Author Archives

Simon Nath

The Healthcare System Link in the San Bernardino Shootings

Dec 2, 2015• 14

By JOE FLOWER

Another day, another mass shooting. At this point the news reports say nearly 30 down, 14 or more dead, multiple perps, at a banquet for the San Bernardino, California, Department of Public Health.

And instantly the argument is all about the guns. I understand that, and I’m not even saying that it’s not about the guns.

And instantly we want to say these folks are crazy and of course that’s true. It doesn’t matter if they frame their reasons around Allah or “no more baby parts” or Obama’s impending takeover of the U.S. using ISIS fascist armies disguised as Syrian refugees pouring over the border from Mexico, doesn’t matter. Anyone who turns a gun on other human beings in a school, a clinic, a public street is we can safely say, nuts, if “nuts” has any real meaning any more.

But there are crazy people in every culture, and we have always had crazy people in ours. The percentage of people who are crazy does not scale across societies and across time with the number of people walking into theaters, malls, and bus stations with guns blazing.

Even the number of guns per capita, or the caliber and size of magazines people can buy, or the rules around buying them do not scale directly with mass violence. There is something else going on here.

Rethinking our Thinking about Diagnostic tests: There is nothing Positive or Negative about a Test result

Dec 1, 2015• 4

By ROBERT McNUTT, MD & NORTIN M HADLER, MD

Making a diagnosis is easy if the test we use to make the diagnosis defines the disease. These sorts of tests, called “reference-standard” tests, when present at any level of the test’s result, make the diagnosis. A spinal fluid culture growing listeria or opioids in the urine are examples.

Using reference-standard tests in clinical medicine, however, is not the norm. The reason for this is that reference-standard tests often don’t exist and if they do they may be dangerous, difficult to obtain, and costly. Hence, we use most often non-reference standard tests that can only raise or lower the likelihoods of diseases. There is nothing particularly new in these comments. Every reader will know such concepts as, the “sensitivity and specificity” of a test. Every reader will remember hearing about, or be able to construct, 2X2 tables showing the sensitivity of a test; the corresponding false negative percent; the specificity of the test; the corresponding false positive percent.

But, despite the ever-present teaching of how tests ‘work”, it is my experience that physicians and patients have difficulty using the measures of a test’s value in clinical care. This difficulty is manifest in the observation that diagnosis mistakes may be common and the perceived mistake is the inciting event in up to 40% of malpractice cases. If the conceptual ideas for appropriate test characteristics are so clear and well taught, why is there so much difficulty in using tests to make a correct diagnosis? I contend that the way we teach and understand testing has not allowed us to advance an ideal, numerate approach to accurately making a diagnosis. I claim, also, that the concept of a single “sensitivity and specificity” for a test is actually suspect, even incorrect.

A Home for Orphan Wearables

Nov 30, 2015

By PAUL LEVY

How many people do you know who’ve bought a Fitbit or similar device to track their exercise patterns–who have then let the whole venture lapse? The Fitbit now resides comfortably and peacefully in their drawer!

Well, there’s a useful way to recycle them, offered by Tufts University professor Lisa Gulatieri. As noted in this article:

Gualtieri started RecycleHealth in April with the goal of giving unused activity trackers — mostly Fitbits so far, but RecycleHealth accepts all devices — a second life. The company has collected about 20 devices so far and has plans to donate them to the Montachusett YMCA in Fitchburg, Massachusetts, where they will be used to help older and lower income individuals have access to devices, as well as to learn about how those populations interact with activity trackers.

Check out the Facebook page for stories on how the idea is spreading, plus more information, including how to get free mailing labels.

Paul Levy is the former CEO of BIDMC and blogs at Not Running a Hospital, where an earlier version of this post appeared.

A Usability Conundrum: Whether it is EHRs or Hospital Gowns, One Size Never Fits All…

Nov 30, 2015• 2

By JEROME H CARTER, MD

Building clinical care systems that intimately support clinical work has to begin with the acknowledgement that clinicians perform many tasks within the context of a patient encounter, and those tasks very in type, number, and sequence. Everyone knows this. So, one might ask, if this is common knowledge, why are there so many problems with EHR usability? The answer is very simple. EHR systems are designed to be one-size-fits-all.

