Author Archives

Simon Nath

Bringing a Complex Health care system Into Alignment

Brett DavisAsk the chief medical officer of a major health system about the issues that keep them up at night and he or she will talk about the need to understand outcomes in complex populations, the need to engage in new business models, novel collaborations with other stakeholders, and engaging “customers” i.e. patients in new ways, all while addressing increasing cost pressures and safety concerns.

Sit down with a franchise leader in oncology at a pharmaceutical or biotech innovator and ask the same questions, and the response will pretty much be the same.

The convergence of business imperatives is largely driven by two factors:  1) the shift to value based healthcare reimbursement from volume, and 2) our rapidly advancing understanding of the causes of disease and health that holds promise to accelerate further because of the proliferation of electronic health information coupled with continued scientific innovation.Continue reading…

When it Comes to Healthcare IT Success Stories, Don’t Count out the Little Guy

Tom GuillaniToday’s healthcare information technology headlines are littered with how large delivery networks are scaling up and successfully building and using IT infrastructure. But the real success story is hiding in the shadows of these large enterprise deployments, in the small and independent practices across the US. The recent ICD-10 transition, that had been foretold to drive small enterprise into financial despair due to their lack of IT savvy and infrastructure, has shown just the opposite. A report from a leading provider of billing software that was based on government and private payer claims analysis for the past 30 days shows a different story.Continue reading…

“Winning” by Defeating the Triple Aim

Joe-FlowerYou follow movies? That is, not just watching them but thinking about how they are built, looking at the structure? In classic movie structure there is a moment near the end of the first act. We’ve established the situation, met our hero, witnessed some good action where he or she can display amazing talents but also what may be a fatal weakness.

Then comes the moment: Some grizzled veteran or stern authority brings the hero up short. Think of Casino Royale, that scene where Daniel Craig’s Bond (after those brutal opening scenes) is back in London and is confronted by Judy Dench’s M. Or Obi Wan Kenobi challenging Luke: “You must learn the Force.” Or that moment in the classic Westerns when the tired, angry old sheriff rips off his badge and throws it on the desk, leaving the whole problem to the young upstart deputy. But before he stomps out the door he turns and says to the young upstart, “You know what your problem is, kid?”

And then he tells him what the problem is: not just the kid’s problem, but the problem at the core of the whole movie. He just lays it out, plain as day.

In healthcare, this is that moment. We are near the end of the first act of whatever you want to calloutthis vast change we are going through.

And where are we? Across America, the cry of the age is “Volume to value.” At conferences we all stand hand over heart and pledge allegiance to the Institute of Health Improvement’s Triple Aim of providing a better care experience, improving the health of populations, and reducing per capita costs of health care.

But in each market, some major players are throwing their muscle into winning against the competition by defeating the Triple Aim, by increasing their volume, raising their prices, doing more wasteful overtreatment, and taking on little or no risk for the health of populations. At least in the short term, the predatory strategies of these players are making it more difficult for the rest of us to survive and serve.

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First, we Devalued Doctors; Now, Technology Struggles to Replace Them

David ShaywitzThe key to driving behavior change, a seasoned marketing executive turned digital health investor told a panel on patient engagement that I moderated this week, is to get beyond the demographics of customers, and to understand the “why” – what are their distinct motivations and drivers?

Customers with similar demographic characteristics might be motivated in very distinct ways, he explained; sophisticated, quantitative market research can help define the different “personalities” present in a particular market.

Healthcare businesses, he emphasized, need to recognize these differences, and customize their approaches based on this nuanced understanding.

On the one hand, it occurred to me he was describing the behavioral component of precision medicine; in the same way it’s important to match an oncology drug with the right biochemical pathway, it’s also essential to customize the motivational approach to the characteristics of each individual.

On the other hand, I realized there was something that seemed a little sad about the idea of developing extensive market analytics and fancy digital engagement tools to simulate what the best doctors have done for years – deeply know their patients and suggest treatments informed by this understanding.

Instead, it seems, we’ve slashed the time physicians get to spend with patients, protocolized and algorithmitized almost every moment of this brief encounter, and insisted the balance of time is used for point-and-click data entry and perhaps a rushed dictation.  We’ve industrialized the physician-doctor encounter – the process and the paperwork — but eviscerated the human relationship; it’s value, unable to translate easily to an excel spreadsheet, was discounted and dismissed.

As I look at the extensive analytic efforts to categorize patients, and the many digital health platforms designed to motivate behavior, it’s hard not to ask whether we’re painfully trying — at scale but without heart — to re-create something we might have been better off not destroying in the first place.

David Shaywitz is based in Mountain View, California. He is Chief Medical Officer at DNAnexus, a Mountain View based company and holds an adjunct appointment, Visiting Scientist, in the Department of Biomedical Informatics at Harvard Medical School.

Potential Bias in U.S. News Patient Safety Scores

flying cadeuciiHospitals can get overwhelmed by the array of ratings, rankings and scorecards that gauge the quality of care that they provide. Yet when those reports come out, we still scrutinize them, seeking to understand how to improve. This work is only worthwhile, of course, when these rankings are based on valid measures.

