Category: Uncategorized

Zen and the Quest For Quality

Aug 25, 2014• 21

By RICHARD GUNDERMAN, MD

Celebrating its 40 anniversary this year, Robert M. Pirsig’s Zen and the Art of Motorcycle Maintenance bears several distinctions. It is listed in the Guinness Book of World Records as the eventual bestseller that was rejected by more publishers than any other, 121. It went on to sell more than 5 million copies, making it the most popular philosophy book of the past 50 years. And it focuses on a truly extraordinary topic, which its narrator refers to as a “metaphysics of quality.”

Quality is a hot topic in healthcare today. Hospitals and healthcare systems are abuzz with the rhetoric of QA and QI (quality assessment and quality improvement), and healthcare payers including the federal government are boldly touting new initiatives intended to replace quantity with quality as the basis for rewarding providers. Yet as Pirsig’s narrator, Phaedrus (see Plato’s dialogue of the same name), comes to realize, quality is very difficult to define.

In fact, giving an account of quality is so difficult that it drove Zen’s author mad. And this is a man whose IQ, 170, would make him one of the most intelligent people in any health system. The problem, of course, is that there is a big difference between intelligence and wisdom, and in the quest for wisdom, mere intelligence often leads us dangerously astray. Something similar is happening in healthcare today, where schemes to improve quality often precede sufficient efforts to understand it.

For example, we seek to gain greater control over healthcare outcomes through measurement, only to discover, to our chagrin, that people are massaging the data to meet their numbers. We create new programs intended to increase patient throughput, only to discover unintended perverse effects on the quality of relationships between patients and physicians. Initiatives intended to reduce error rates turn out again and again to stifle innovation.Continue reading…

Share Your Primary Care Innovations

Aug 24, 2014

By THE AMERICAN RESIDENT PROJECT

Where: Harvard Medical School
When: September 16th, 2014
What: Primary Care Innovations Pitch Off

By 2015 the U.S. will need an additional 52,000 physicians to meet the country’s needs. Primary care providers are in particularly high demand for the valuable role they play in managing chronic conditions, providing preventive care services and leading patient-centric care delivery models. The health care community is coming together to ask: What does the future of primary care look like?

What innovations are already being implemented?

The Primary Care Challenge

For two months, we will be accepting submissions as part of the effort to raise the profile of innovative ideas in primary care delivery. Any U.S. medical student, resident or physician is encouraged to submit a description of a creative program that their practice has implemented around primary care delivery. A variety of prizes will be offered to finalists and participants, including an all-expenses paid trip to Boston for five finalists to share their proposals in-person with experts and peers at our Primary Care Innovations event.

Starting this month you can check out the Primary Care Challenge website for step-by-step instructions on how to submit your program and take advantage of this great opportunity. Feel free to share your thoughts with us on Twitter and use #PCC14

The Data Response Curve (In Honor of the Dose Response Curve)

Aug 24, 2014• 10

By JORDAN SHLAIN, MD

All medical students learn about the dose response curve in pharmacology lectures. The dose-response curve informs us of how we should dose a medication in the context of its efficacy and its toxicity. Too little medicine won’t have the desired effect, and too much medicine can be toxic.

In the era of digital health, data have become the new “big pharma,” and we are facing the emergence of a data-response curve in which access to too little data is inactionable, and access to too much data can be overwhelming. Digital health devices abound today, and has enabled quantification of nearly every health and wellness metric imaginable. Sadly, in our exuberance about these new sources of data, we often conflate “more data” with “better data.”

In the era in which data have become the booming commodity of exchange in healthcare, we describe an emerging data-response curve. Large data sets can be at best clarifying or at worst self-contradictory. Too little data on the data-response curve, as with medication dosing, can be insufficient for effective action or decision-making. Too much data can be toxic to the user such as the physician, leading to poor decisions or worse, to analysis paralysis.

We live in a world of exploding data, and we need to be thoughtful. Medicine is a people business in need of data, not a data business on need of people. In reductive form, all humans make decisions based on inputs (data) from their environment and on individual analysis of the data in the form of non-linear, non-quantifiable perception. When we as doctors, policy-makers, or simply as human beings receive these inputs, one of three things happens: 1. We make a decision to do something (for example a treatment decision based on abnormal data), 2. We make a decision to do nothing (for example, normal data which we believe requires no action), or 3. We need more data in order to make an informed decision to do item #1 or item #2. More does not necessarily equal better data. More data is simply more.

Better data are actionable data wrapped in the context of the patient and the patient’s condition. Imagine each piece of objective data connected to concurrent subjective data, and surfaced in the context of a specific condition relevant to the patient. HealthLoop enables patients to generate contextual objective data married to their subjective symptoms and served to a clinician in an actionable context. High signal and low noise are the digital health equivalents of on the dose-response curve of a favorable therapeutic window.

See where some folks live on the Chart. Where do you live?

What PHR Should I Use? It’s Complicated.

Aug 24, 2014• 30

By LESLIE KERNISAN, MD

A friend called me the other day: he is moving his 93 year old father from New England to the Bay Area.

