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Simon Nath

Uberizing Health, Data is the Vehicle … And a Right

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By LEONARD KISH

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No, there is no Uber of healthcare, even as everyone claims to be or wants to be the Uber of healthcare. Others rail against it.

Part of it is that an Uber for healthcare sounds great! The sharing economy! But what is it? What would it even look like? Everyone has their own interpretation: is it house calls? appointment scheduling like ZocDoc? telehealth? PatientsLikeMe?

The movement Uber, AirBnB and the like embody is often referred to as “the sharing economy.” No matter what you call it: sharing, borrowing or buying, it’s a platform for effective exchange, enabled by the peer to peer connections over the internet, but it’s not new, just more mobile, more convenient with more specific use cases around surplus capacity of some sort.

The model was pioneered by companies like craigslist and eBay, who first offered free or low-cost methods of buying and selling everything from toys to automobiles; and sharing information to everything from lost dogs to love connections. Using these early internet tools to find a job, a book group, or a place to unload your old IKEA furniture led the way to today as the sharing takes place with mobile assets (cars) enabled by smart phones.

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The Cost-effective Cardiologist..

• 1

By ANISH KOKA, MD

Anish KokaSafe, appropriate, effective care at a reasonable cost.  Such a simple goal.  The message is clear. Leaders in hospitals, congress, and even my chihuahua echo the dawning of a new age in health care. Down with the private practice, fee-for-service mentality, they all say.  I pay attention to a lot of this chatter since I happen to be in private practice.  I split my time on the internet between the latest exploits of the Kardashians and gravestones for my practice.  I can picture the epitaph:

In loving memory of

Koka Cardiology
3/1/2013 – 3/1/2016.
Shed not for her the bitter tear
Nor give the heart to vain regret
‘Tis but mere ashes that lie here
The gem that filled it sparkles yet

As I shuffled towards this abyss, my reverie was broken by a letter.  It was from Independence Blue Cross (IBC) in Pennsylvania.  It was titled: The Cardiology/Invasive Cardiology Comparative Cost report.  It looked like a report card, so I opened it with some trepidation.
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Two HIT Developers Respond: Why We’re Still Optimists About Technology’s Potential

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By ANDY ORAM and SHAHID SHAH

The authors of this article like to believe that we can remain humanists while transitioning from a paper-native to a digital-native industry. We even believe you can remain a humanist while following regulations and sticking to industry guidelines. Margalit Gur-Arie doesn’t seem to feel that way. We have read her work over the years and established that she takes a staunchly humanistic approach to health IT. But even though she’s a leader in that space, she appears to doubt the contributions that either technology or regulation make to a humane health system.

Gur-Arie’s most recent posting dismisses all the tools that electronic health records throw in the way of the doctor: clinical decision support (now often called evidence-based medicine–were we Gur-Arie, we’d say it’s because who can argue against evidence?), reminders, pull-down menus to provide a limited range of choices, and more.

One immediate response is to suggest that, instead of blaming the tools, one should blame the requirements imposed on clinicians by payers and governments–the “thousands of meaningless regulatory words” as Gur-Arie writes eloquently. But the real answer is that these requirements (well, the ones that were thought through) enhance the health care system, and that the problem with current EHRs is that they just “pass through” the requirements, intensifying the burden placed on doctors, instead of finding true innovations when implementing those requirements.

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Tackling Rising Pharmaceutical Prices: 50 Shades of Gray

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By SUSAN DENTZER

Global New Active Substances (NAS) Available Since 1996

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Here’s the problem with high and rising pharmaceutical prices:  It’s not just one problem, but many.  Addressing them will require a range of solutions – many of them difficult to execute, and possibly tough medicine to swallow.

These were key takeaways from the recent U.S. Department of Health and Human Services Pharmaceutical Forum,which I moderated.  A broad group of stakeholders participated, including patients, consumer groups, pharmaceutical companies, pharmacy benefits managers, insurers and others.  The key issues: Obtaining the greatest value for the dollars we spend on drugs –and having a vital biopharmaceutical sector that produces vaccines, effective treatments,and cures, at affordable costs for patients and the nation.

Having slowed along with the rest of health care spending in recent years, pharmaceutical spending is now roaring ahead. Total pharmaceutical sales, now about $400 billion annually, are projected to reach as high as $590 billion in 2020, according to Doug Long, vice president of industry relations at IMS Health. New National Health Expenditure data show that national retail prescription drug spending grew 12.2 percent in 2014 – a sharp increase over 2.4 percent growth in 2013  — in large part due to increased spending for new drugs, such as cures for Hepatitis C.

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What Would Issac Asimov Do?

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By PAUL LEVY

I_Robot

The Three Laws of Robotics  are a set of rules devised by the science fiction author Isaac Asimov. The rules were introduced in his 1942 short story “Runaround“, although they had been foreshadowed in a few earlier stories. The Three Laws, quoted as being from the “Handbook of Robotics, 56th Edition, 2058 A.D.”, are:

  1. A robot may not injure a human being or, through inaction, allow a human being to come to harm.
  2. A robot must obey the orders given it by human beings except where such orders would conflict with the First Law.
  3. A robot must protect its own existence as long as such protection does not conflict with the First or Second Laws.

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This Is Not A Disruptive Blog Post

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By MICHEL ACCAD, MD

Michel AccadFrank Knight, risk and uncertainty

In this article, I wish to introduce the reader to the theory of entrepreneurship advanced by Frank Knight (1885-1972), and show that the common, everyday work of the physician could be considered a form of entrepreneurial activity in the Knightian sense.

