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Top THCB Blog Posts of the Last Two Weeks

Practice Redesign Isn’t Going to Erase the Primary Care Shortage (36)

By Jeff Goldsmith

The current thinking is that new technologies, better information and a more scientific approach to the practice of medicine will let doctors do more than ever before, allowing them to leap tall buildings at a single bound, see record numbers of patients and improve their patient satisfaction scores. And that may well turn out to be true, argues the University of Virigina’s Jeff Goldsmith, but we’re still faced with a problem that is not going to go away until we come up with a solution: a shortage of living, breathing human beings with medical degrees going into primary care.

Wellness Programs Aren’t Working.
Three Ideas That Could Help (25)

By Mike Miesen

Do wellness programs work? Recently, the heretical idea that they might not actually be all they’re cracked up to be has been gaining ground. Faced by mounting evidence that much of what we’re doing in wellness isn’t working very well, a lot of people are sitting down to work on the problem. How to build new programs that do better? Simple technologies and the right data are the answer, argues THCB contributor Mike Miesen.

JAMA EHR Study: Misdiagnosis Poses Serious Potential For Harm (18)

By Evan Falchuk

A new study published last month finds that misdiagnosis is a serious problem in American hospitals. Could electronic medical records help remedy the situation? Writing from Boston, Evan Falchuck argues that the key to dealing with this problem may be a rethink of how we do medicine in the age of digital health.

A National Caregiver Corps:
What the Administration Could Do (17)

By Janice Lynch Schuster

With millions of Americans nearing retirement age, the healthcare system is ill-prepared with another influx of patients, some critics argue. Throw in a healthcare system in transition, an uncertain economy and a deteriorating safety net and you have downright scary situation. Faced with this crisis, writes Janice Lynn Schuster,  the administration should create a national caregiver corps similar to the Peace Corps or Americorps, enlisting Americans to help protect the well being of vulnerable generations. Add technology to the mix and you just might have something.  We urge you to sign her petition.

Why Become A Doctor? (13)

By Vineet Arora, MD

Confronted with stories of burnout, liability issues, student debt and an uncertain forecast for many popular specialties, many young medical school candidates are looking elsewhere. The rules of the game are changing and changing quickly argues the University of Chicago’s Vineet Arora, but the argument for going into medicine is still compelling.
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Health Reform Should Include Legal Care for Patients

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By Joel Teitelbaum & Tom Koutsoumpas

If the country is serious about reforming the healthcare system, then it needs to look beyond just improving access to medical care.  Reforms must acknowledge and address the underlying causes of poor health, many of which cannot be adequately treated by healthcare professionals alone.  Indeed, for some 50 million low-income Americans, the barriers to getting healthy represent unmet legal needs better remedied by a lawyer than a healthcare professional.

Unenforced sanitary codes leave families living in unsafe housing where children are made sick by mold, or made sicker by the fact that utilities in their homes have been wrongly shut off.  Health system complexities and inefficiencies prevent seniors from benefitting from the insurance and long-term care coverage to which they are entitled, and keep wounded veterans from accessing durable medical equipment such as a wheelchair or other crucial supports.  In each of these cases, traditional healthcare services – no matter how expertly administered, and no matter how capable and compassionate the clinician – will not improve individuals’ health.  Rather, legal assistance is crucial to negotiate with landlords and utility companies, appeal denied insurance claims and expedite access to veteran benefits and services.

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Washington’s New Open Source IT Law Could Change Everything. Let’s Count the Ways …

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By Edmund Billings, MD

In these politically polarized times, Americans expect Republicans and Democrats to disagree on every detail right down to what day of the week it is. This is especially true in the posturing hurly-burly of the House, where members can appeal to the few select priorities of a gerrymandered district to win re-election.

So it’s remarkable and unexpected when any legislation exits a House committee with unanimous bipartisan support. It’s even more surprising when the legislation potentially threatens the status quo for established corporate interests—in this case information technology companies.

The Federal Information Technology Acquisition Reform Act (FITAR)—sponsored by California Republican Darrell Issa along with Virginia Democrat Gerry Connolly, and supported by every member of the House Oversight and Government Reform Committee—threatens to put open-source software on par with proprietary by labeling it a “commercial item” in federal procurement policies. The proposal wouldn’t give open source a privileged position, just an equal one.