This is, of course, a relatively common scenario: aging adult moves — or is moved by family — to a new place to live.

Seamless transition to new medical providers ensues. As does optimal management of chronic health issues. Not.

Naturally, my friend is anxious to ensure that his father gets properly set up with medical care here. His dad doesn’t have dementia, but does have significant heart problems.

My friend also knows that the older a person gets, the more likely that he or she will benefit from the geriatrics approach and knowledge base. So he’s asked me to do a consultation on his father. For instance, he wants to make sure the medications are all ok for a man of his father’s age and condition.

Last but not least, my friend knows that healthcare is often flawed and imperfect. So he sees this transition as an opportunity to have his father’s health — and medical management plan — reviewed and refreshed.

This last request is not strictly speaking a geriatrics issue. This is just a smart proactive patient technique: to periodically reassess an overall medical care plan, and consider getting the input of new doctors while you do this. (Your usual doctors may or may not be able to rethink what they’ve been doing.) But of course, if you are a 93 year old patient — or the proxy for an older adult — it’s sensible to see if a geriatrician can offer you this review.

An Open Letter on Open Healthcare Data

Aug 22, 2014• 36

By KEITH FIGLIOI

This week a host of organizations responded to a Senate Finance Committee request for feedback on how to better use healthcare data.

The inquiry is timely, given the widespread frustration providers have with health information technology (HIT), and electronic health records (EHR) systems in particular. This frustration stems from many HIT/EHR systems are locked in proprietary systems. This hinders technology’s ability to connect and exchange information freely between disparate systems, devices and sensors along the care continuum, thus undermining the overall goal of using HIT to improve efficiencies and reduce costs.

An example illustrates the point. Because HIT systems don’t work together, most hospitals use nurses to manually double check input from disparate “smart” devices. For instance, an infusion pump reports the level of pain medication being administered to a patient, as does the EHR. But these numbers sometimes don’t match, and must be double checked by at least two nurses to confirm the right dosing. Not only is this a step back for efficiency, but it’s also another manual process that has the potential to create errors and patient safety issues.

There are also economic consequences of data fragmentation. According to the Office of the National Coordinator (ONC), U.S. providers are spending $8 billion a year due to the lack of interoperability.

To address this problem and reduce the unnecessary fragmentation of healthcare data, it’s time to require the use of open and secure applications programming interfaces (APIs).

In April, a group of America’s leading scientists, named JASON, published a report that found the current lack of interoperability among HIT data sources is a major impediment to the exchange of health information. They recommended that EHR vendors be required to develop and implement APIs that support health data architecture. The recommendation was also endorsed by the President’s Council of Advisors on Science and Technology (PCAST) in May. Requiring open APIs as a foundational standard for healthcare data would reverse the current legacy of locked systems and enable the real-time exchange of information in EHR systems to reduce costs and improve patient safety.

Is the Patient the One With the Disease?

Aug 21, 2014• 16

By RICHARD GUNDERMAN, MD

“The patient is the one with the disease.” This medical aphorism, often quoted as rule number four from Samuel Shem’s 1978 novel, The House of God, has probably been around as long as medicine itself. Its point is that doctors need to learn to accept their own vulnerability and fallibility before they can devote themselves fully to the care of their patients. And so long as medicine was built on the relationship between two parties, patients and doctors, the rule worked reasonably well.

More recently, however, the party is being transformed into a crowd. A third player is increasingly encroaching on the doctor-patient relationship, and more and more doctors are beginning to suspect that it may be the vector of much of contemporary healthcare’s pathology. Who is the third party? Its precise identity is often difficult to pin down, but its seat in the doctor’s office and at the patient’s bedside is often occupied by a hospital, a health insurer, or a government agency.

This third party usually does not see individual patients. Instead it sees aggregates, such as rates of mortality, disease incidence, and the utilization rates of particular tests, procedures, and pharmaceuticals. It tends to be particularly interested in parameters such as efficiency, safety, cost, and revenue. Because it is largely blind to individuals, however, its risk of developing certain disorders is dramatically increased. And when it falls ill, both patients and doctors suffer.

Before patients and doctors can respond effectively to such pathologies, they must first recognize that they exist. One of the first steps in recognizing a disorder is applying a name to it, and one physician who has taken up this challenge is Adam Ratner, MD, one of the founders of the San Antonio-based non-profit, The Patient Institute. Ratner, who has been struggling to clarify the nature of these pathologies for many years, believes that healthcare is in the midst of an unrecognized epidemic.

CDC Laboratory Guidance on Ebola

Aug 20, 2014• 15

By Tom Frieden, MD

For more than four decades, Ebola virus had only been diagnosed in central or eastern Africa.

Then late this past March, the first cases of Ebola began appearing in a surprising part of the continent. The Ministry of Health in Guinea notified WHO of a rapidly evolving outbreak of Ebola virus disease. The outbreak in Guinea was the first sign the virus had made the jump across the continent.

Ebola then spread quickly to Sierra Leone and Liberia, and then to Nigeria.