Certainly, few rankings receive as much attention as U.S. News & World Report’s annual Best Hospitals list. This year, as we pored over the data, we made a startling discovery: As a whole, Maryland hospitals performed significantly worse on a patient safety metric that counts toward 10 percent of a hospital’s overall score. Just three percent of the state’s hospitals received the highest U.S. News score in patient safety — 5 out of 5 — compared to 12 percent of the remaining U.S. hospitals. Similarly, nearly 68 percent of Maryland hospitals, including The Johns Hopkins Hospital, received the worst possible mark — 1 out of 5 — while nationally just 21 percent did. This had been a trend for a few years.

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Listen to People you don’t Like!

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The Aga Khan delivered the Samuel L. and Elizabeth Jodidi Lecture at Harvard University yesterday.  He has been a strong proponent of pluralism in the world and has devoted billions of dollars in resources from the Aka Khan Development Network to enhancing education, health care , culture, and economic development in the world’s poorest countries in Asia, Africa, and the Middle East. The full text is here, but I offer a pertinent excerpt, with lessons about an increasingly divisive level of political debate in the US and elsewhere:

In looking back to my Harvard days (in the 1950s), I recall how a powerful sense of technological promise was in the air — a faith that human invention would continue its ever-accelerating conquest of time and space. I recall too, how this confidence was accompanied by what was described as a “revolution of rising expectations” and the fall of colonial empires. And of course, this trend seemed to culminate some years later with the end of the Cold War and the “new world order” that it promised.

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Middle Age Can Be Hazardous to Your Health

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Despite the many flaws in our healthcare system, we could always point to data showing that over the last few decades we were living longer and healthier lives—even if not quite as long and healthy as our contemporaries in many European and some Asian countries.

It now appears that’s no longer true for one segment of the U.S. population.

I’m talking, of course, about the surprising findings released last week that the death rate among non-Hispanic white men and women ages 45 to 54 increased from 1999 to 2013 after decreasing steadily for 20 years, as it did for other age cohorts and ethnic groups.

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Physician Disrupt Thyself

MARC-DAVID MUNK, MD(Stepping away from health policy and business this week, a quick post on alternative careers in medicine).

Wrapping up a great week spent with emergency medicine friends attending this year’s American College of Emergency Physicians national meeting in Boston. Over the course of a few receptions and dinners, more than one old friend has stopped to ask me about how I made the decision to step away from caring for patients in the emergency department and into a nonclinical role at a progressive startup healthcare company. A few friends confessed that they love the idea of getting their hands dirty fixing a broken healthcare system– but don’t know where to begin.

I have a very limited perspective and I’m no expert on career pivots. But I often look to an article I came across a few years ago, written by Whitney Johnson in the Harvard Business Review. Her article is called Disrupt Yourself.

In the piece (and later in her book) Johnson argues that people can successfully transition into satisfying roles in new businesses but often need to “disrupt” themselves and their current careers. This disruption is needed because moving to another job or field (even one adjacent to the one you’re in) is hard. I think that this is particularly true in medicine where the time and money needed to become a doctor creates incumbents, inherently resistant to change.  Physicians are, by nature of our training and regulation, IBMs and Microsofts. We are slow to change. We can plateau.

Disrupt Thyself


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Can Community Organizing and The “third place” Improve Public Health?

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The majority of health problems in modern developed countries are self-inflicted, the results of lifestyle choices. These problems don’t respond to a pill–or even to bariatric surgery. Moreover, the medical profession hasn’t found ways to change lifestyle.

For instance, one study found that only one of six overweight adults in the US have sustained a weight loss–and that was an improvement over other studies. Another site claims that 90-95% of all dieters regain their weight within five years. It’s encouraging to note an 80% improvement among people with obesity who get treatment–but the source doesn’t say what “treatment” is. It apparently goes far beyond advice and Weight Watchers–so only 10% of obese Americans get treatment in the first place.

Health problems are killing us, and bankrupting us along the way. It’s well known that a tiny percentage of patients generate the most treatment and the highest health care costs, as Atul Gawande pointed out in a famous New Yorker article.

Of course, lifestyle doesn’t lie behind all hot-spotters (for some we can blame birth defects or other debilitating accidents, and for others we can blame over intervention in dying people), but a lot of them just just exhibit exaggerated versions of the common behavior problems most Americans face: bad eating, drug use, lack of exercise, etc.

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What Doctors should Know when Joining a Startup – Five Key Books

Davis LiuWhat should doctors know before joining a startup? I don’t know if these were questions medical school graduates in the Bay Area asked themselves as they opted to join a startup rather than completing their medical training in residency programs. These new doctors felt they could make a bigger impact on patient care by leaving the system and its current status quo.

Why not? In the Bay Area, small startups and former startups like Facebook, Google, and Apple are literally blocks away from academic medical centers. Everyone knows someone working at a startup. At a healthcare innovation summit, Vinod Khosla, co-founder of Sun Microsystems and venture capitalist reassured technology entrepreneurs that the opportunities to disrupt healthcare were tremendous. After all,

“Health care is like witchcraft and just based on tradition.”

Khosla encouraged attendees to develop technology that would stop doctors from practicing like “voodoo doctors” and be more like scientists. Disruption required having an outsider point of view. Khosla highlighted how CEO Jack Dorsey of Square was able to disrupt and provide services more cheaply than the traditional methods of the electronic payment system accepting Visa and Mastercard because only 2 percent of the employees at Square ever worked in the industry.


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