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Why Medicare Cuts Will Quietly Kill Seniors

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By MICHAEL L. MILLENSON

The recent news that thousands of seniors with cancer are being denied treatment with expensive chemotherapy drugs as a result of sequestration-mandated budget cuts raises the question of whether other patients are being equally harmed, but less visibly.

A careful study of the impact of past federal budget cutting suggests a troubling answer. That study, in a National Bureau of Economic Research Working Paper published in 2011 and revised last year, established an eerily direct link between slashing hospital reimbursement and whether Medicare patients with a heart attack live or die.

Using data from California hospitals, researchers Vivian Y. Wu of the University of California and Yu-Chu Shen of the Naval Postgraduate School examined mortality rates for heart attack patients following the Medicare payment cuts resulting from the Balanced Budget Act (BBA) of 1997. The impact of the BBA was not as sudden or clear as the current situation, where Medicare’s two percent across-the-board cut on April 1 instantly transformed some expensive chemotherapy drugs into money losers, but it was significant and long-lasting.

The researchers examined hospitals claims data for a three-year period before the BBA, a three-year period when the BBA first took effect and, finally, a six-year period after budget cuts had either permanently changed care or failed to do so. They also tried to adjust for the severity of illness of the heart attack patients – the condition is formally known as acute myocardial infarction (AMI) – and other factors.

In the end, the researchers were able to trace a clear path from Congressional budget decisions to the patient’s bedside. Payment reductions triggered by the BBA , Wu and Shen concluded, led to “worse Medicare AMI patient outcomes, and more importantly, that the adverse effect only became measurable several years after the policy took place.”

They even quantified the effect: every thousand dollars of Medicare revenue loss from the BBA translated to a six to eight percent increase in mortality rates from heart attack.Continue reading…

Twitter Study of Vaccine Messages: Opinions Are Contagious, But In Unexpected Ways

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By Beth Skwarecki

Remember 2009? The H1N1 pandemic we were all waiting for? I do. I was pregnant; H1N1 was particularly risky for pregnant women. The vaccine wasn’t available until after I had my baby, but when they held a clinic an hour north of where I live, I brought my husband there so we could both get our shots. My infant son was too young to be vaccinated, so I wanted to protect him through herd immunity.

A study came out recently on twitter messages from that time. How did pro-vaccine sentiments spread, versus anti-vaccine ones? Which messages were more contagious?

I talked to one of the authors, Marcel Salathe, today. He’s an infectious disease researcher studying the spread and transmission, not (just) of disease, but of information. “We assume people infect each other with opinions about vaccinations,” he said, and the H1N1 scare was a good opportunity to put some of his group’s theories to the test.

They collected nearly half a million tweets about the H1N1 flu vaccine. In 2009, H1N1 wasn’t included in the regular flu shot, and became available partway through flu season as a separate dose. With a possible pandemic looming, people had plenty of motivation to get the vaccine and encourage others to get it—butanti-vaccine sentiments were in circulation too.

The result, striking but perhaps not surprising: negative opinions were more contagious than positive ones. (Specifically, someone who read a lot of anti-vaccine messages was more likely to follow up by tweeting or retweeting negative messages of their own.)

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Teaching Value: Medical Educators Need to Take Charge and Help Deflate Medical Bills

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By Neel Shah, MD, Christopher Moriates, MD & Vineet Arora, MD

At a time when one in three Americans report difficulty paying medical bills, up to $750 billion is being spent on care that does not help patients become healthier. Although physicians are routinely required to manage expensive resources, traditional medical training offers few opportunities to learn how to deliver the highest quality care at the lowest possible cost. While the gap is glaring the problem is not new.

In 1975, the department of medicine at Charlotte Memorial Hospital initiated a system to monitor medical costs generated by house officers. In the Journal of Medical Education leaders of the Charlotte initiative described how simply being aware of how clinical decisions impact the costs of care could decrease inpatient length of stay by 21%. Over the last four decades there have been dozens of similar efforts to educate medical students and residents about opportunities to improve the value of care. Some interventions were simple like the one in Charlotte, and simply revealed the cost of routine tests to their trainees. Others provided more sophisticated didactics, interrogated medical records to give trainee-specific feedback on utilization, or creatively leveraged the hospital computer order-entry systems.

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What If Doctors Had Instant Access to All Medical Research?