One-size-fits-all (OSFA) is such a fundamental precept of EHR design that no one even questions it. Instead, there is a pursuit of every possible means of fixing EHR systems, while allowing them to remain OSFA. Why? Because it is a design assumption carried over from past software design/development limitations. Achieving the highest possible level of usability requires dumping deeply-ingrained OSFA thinking.

How did OSFA become so entrenched in EHR designs? Here are the main reasons.

Poor choice of design metaphor
Paper charts are the inspiration for current EHR systems. Charts are OSFA. No clinician was allowed to customize the chart to fit his/her personal work habits or information needs. Every hospital or practice has strict rules about chart organization and use. There are legal rules that dictate how charts must be stored and what they must contain. There is an entire profession dedicated to charts. Charts are designed to be standardized information repositories; they are not designed to aid in care delivery. Paper charts are a means to an end, and I have never heard anyone gush over how wonderful a paper chart was or how it made their lives so much better. However, since paper charts are (were) a fact of life, one simply adapted to them, like it or not.

Closing the Loop on The Need for Better Telemedicine

Nov 25, 2015• 2

By ANDREW ALTERDORFER

I’ve had the great privilege of presenting our virtual care company, CirrusMD, to potential customers and investors at some of the premier health technology conferences this fall, making the cut for both the Health 2.0 Traction event and this week in the finals of the mHealth Summit and HIMSS Venture+ event. (Breaking: we won the mHealth Summit and HIMSS Venture+ mature startup company award!)

Still, we often get an initial response, “Who needs another telemedicine company with the likes of Teladoc and American Well raising big rounds this year?” One writer even went so far as to share the thought in Forbes on the fragmentation of the digital health landscape after Health 2.0.

I want to take the opportunity to use an analogy to explain why were are different from other telemedicine offerings on the market, and why we are getting such great traction and recognition. In fact, we’re working to “unfragment” the healthcare landscape by closing up some very loose ends that occur in a typical telemedicine experience.

How to Safeguard your Career in Treacherous Healthcare Times

Nov 25, 2015• 2

By MICHEL ACCAD, MD

Dear medical student,

I am honored by the opportunity to offer some advice on how to safeguard your professional career in a treacherous healthcare system.

I will not elaborate on why I think the healthcare system is “treacherous.” I will assume—and even hope—that you have at least some inkling that things are not so rosy in the world of medicine.

I am also not going to give any actual advice. I’m a fan of Socrates, so I believe that it is more constructive to challenge you with pointed questions. The real advice will come to you naturally as you proceed to answer these questions for yourself. I will, however, direct you to some resources to aid you in your reflections.

I have grouped the questions into three categories of knowledge which I am sure are not covered or barely covered in your curriculum: economics, ethics, and philosophy of medicine.

I have found that reflecting on these questions has been essential to give me a sense of control over my career. I hope that you, in turn, will find them intriguing and worth investigating.

One more thing before we proceed. Don’t be overwhelmed by the depth of the questions posed and don’t attempt to answer them today, in a week, or in a year. In many ways, these are questions for a lifetime of professional growth. On the other hand, I believe that the mere task of entertaining these questions in your mind will be helpful to you.

So here we go:

Obamacare is failing? Not so fast.

Nov 23, 2015• 14

By JOE FLOWER

“See? Obamacare is failing!” according to industry expert C. Little, citing Wolf Report 712A just filed by Boy W. Cried.

What is the hue and cry about this time? United Healthcare is saying it has lost large bales and wads of money on Obamacare exchange plans, and just may give up on them entirely. Anthem and Aetna allow that they are not making very much either. Some new not-for-profit market entrants have gone belly up, and the others are having a hard time.

Before we perform the Last Rites over Obamacare, perhsp we should think for a moment about the hit ratio of the first 711 Wolf Reports from Boy W. Cried and ask a few questions.

First: Do we trust implicitly the numbers that the health plans are giving out in press releases, citing unacceptably high medical loss ratios? Medical loss ratios (MLRs) are self-reported. Yes, there is a certain amount of accountability. The numbers have to square with expenses given on their corporate tax forms and so on, but there is wiggle room in just what is reported and how. If is a reasonable supposition that if you wanted to look for the professionals with the greatest skill in juggling numbers, you would find them working for insurance companies, especially health plans, because the stakes are so high. These numbers people at the top of their game have huge incentives to report a high MLR, so if there is wiggle room, I am sure they will find it.

