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The HIT Job

Feb 26, 2013• 44

By Bob Wachter, MD

I’m well aware that a good fraction of the people in this country – let’s call them Rush fans – spend their lives furious at the New York Times. I am not one of them. I love the Grey Lady; it would be high on my list of things to bring to a desert island. But every now and then, the paper screws up, and it did so in a big way in its recent piece on the federal program to promote healthcare information technology (HIT).

Let’s stipulate that the Federal government’s $20 billion incentive program (called “HITECH”), designed to drive the adoption of electronic health records, is not perfect. Medicare’s “Meaningful Use” rules – the standards that hospitals’ and clinics’ EHRs must meet to qualify for bonus payments – have been criticized as both too soft and too restrictive. (You know the rules are probably about right when the critiques come from both directions.) Interoperability remains a Holy Grail. And everybody appreciates that today’s healthcare information technology (HIT) systems remain clunky and relatively user-unfriendly. Even Epic, the Golden Child among electronic medical record systems, has been characterized as the “Cream of the Crap.”

Employee Benefits Gone Wild

Feb 26, 2013• 4

By John Goodman

Say “employee benefits” and pensions and health care will jump to most people’s minds. Maybe life and disability insurance will pop up as well. But employers in Silicon Valley are going way beyond that. They’re providing housekeeping, cooking, babysitting and a host of other services as perks for their employees. According to The New York Times, here is what some California companies are doing:

At Evernote, a software company, 250 employees — every full-time worker, from receptionist to top executive — have their homes cleaned twice a month, free.
Stanford School of Medicine is piloting a project to provide doctors with housecleaning and in-home dinner delivery.
Genentech offers take-home dinners and helps employees find last-minute babysitters when a child is too sick to go to school.

To hear the employer representatives tell it, companies are providing their workers with services that make it easier to balance home and family life in an age when there are few stay-at-home spouses and work is stressful.

But a more likely explanation is economics.

Death of an Evangelist

Feb 25, 2013• 37

By Rob Lamberts, MD

It feels like part of me is dying. I am losing something that has been a part of me for nearly 20 years.

I bought in to the idea of electronic records in the early 90′s and was enthusiastic enough to implement in my practice in 1996. My initial motivation was selfish: I am not an organized person by nature (distractible, in case you forgot), and computers do much of the heavy lifting in organization. I saw electronics as an excellent organization system for documents. Templates could make documentation quicker and I could keep better track of labs and x-rays. I could give better care, and that was a good enough reason to use it.

But the EMR product we bought, as it came out of the box, was sorely lacking. Instead of making it easier to document I had to use templates generated by someone else – someone who obviously was not a physician (engineers, I later discovered). So we made a compromise: since it was easier to format printed data, we took that data and made a printed template.
Continue reading…

Praying For Obamacare to Fail

Feb 24, 2013• 53

By J.D. KLEINKE

“Make it work.”

This advice on health reform to Democrats earlier this month illustrates that President Clinton knows what the opponents of Obamacare also know: success is the best political revenge.

As the health reform law moves off the drawing board into the real world, its opponents are doing their best to make it not work — by shifting their energies from fulminations about the boogeymen they imagine in the law to hampering, complicating or outright obstructing its implementation.

For openers, half the states have announced they will probably not expand their Medicaid programs under the law — though there have been defectors, most notably Florida. This will leave a large segment of the uninsured priced out of even the subsidized insurance markets created under Obamacare, while adding enormous complexity and uncertainty for small businesses and multi-state employers who want to comply with the law and cover their lower-income workers.

The same states, more or less, are also refusing to establish health insurance exchanges — online marketplaces where small businesses and individuals can purchase private health insurance — the fulcrum of the law’s provision for those not covered by Medicaid. As of last Friday’s deadline, 24 states and the District of Columbia were going ahead with exchanges and 26 were not.

Data Mining Systems Improve Cost and Quality of Healthcare – Or Do They?

Feb 24, 2013• 3

By William Hersh, MD

Several email lists I am on were abuzz last week about the publication of a paper that was described in a press release from Indiana University to demonstrate that “machine learning — the same computer science discipline that helped create voice recognition systems, self-driving cars and credit card fraud detection systems — can drastically improve both the cost and quality of health care in the United States.” The press release referred to a study published by an Indiana faculty member in the journal, Artificial Intelligence in Medicine [1].

While I am a proponent of computer applications that aim to improve the quality and cost of healthcare, I also believe we must be careful about the claims being made for them, especially those derived from results from scientific research.

