are down from before I started this practice. This will take time, however, and I am not sure the sample size is large enough to account for the normal variations (either in my favor or against).
Yet some anecdotes from the recent past suggest the answer, giving evidence of significant savings, both financial and life quality, that my patients and their payors get. This is an important case to be made to both the patients (who want to know if their $30-60/month is worth it) and payors (who could financially benefit from promoting this practice model). I realize that this does not constitute a proof of concept, but it is not without meaning.
PATIENT 1. MEDICARE. AGE: 90+
Pt had a head injury and came to my office wondering if they should go to the ER. I assessed the mental status did an exam, determining that this was not necessary. Set up imaging study that day (CT without contrast) which came back negative.
In my old office, the nurse who answered the message would have immediately suggested going to the ER, not checking with me on this.
Cost: CT without contrast as outpatient – cash price $300, not sure about negotiated price.
Savings: Avoided ER with head injury work-up. Cost: ? (More than $300 by far).
Why Calling it a “Tech Surge” May Not Be the Best Idea in History
Now that our federal government is back at work and the short term debt ceiling thing is resolved, it should be no surprise that the news cycle is now obsessed with Obamacare and its flawed implementation. Over the weekend I must have seen a dozen articles about this online and in the NY Times, and then I woke up this morning to a bunch of new things about the Healthcare.gov site underlying tech, how screwed up it is, and what / how the Health and Human Services agency is going to do to fix it.
The punch line – a tech surge.
To ensure that we make swift progress, and that the consumer experience continues to improve, our team has called in additional help to solve some of the more complex technical issues we are encountering.
Our team is bringing in some of the best and brightest from both inside and outside government to scrub in with the team and help improve HealthCare.gov. We’re also putting in place tools and processes to aggressively monitor and identify parts of HealthCare.gov where individuals are encountering errors or having difficulty using the site, so we can prioritize and fix them. We are also defining new test processes to prevent new issues from cropping up as we improve the overall service and deploying fixes to the site during off-peak hours on a regular basis.
From my perspective, this is exactly the wrong thing to do. Many years ago I read Fredrick Brooks iconic book on software engineering – The Mythical Man-Month. One of his key messages is that adding additional software engineers to an already late project will just delay things more. I like to take a different approach – if a project is late, take people off the project, shrink the scope, and ship it faster.
I think rather than a tech surge, we should have a “tech retreat and reset.” There are four easy steps.
- 1. Shut down everything including taking all the existing sites offline.
- 2. Set a new launch date of July 14, 2014.
- 3. Fire all of the contractors.
- 4. Hire Harper Reed as CTO of Healthcare.gov, give him the ball and 100% of the budget, and let him run with it.
If Harper isn’t available, ask him for three names of people he’d put in charge of this. But put one person – a CTO – in charge. And let them hire a team – using all the budget for individual hires, not government contractors or consulting firms.
Hopefully the government owns all the software even though Healthcare.gov apparently violates open source licenses. Given that, the new CTO and his team can quickly triage what is useful and what isn’t. By taking the whole thing offline for nine months, you aren’t in the hell of trying to fix something while it’s completely broken. It’s still a fire drill, but you are no longer inside the building that is burning to the ground.
It’s 2013. We know a lot more about building complex software than we did in 1980. So we should stop using approaches from the 1980s, admit failure when it happens, and hit reset. Doing a “tech surge” will only end in more tears.
Brad Feld is the managing director at the Foundry Group. This post originally appeared at his site, FeldThoughts.
Healthcare.com Would Have Worked Better
Is this any way to build a railroad?
By now you’ve heard that the “Obamacare exchanges” did not launch on October 1 so much as stumble out into public view, barely able to crawl.
Three weeks later, the federal version — “healthcare.gov,” which is actually the same exchange re-deployed 36 times in 36 states — is still barely able to crawl. By contrast, most of the 15 exchanges operated by individual states and the District of Columbia are working more or less fine, for varying reasons we will explore in a moment.
Why the epic fail for healthcare.gov, estimated to have generated a health insurance enrollment rate of less than one-half of one percent among nearly 10 million visitors? Information technologists have identified lunk-headed flaws in its overall design, while pointing to the way the Federal government rolled it out, all at once, all across the nation — as if it were a campaign commercial and not one of the most complex undertakings in the history of e-commerce.
Which would be for good reason: the federal exchange is a campaign commercial, one the Administration had no choice but to broadcast after its opponents went to war on every front against implementation of the Affordable Care Act.
The architects of the ACA expected that states would build their own exchanges. The federal exchange was supposed to be a failsafe — a fallback for a few straggler states unable to build their own in time for the October 1 launch. For the rest, healthcare.gov was supposed to do two things: point people to their state’s exchange; and handle the very complicated task of querying tax and other federal databases to verify people’s eligibility.
Instead, it found itself saddled with the entire e-commerce job for 36 refusenik states.
If Gun Violence is a Health Epidemic, Can We Quarantine It Like a Virus?
At least two-thirds of the perpetrators and victims of gun violence are males under the age of 30. What else do they have in common? They live in neighborhoods with high crime rates and low family incomes, they knew each other before the violence broke out, they usually aren’t employed.
But there’s another commonality these young people share which isn’t often mentioned in discussions about gun violence and crime.
It turns out that the part of the brain that controls processing of information about impulse, desire, goals, self-interest, rules and risk develops latest and probably isn’t fully formed until the mid-20s or later. And while adolescents and young men understand the concepts of ‘good’ versus ‘bad’ as well as older adults, they tend to let peer pressures rather than expected outcomes guide their behavior when choosing between risks and rewards.