Beyond that, MLR is reported by state, by market segment (large group, small group, individual), against what portion of a premium is “earned” within that reporting period, and by calendar year rather than any company’s financial year. To say, “Our MLR is X” is to claim that X the correct aggregate number across their entire multi-state system, from all their subsidiaries, appropriately weighted for the size of each region. We don’t have access to those numbers, just to what they are telling us. There are plenty of reasons for them to want to report the highest MLR they can get away with, plenty of reasons to be skeptical of the numbers they are giving out, and plenty of reasons not to base drastic policy changes on such pronouncements.

A Radical Policy Proposal: Go Easy On Older Docs

Nov 23, 2015• 5

By DIANE EVANS

Through Dec. 15, federal regulators will accept public comments on the next set of rules that will shape the future of medicine in the transition to a super information highway for
Electronic Health Records (EHRs). For health providers, this is a time to speak out.

One idea: Why not suggest options to give leniency to older doctors struggling with the shift to technology late in their careers?

By the government’s own estimate,in a report on A 10-Year Vision to Achieve an Interoperable Health IT Infrastructure, a fully functioning EHR system, for the cross-sharing of health records among providers, will take until 2024 to materialize.The technology is simply a long way off.

Meanwhile, doctors are reporting data while the infrastructure for sharing it doesn’t exist. Now, for the first time, physicians will be reporting to the federal government on progress toward uniform objectives for the meaningful use of electronic health records. Those who meet requirements will be eligible for incentive payments from Medicare and Medicaid, while those who don’t may face penalties. In addition, audits are expected to begin in 2016.

The Limitations of Healthcare Science

Nov 21, 2015• 2

By SIDNEY LE

Every once in awhile on the wards, one of the attending physicians will approach me and ask me to perform a literature review on a particular clinical question. It might be a question like “What does the evidence say about how long should Bactrim should be given for a UTI?” or “Which is more effective in the management of atrial fibrillation, rate control or rhythm control?” A chill usually runs down my spine, like that feeling one gets when a cop siren wails from behind while one is driving. But thankfully, summarizing what we know about a subject is actually a pretty formulaic exercise, involving a PubMed search followed by an evaluation of the various studies with consideration for generalizability, bias, and confounding.

A more interesting question, in my opinion, is to ask why we do not know what we do not know. To delve into is a question requires some understanding of how research is conducted, and it has implications for how clinicians make decisions with their patients. Below, I hope to provide some insights into the ways in which clinical research is limited. In doing so, I hope to illustrate why some topics we know less about, and why some questions are perhaps even unknowable.Continue reading…

Yes, People Shop for Health care. But are they Good at it?

Nov 19, 2015• 16

By JEANNE PINDER

We used to hear “no one shops for health care.” But we know that not to be true;here’s a blog post I wrote about how people are doing just that.

So, now that we know they do shop, do they do it well? That’s a good question too.

A recent study from some Berkeley economists found that people on high deductible plans don’t shop well. Sarah Kliff, writing about it in Vox, says the study “shows that when faced with a higher deductible, patients did not price shop for a better deal. Instead, both healthy and sick patients simply used way less health care.”

I read the paper, by Zarek C. Brot-Goldberg, Amitabh Chandra, Benjamin R. Handel and Jonathan T. Kolstad, and had some questions and thoughts: First, the company studied has relatively well-paid workers — “employees at the firm are relatively high income (median income $125,000-$150,000),” we are told. Higher income=Less price sensitivity.

Also, we know women shop more for health care and men shop less; women make 80 to 90 percent of the health care decisions in the U.S., and they are deeply in touch with this issue, while men aren’t. I did not see a gender breakdown in the methodology. So I wonder: Men or women?

Also, we learn that workers got tools to use to assess care, but we don’t see those tools — and believe me, I have seen some terrible ones. For example, here’s a post from one of our partners, Elana Gordon at WHYY public radio in Philadelphia, about how bad one insurer’s tools were for one couple.

Also, we don’t know what kind of education on their new system the workers got, so it’s a little bit murky (though the original study is incredibly long).