After reading and analyzing the paper, I am skeptical of the claims made not only by the press release but also by the authors themselves. My concern is less about their research methods, although I have some serious qualms about them I will describe below, but more so with the press release that was issued by their university public relations office. Furthermore, as always seems to happen when technology is hyped, the press release was picked up and echoed across the Internet, followed by the inevitable conflation of its findings. Sure enough, one high-profile blogger wrote, “physicians who used an AI framework to make patient care decisions had patient outcomes that were 50 percent better than physicians who did not use AI.” It is clear from the paper that physicians did not actually use such a framework, which was only applied retrospectively to clinical data.

What exactly did the study show? Basically, the researchers obtained a small data set for one clinical condition in one institution’s electronic health record and applied some complex data mining techniques to show that lower cost and better outcomes could be achieved by following the options suggested by the machine learning algorithm instead of what the clinicians actually did. The claim, therefore, is that if the data mining were followed by the clinicians instead of their own decision-making, then better and cheaper care would ensue.

How Much are Misaligned Incentives in Health Care Costing Tax Payers?

Feb 23, 2013• 28

By Elizabeth Dzeng, MD

On Christmas Eve, I took care of a patient who had just undergone surgery for an infected artificial shoulder. He was to be discharged on intravenous antibiotics three times a day for six weeks. This is a pretty common treatment. Patients are generally able to give themselves this medication with the help of a home care nurse who visits once a week. The total cost of this is approximately $7000 for nursing visits, antibiotics and supplies ($120 per visit for eight nursing visits plus $143 per day for antibiotics)

The social worker informed him that Medicare would not pay for home care nurse visits or supplies. BUT, Medicare pays for inpatient rehabilitation, which he would be eligible for to receive these antibiotics. Given the choice of paying $7000 for home administration versus $0 for inpatient rehabilitation, naturally he chose inpatient rehabilitation.

The problem is, is that his inpatient stay costs taxpayers approximately $21,000. $350 for room and board plus additional costs for antibiotics and supplies, totaling approximately $500 a day. Furthermore, although he was well enough to be discharged home before Christmas, he needed to stay until he could be placed in rehab. Because of holiday scheduling, most rehabilitation facilities were not accepting admissions. Thus, he had to stay in the hospital an extra four days in the hospital over the weekend and holidays. Given that the average cost of a hospital stay is $2338 in Maryland that added an additional $9352 or so of unnecessary expenses.

In sum, because financial incentives encouraged my patient to spend $0 rather than $7000 out of pocket, Medicare spent an unnecessary added $30,000 on his hospitalization and care.

My Patient’s Keeper

Feb 19, 2013• 11

By Leora Horwitz, MD

Six years ago, my husband saved my life.

I had a severe allergic reaction to a medicine in the hospital in the middle of the night; he ran for the nurse. As for me, despite being a doctor myself, I couldn’t even breathe, let alone call for help. And so, even before and certainly since, I advise my patients not to be alone in the hospital if they can help it. I don’t even think anyone should be alone for office visits. There is too much opportunity to misunderstand the doctor, forget to ask the right questions, or misremember the answers.

National organizations like the American Cancer Society give the same advice: when possible, bring a friend.

As a patient safety researcher and an advocate for high quality healthcare, however, I find giving this advice distasteful. Is a permanent sidekick really the best we can do to keep patients safe? What about those who are already vulnerable because they don’t have such a superhero in their lives, or that superhero just has to punch in at some inflexible job?

Let’s take another look at the circumstances that ended up with my husband shouting, panic-stricken, in the hallway. The medicine I was given is known to cause severe allergic reactions. It is so well-established, in fact, that the standard protocol for giving this medication is to give a small test dose first. It was the test dose that nearly did me in. The hospital followed standard procedure by giving me the test dose. But they chose to do it at midnight, when the hospital is staffed by a skeleton crew, even though the medicine wasn’t urgent. Strike one for safety.Continue reading…

Progress Note: So, It Turns Out Starting a Business Is Really, Really Hard…

Feb 18, 2013• 17

By Rob Lamberts, MD

I am not sure if my lack of blogging is a good sign or a bad one. It’s been a week and a half since I started my new practice and I finally am getting this chance to come up for air. It’s been an über hectic and very draining time, but I am happy to report that the end of the week was significantly better than the beginning.

Here are some things I am learning.

1. Starting a business is really, really hard

I did my best to make my business as simple as possible, mainly because I understand my own deficiencies when it comes to business-related activities. Of course, being in a leadership role of a practice for the past 16 years helps me understand incredibly confusing concepts like accounts receivable, budgets, paying bills, and avoiding going to jail for spending all the collections on lottery tickets and reporting it as “research.” I purposefully designed the business to require as little accounting as possible, and in general I think I accomplished that. People come in to see me, pay me by swiping their card on the nifty card-reader on my iPhone, and I email them the receipt. That’s not the hard part (aside from people touching the “skip signature” button with their hand while they are signing).