Take this neurological-behavioral profile of males between ages 15 to 30 and stick a gun in their hands. The brain research clearly demonstrates that kids and young adults walking around with guns understand the risks involved. Whether it’s the NSSF’s new Project ChildSafe, the NRA’s Eddie Eagle or the grassroots gun safety programs that have expanded since Sandy Hook, nobody’s telling the kids something they don’t already know.
So what can we do to mitigate what President Obama calls this ‘epidemic’ of gun violence when the population most at risk consciously chooses to ignore the risk? I suggest that we look at what communities have done to protect themselves from other kinds of epidemics that threatened public health in the past.
And the most effective method has been to quarantine, or isolate, the area or population where the threat is most extreme. It worked in 14th-century Italy, according to Boccaccio in The Decameron. Why wouldn’t it work now?
Last month the city of Springfield, Mass., recorded its 12th gun homicide. If the killing rate continues, the city might hit 15 shooting fatalities this year, a number it actually surpassed in 2010. This gives the city a homicide rate of 10.2 per 100,000 residents, nearly three times the national rate. Virtually all the violence takes place in two specific neighborhoods bounded by Interstate 291 and State Route 83, and all the victims are between 15 and 30 years old.
Should the Obamacare Exchanges Be Shut Down?
My sense is that the biggest reason Obamacare is now in trouble is because of the top-secret way in which the administration has handled the rollout. If they had developed the computer system in a transparent way, the marketplace would have told them long ago this would not work.
No one outside the inner circle at the Department of Health and Human Services has any idea what’s really going on behind the Wizard’s curtain. Hasn’t for months. Doesn’t now.
So any technical advice any of us could give would be, to say the least, uninformed.
If I were on the inside, and it were up to me, the first thing I would do is bring in a group of heavyweight information technology experts to tell me just what was really going on. The administration cannot trust the people who have been working on this because they told them to launch this mess on October 1 and almost three weeks in there has been no improvement on the website or in the backroom––they no longer have credibility.
I would ask those experts to very quickly answer three questions:
- Can this thing be fixed on the fly––as the administration appears to be trying to do?
- If it can’t be fixed on the fly––and three weeks into this that sure looks doubtful––then can it be taken down for one or two months with a high degree of confidence it can be brought back up in time to enroll people sooner rather than later?
- If the first two options are not possible, just how long will the computer system have to be shutdown before Obamacare can be launched in a way that there can be confidence it will work smoothly?
Then I would take their advice.
The Great Coronary Angioplasty Debate: Giving Patients the Right to Speak
Earlier this month, the editors of THCB saw fit to post my essay, “The End of the Era of Coronary Angioplasty.”
The comments posted on THCB in response to the essay, and those the editors and I have directly received, have been most gratifying. The essay is an exercise in informing medical decisions, which is my creed as a clinician and perspective as a clinical investigator.
I use the recent British federal guideline document as my object lesson. This Guideline examines the science that speaks to the efficacy of the last consensus indication for angioplasty, the setting of an acute ST-elevation myocardial infarction (STEMI). Clinical science has rendered all other indications, by consensus, relative at best. But in the case of STEMI, the British guideline panel supports the consensus and concludes that angioplasty should be “offered” in a timely fashion.
I will not repeat my original essay here since it is only a click away. The exercise I display is how I would take this last consensus statement into a trusting, empathic patient-physician discourse. This is a hypothetical exercise to the extent that little in the way of clear thinking can be expected of a patient in the throes of a STEMI, and not much more of the patient’s caring community.
So all of us, we the people regardless of our credentials, need to consider and value the putative efficacy of angioplasty (with or without stenting) a priori. For me, personally, there is no value to be had rushing me from the “door to the balloon” regardless of the speed. You may not share this value for yourself, but my essay speaks to the upper limits of benefit you are seeking in the race to the putative cure by dissecting and displaying the data upon which the British guideline is based.
There is an informative science, most of which cannot deduce any benefit and that which deduces benefit finds the likelihood too remote for me to consider it worth my attempt. A hundred or more patients with STEMI would have to be rushed to the catheterization lab to perhaps benefit one (and to harm more than one).
State Surveillance Endangers the Affordable Care Act: A Case Study
… and a call to action. This case study is based on my meeting with the Center for Health Information and Analysis (CHIA) in my home state. CHIA is an all payers claims database, a massive collection of diagnoses, locations, dates and prices for all of your health services across all of your providers and insurers. Whether it’s claims or health records, almost every state and many private clearing houses are setting up to monitor you.
Your information can be used by business to manipulate prices for maximum profit, or by you to inform your choice of health insurance plans and health care providers.
Unfortunately, business can get your information but you can’t. This reflects an industry strategy to obstruct the market-based features of the Affordable Care Act. I hope you will take this case study, edit it, and file it with the Attorney General and Governor in your state to ask for your data as a consumer protection issue. That’s what I’m about to do.
My state is #1! Go Massachusetts! My state is #1 in health care costs. It’s also #1 in implementing a health insurance exchange (Romneycare 2006) and a leader in state surveillance with the 2012 cost containment law known as Chapter 224. Chapter 224 mandates various state surveillance mechanisms including a health information exchange that monitors encounters and an all payer claims database called “the center”.
The cost containment law also includes some consumer protections. Line 1909 states:
“To the maximum extent feasible, the center shall also make data available to health care consumers, on a timely basis and in an easily readable and understandable format, data on health care services they have personally received.”
Although the state surveillance is in place, and the price fixing that keeps us #1 is ongoing, the consumer protection part of the law is not implemented. So, I took the opportunity to meet with the executive director of CHIA and their chief legal counsel and get the scoop on why the state is not following the law. To paraphrase their explanation: “It’s too hard.”