Knight was an influential American economist. He is best known for his book Risk, Uncertainty, and Profit in which he proposed to distinguish risk and uncertainty as follows:

Risk pertains to situations where outcomes occur with a frequency that is quantifiable according to probability distributions.

Risk may be mathematical and a priori knowable, meaning that the probability function that governs the outcome is known with certainty, as in the case of a coin toss (assuming the coin to be well balanced).

Risk may also be statistical, where the outcome can be estimated according to an empirically discoverable probability function. This is the case in situations where we know the set of possible outcomes and can make observations under controlled conditions to determine the probability of occurrence of each outcome.

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Reduction in Hospital Errors—Progress, But Still Not Enough

By STEVE FINDLAY

Steve Findlay

Fifteen years after the landmark IOM report To Err is Human, we still haven’t figured out how to count medical errors and iatrogenic harm—let alone sharply reduce them. The debate surrounding this persists, as it must. For example, see the dialogue on THCB between Anish Koka and John James on the often-used figure of 400,000 deaths per year from medical errors. See also this Health Affairs blog from 2012 by Michael Millenson.

A simple answer to why it’s so hard to count medical errors, harm and deaths is that—well, it’s just a damn hard thing to do. Think about it: how on earth would we document every mistake, even fatal ones. It seems nearly impossible. It’s not like counting auto accidents or plane crashes. The majority of medical errors occur at a nuanced level, but yet can have profound effects down the road, as the IOM’s report on diagnostic errors recently emphasized.

A more complex analysis of why medical errors are hard to count and prevent would start with the fact that reporting is still largely voluntary. For example, we know next to nothing about medical errors in doctor’s offices and outpatient surgery centers, and we don’t have a complete picture for hospitals.

Then there’s the whole issue of which medical mistakes are truly preventable and should be counted as such—that’s part of the debate between Koka and James. The upshot: preventability remains very much in the eye of the beholder.  Patient safety activists argue that the debate over preventability is a diversion from pursuing a strategy of zero tolerance for errors. As support, they often point—justifiably—to success stories where concerted efforts have led to dramatic reductions in errors and hospital acquired infections. But doctors have long countered that medicine is a human enterprise that can never be perfect, that mistakes are inevitable, and that they have less control over medical outcomes than is often assumed.

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What’s Missing in the Debate Over Employer Wellness Programs

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By SUSAN DENTZER

Susan-Dentzer-For-PostBy now, Americans are no doubt getting used to debates that put show over substance and skirt the genuinely profound issues the nation faces. But although we may have come to expect as much in this political season, we deserve better when it comes to contemplating the role of employers in improving employees’ health.

A recent “debate” sponsored by the Population Health Alliance about employer wellness programs – the various health promotion and disease prevention strategies that about half of U.S. employers offer,  such as weight loss, smoking cessation and onsite gym classes – fell into the depressing pattern of highlighting the largely irrelevant at the expense of the important. The debate, which took place last November 2 at the alliance’s 2015 Forum in Washington, DC, pitted two frequent combatants:Al Lewis, founder of Quizzify and co-author of a book critiquing wellness programs, and Ron Goetzel, senior scientist at Johns Hopkins University’s Bloomberg School of Public Health and leader of the “Promoting Healthy Workplaces” program supported by the Robert Wood Johnson Foundation.

The ostensible topic was whether wellness programs benefited employees, companies, and society at large, but the debate never actually addressed this broad question. Most of the time, the session’s verbal jousting focused on a far narrower issue: whether companies saw any financial return on investment (ROI) on the dollars they plow into wellness programs.

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The Meaning of “Value” in Health Care

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By PAUL KECKLY

Paul KeckleyThere are terms in healthcare circles that get thrown around as if there’s a common and widely accepted definition.

Consider “quality:” every hospital touts its quality, every physician confidently affirms their delivery of high quality care, and every trade and professional sector in healthcare has its own definition that aligns with attributes of quality they deem most important. “Quality” is touted on every website and in every boardroom, but rarely is it defined and measured consistently.

“Outcomes” is another. Most ascribe positive outcomes in their performance, but the indicators on which they’re based and the time periods over which they’re captured—days, weeks, months, or years—varies from user to user. Valid and reliable measures are ephemeral: process measures are used more frequently because they’re easier for regulators, policymakers and payers to monitor; i.e. “advising a patient to stop smoking or lose weight” but these may have little to do with the actual outcome.

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On the Preventability of Lethal Errors: A Response to Dr. Koka

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By JOHN T JAMES, PhD

In my opinion, the title of Dr. Koka’s post (“Very Bad Numbers“) is far too inflammatory for a subject that needs to be taken seriously. Dr. Koka’s summary of the approach I took in my JPS study is a reasonable summary, minus a few key points. Preventability of lethal errors is the problematic issue. The nine authors of the Classen paper did postulate that virtually all serious adverse events they found are preventable; I did not pull this out of the air. Preventability is a highly subjective area. A few years ago everyone assumed that hospital acquired infections were simply the cost of doing business. Now we know that the majority of infections can be prevented. The major difference Dr. Kota and I have is that he wants to rely exclusively on the Landrigan study, which is an excellent and large study, but it is not representative of the nation. It represented hospitals in North Carolina. That state was chosen because it was much more aggressive in efforts to reduce medical harm than the average state in the nation. The OIG study (2010) was in fact an attempt to be representative of the Medicare population across the country, but it is just Medicare beneficiaries. As I noted in my paper, none of the four studies can stand alone, not even the Landrigan paper.Continue reading…

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