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By Stanford Med

We are asking doctors to help us study what access to all medical research would mean for their practice. To study the value of such access, we are providing physicians who participate in this Stanford University Public Access Study with eleven (11) months of complete access to virtually all medical journals, as well as to an evidence-based clinical decision-support service.

Participating physicians will have free, one-click access to this vast body of research on their computer or tablet, whenever and wherever they are online. The study is intended to inform current discussions and legislation on the state of public and professional access to federally funded medical research.

Demands on Participant:  Participants must be a physician licensed to practice in the United States. Data will be collected on participants’ use of research, with selected participants asked to participate in a 30-minute confidential interview. As a control measure, participants are given an extra month of the evidence-based clinical decision-support service, either prior or following the eleven months of access to the research literature.

To learn more and/or to begin immediate participation (after providing informed consent) in the Public Access Study, follow this link: http://nihpublic.stanford.edu/.

The principal investigator of the Public Access Study is John Willinsky, Khosla Family Professor, Stanford University, Stanford CA; jo************@******rd.edu.

ONC Holds A Key To the Structural Deficit

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By Adrian Gropper, MD

It’s called Blue Button+ and it works by giving physicians and patients the power to drive change.

The US deficit is driven primarily by healthcare pricing and unwarranted care. Social Security and Medicare cuts contemplated by the Obama administration will hurt the most vulnerable while doing little to address the fundamental issue of excessive institutional pricing and utilization leverage. Bending the cost curve requires both changing physicians incentives and providing them with the tools. This post is about technology that can actually bend the cost curve by letting the doctor refer, and the patient seek care, anywhere.

The bedrock of institutional pricing leverage is institutional control of information technology. Our lack of price and quality transparency and the frustrating lack of interoperability are not an accident. They are the carefully engineered result of a bargain between the highly consolidated electronic health records (EHR) industry and their powerful institutional customers that control regional pricing. Pricing leverage comes from vendor and institutional lock-in. Region by region, decades of institutional consolidation, tax-advantaged, employer-paid insurance and political sophistication have made the costliest providers the most powerful.

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What Do mHealth Leaders Need Most From Our Government? Clarity.

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By Jonathan Spalter

My job and my life intersected in a profound way when my daughter was diagnosed with Type I diabetes. Years working in mobile innovation didn’t prepare me for how personally relevant mHealth so quickly became. Her clinical trial at Stanford University, supported by the National Institutes of Health through Congress’ Special Diabetes Program, featured a world-class endocrinologist working alongside software coders, applications developers, algorithm writers, network engineers and other mobile innovators. They were all pushing together for what could be a revolution in diabetes management—the artificial pancreas.

Recently I had the opportunity to talk about my daughter’s experience and share my thoughts on how government can help encourage the next wave of mHealth innovation, when I was invited to testify before Congress on mobile innovation and health care.

America’s leadership in the mobile economy — 40,000 apps and counting in the broad mHealth category — matches America’s leadership at the cutting edge of medical technology.

Mobile devices, wireless networks and targeted applications are enabling better, more seamless and cost-effective care that empowers and informs stakeholders on both sides of the stethoscope.

The virtuous cycle of investment in the mobile ecosystem — from networks, to handsets and tablets, to applications — provides an unparalleled foundation for dramatic advances in the nation’s health and wellness. My message to Congress was to lean in and strike a reasonable and circumspect balance that both protects patient safety and privacy and propels the dramatic, mobile-fueled advances we are seeing through American medicine today.

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The True Collaborative Health Record

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By Rob Lamberts, MD

I’ve been going about this all wrong.

It’s not my dumping of the payment system so I can focus on care over codes, my use of technology to connect better with patients, or my vision of the “collaborative record” that is wrong. It’s the fact that I am doing this without my most important resource: my patients.

I realized this while driving in to work this past week. My first patient was a tech-savvy guy I’ve known for a long time. Not only does he know me, and knows more than me about technology, he also is a regular reader of my blog (bless his heart)…and he still chose to switch to my practice! So I was looking forward to running some of my ideas by him to see if my thoughts have strayed to the land of silliness (which they often do) or if I am actually onto something. This line of thought led me to think about collaborating with him to work on my IT vision, since he does work for an IT company. My line of thought then careened into the brick wall of the obvious: why just him? I’ve been getting suggestions and offers for help from many of my patients, who are clearly intrigued by my direction and desirous to lend their expertise on the project. So why not involve any of my patients who want to be part of this project?

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