As the world learned of the cases, CDC began receiving questions from American hospital labs. They were looking for guidance on how to handle testing for patients who had recently returned to the U.S. from West Africa with potential Ebola symptoms.

If U.S. hospitals were to run laboratory tests on these patients, how could they be sure their staff could safely handle materials that might contain this dangerous virus? Did they need the kind of personal protective equipment they saw CDC scientists using when they were testing for Ebola?

Should We Send Docs to Tech School?

Aug 19, 2014• 5

By BILL CROUNSE, MD

An article in Information Week caught my eye recently . It reviews a new program offered by Texas A&M with support from Dell to help medical students and other healthcare professionals “come to terms with the ways technology is changing their jobs”. The article, Doctors Can Go Back to Tech School, says Texas A&M will launch its new health technology academy later this year as part of its continuing medical education program.

Now, don’t get me wrong. I’m all for education and career improvement. I’m just not sure that the best way to improve Health IT is to get more physicians trained in IT so they can, as the article suggests, move into IT roles. How about giving full time clinicians who have an interest in improving Health IT some extra support and time so they can help those who work in IT better understand what clinicians need to do their jobs efficiently and safely? How about just a little paid time away from the daily treadmill of patient care to educate IT about the nuances of medicine and clinical workflow? I believe understanding that would do more to help IT deliver better solutions.

Over the course of my career, I’ve been many things. First and foremost, I am a physician. Only a true clinician understands how clinicians think and work. For many years, I continued to practice even when it no longer made a whole lot of sense with regards to my income or available time. I was a biology major in college. I went to medical school and did a residency in family medicine. I never had any formal training in either business or technology. I learned the ropes by doing. It was often trial by fire. I’ve had my share of success as well as a few failures along the way. When I advanced into the role of a hospital CIO and CMIO, it wasn’t because I knew tech. When my then CEO asked me to step into the CIO role, I’ll never forget what he said to me. He said, “I want to put a civilian in charge of the military”, meaning a doctor in charge of a department that existed to serve clinicians and their patients but had become a renegade army running out of control and way over budget.

HIT: How the VA Reform Bill Benefits Entrepreneurs

Aug 19, 2014• 3

By DOUGLAS NAEGELE, DAVID BLACKBURN & ERIC KLOS

Earlier this month, the U.S. Senate passed a Department of Veterans Affairs health reform bill in response to scandals in patient care at VA centers. The $16.3-billion bill,signed by President Barack Obama, includes measures that will attempt to overhaul information technology and introduce telemedicine procedures at VA clinics and hospitals.

But who’s going to implement these reforms? Infield Health President Doug Naegele talked with G2Xchange Health Cofounders David Blackburn and Eric Klos to understand how the bill might create new opportunities for health entrepreneurs.

Can you talk for a minute about how some of the bill’s provisions make room for entrepreneurs?

This bill has a number of specific information technology mandates for the VA that are ripe for innovation. Many of the mandates are a direct response to excessive wait times, the need for information sharing when our veterans access care outside the VA, and the gaming that was done by VA staff to hide wait time issues at VA facilities. Three examples of opportunity areas for entrepreneurs include:

1) Digital Waiting List – You may have seen billboards on the highway that show the Emergency Room wait time at a local hospital. This is an example of the type of transparency that would permit veterans to monitor the average wait times by facility and type of care.

2) The VA has 90 days to establish a system to monitor and issue Veterans a “Veterans Choice Card,” which will facilitate the receipt of care from non-VA health providers.

3) Data for patient safety, quality of care and outcomes must be extrapolated from the existing VA electronic health records (VistA) and published as a comprehensive database within 180 days. This data must be “fed”’ into the HHS Hospital Compare website. Again, transparency is a key driver for the VA.

An Open Letter to Primary Care Physicians

Aug 19, 2014• 46

By JACK COCHRAN, MD and CHARLES KENNEY

Dear Doctor,

The future is in your hands.

You have the opportunity to make primary care better.

More efficient.
More accessible.
And more affordable.

We know you and other primary care doctors have more responsibilities than ever. But you also have great influence, along with the ability and opportunity to change this country’s health care system for the better.

Primary care is essential to the quality of health care, and we need you now more than ever.

Maneuvering the Minefield

According to research firm Harris Interactive, “the practice of medicine is … a minefield. … Physicians today are very defensive – they feel under assault on all fronts.’’* Harris questions, “how much fight the docs have left in them. Some are still fired up … while others have already been beaten down.’’

Those who feel frustration, anger and burnout say they are squeezed by administrators, regulators, insurance companies and more. They worry about the possibility of a lawsuit that could destroy your career.

The question is: What can be done about it? Some of you may choose to remain in the status quo. Some of you have chosen to retire early or otherwise leave the field of medicine entirely. Yet some of you have said enough is enough and found specific solutions that mark a pathway forward. You sought – and found – specific solutions that mark a pathway forward.

If you’ve rejected the status quo and joined your fellows in search of innovations from other practices that you have applied at home, congratulations. You’re a physician leader who’s doing great things for your patients, your colleagues and yourself. You are undoubtedly more satisfied in your work than before, and you are quite likely providing better care.