The hardest part of starting a business for me is knowing what overhead items are necessary and what are not. Building the office took a month longer than I expected and cost twice as much. Yet I signed “yes” to all of the things that added cost. Some of them were necessary, like doing the things needed to comply with ADA, compliance with electrical code, and having furniture. But where to draw the line? I want the office to send a message of “professional, yet welcoming,” which means it can’t look cheap but doesn’t look posh either. I want the office to be consistent with my logo, a door opening that says “come on in,” and “welcome.” But everything adds cost, and mounting cost is tough when delay in opening means I am earning nothing.

Everyone is willing to give advice, but most of the advice given has little foundation in my reality. People say “it will all work out,” or “you’ll do great,” reassuring me that I don’t have to fret about things. It’s as if I can sit back and relax while things “work out.” The reality is that the reason they will work out is that I will spend most of my waking hours (and some while I’m not awake) working, worrying, thinking about details, and trying to plan for a very uncertain future. Continue reading…

Is the Patient Safety Movement in Critical Condition?

Feb 18, 2013• 18

By Bob Wachter, MD

These should be the best of times for the patient safety movement. After all, it was concerns over medical mistakes that launched the transformation of our delivery and payment models, from one focused on volume to one that rewards performance. The new system (currently a work-in-progress) promises to put skin in the patient safety game as never before.

Yet I’ve never been more worried about the safety movement than I am today. My fear is that we will look back on the years between 2000 and 2012 as the Golden Era of Patient Safety, which would be okay if we’d fixed all the problems. But we have not.

A little history will help illuminate my concerns. The modern patient safety movement began with the December 1999 publication of the IOM report on medical errors, which famously documented 44,000-98,000 deaths per year in the U.S. from medical mistakes, the equivalent of a large airplane crash each day. (To illustrate the contrast, we just passed the four-year mark since the last death in a U.S. commercial airline accident.) The IOM report sparked dozens of initiatives designed to improve safety: changes in accreditation standards, new educational requirements, public reporting, promotion of healthcare information technology, and more. It also spawned parallel movements focused on improving quality and patient experience.

As I walk around UCSF Medical Center today, I see an organization transformed by this new focus on improvement. In the patient safety arena, we deeply dissect 2-3 cases per month using a technique called Root Cause Analysis that I first heard about in 1999. The results of these analyses fuel “system changes” – also a foreign concept to clinicians until recently. We document and deliver care via a state-of-the-art computerized system. Our students and residents learn about QI and safety, and most complete a meaningful improvement project during their training. We no longer receive two years’ notice of a Joint Commission accreditation visit; we receive 20 minutes’ notice. While the national evidence of improvement is mixed, our experience at UCSF reassures me: we’ve seen lower infection rates, fewer falls, fewer medication errors, fewer readmissions, better-trained clinicians, and better systems. In short, we have an organization that is much better at getting better than it was a decade ago. Continue reading…

Let Them Eat Cupcakes

Feb 17, 2013• 8

By Katie Booth

Can the FDA ban cupcakes?

While this may seem like a silly question, the Center for Science in the Public Interest (“CSPI”) has filed a petition with the FDA urging the agency to regulate the amount of sugar (including high fructose corn syrup) in soft drinks. According to the executive director of CSPI, sugar is a “slow-acting but ruthlessly efficient bioweapon” that causes “obesity, diabetes, and heart disease.”

If soft drinks are a problem, surely cupcakes are too. A twelve-ounce can of Coca-Cola contains 39 grams of sugar. A seasonally-appropriate red velvet cupcake from Sprinkles contains 45 grams of sugar—and who can eat just one? National cupcake consumption increased 52% between 2010 and 2011, and U.S. consumers ate over 770 million cupcakes last year. Sugary soft drink consumption, on the other hand, is down 23% since 1998 and 37% since 2000.

While the FDA can’t regulate sugar as a bioweapon, it probably could regulate sugar as a food additive.

Under the Food, Drug, and Cosmetic Act, a food additive is “any substance the intended use of which results or may reasonably be expected to result—directly or indirectly—in its becoming a component or otherwise affecting the characteristics of any food.” This broad definition would include sugar. The FDA does not, however, regulate food additives that are “generally recognized as safe” (“GRAS”). Presumably the FDA considers sugar to be GRAS—for now. Continue reading…