According to Gallup surveys, four of five Americans believe the quality of care they receive is good or excellent, and the majority think it is the best available in the world. Surveys by Roper, Harris Interactive, Kaiser Family Foundation, Harvard’s Chan School of Public Health, and others show similar findings. And the public’s view hasn’t changed in two decades despite an avalanche of report cards about its performance, a testy national debate about health reform and persistent media attention to its shortcomings and errors. But is the public’s confidence in the quality of the care we provide based on an informed view or something else? It’s an important distinction.
Two considerations are useful for context:
Measuring quality of care objectively in the U.S. system is a relatively new focus. And we’re learning we’re not as good as they think we are. Historically, the public’s view about “quality of care” has been anchored in two strong beliefs: 1-the U.S. system has the latest technologies and drugs, the world’s best trained clinicians and most modern facilities, so it must be the best and 2-the care “I receive” from my physicians and caregivers is excellent because they’re all well-trained and smart.
1986 was a great year. In the heyday of the worst-dressed decade in history, the Russians launched the Mir Space Station, Pixar was founded, Microsoft went public, the first 3D printer was sold, and Matt Groening created The Simpsons. Meanwhile, two equally important but entirely different scientific leaps occurred in completely separate academic fields on opposite sides of the planet. Now, thirty two years later, the birth of deep learning and the first implementation of breast screening are finally converging to create what could be the ultimate early diagnostic test for the most common cancer in women.
A brief history of deep learning
1986: In America, a small group of perceived agitators in the early field of machine learning published a paper in Nature entitled “Learning representations by back-propagating errors”. The authors, Rumelhart, Hinton and Williams had gone against the grain of conventional wisdom and proved that by re-running a neural network’s output errors backwards through a system, they could dramatically improve performance at image perception tasks. Back-propagation (or back-prop for short) wasn’t their discovery (for we all stand on the shoulders of giants) but with the publishing of this paper they managed to finally convince the sceptical machine learning community that using hand-engineering features to ‘teach’ a computer what to look for was not the way forward. Both the massive efficiency gains of the technique, and the fact that painstaking feature engineering by subject matter experts was no longer required to discover underlying patterns in data, meant that back-propagation allowed artificial neural networks to be applied to a vastly greater array of problems that was previously possible. For many, 1986 marks the year that deep learning as we know it was born.
Every physician is taught to listen to patients. Every physician acknowledges it’s an essential skill. Yet, study after study shows physicians interrupt their patients within a few seconds of their patients’ oral presentation of their problem(s). The author, Prof. Terry Hannan, MD, teaches us to shut up for a few minutes. If we do so, medical care will be safer, more efficient, kinder, and patients will help clinicians be better healers.
This book convincingly demonstrates the value of listening to patients; of discovering what is missing or wrong in the chart, of understanding the real etiology, and of the all-powerful value of honest communication. The book is a passionate defense of the physician as a human being who can listen and communicate with patients to help heal and understand. The physician, granted awesome authority and respect by society, is in a unique position to help patients understand and heal themselves in addition to bringing the needed care and science for their benefit. Included here, is knowing when to prevent unneeded care.
All of that said, the reason everyone should read this book–both clinicians and lay readers–is for the short stories of patient’s lives and experiences as they impact their illnesses and the role of healthcare. The stories are inevitably warm, humane, sensitive, and insightful. They give us hope for humans’ ability to help others, or at least to understand and ease their pain.
Each of the stories is this very short book is only a page or three long. Each is personal and poignant. Each gives us hope for medical care and for humanity.
The 19th century was about the Industrial Revolution. The 20th century, the Digital Revolution. As we march closer to the third decade of the 21st century, it is becoming clearer that this century’s revolution will be the Data Revolution. After all, companies are monetizing it, countries are weaponizing it and people are producing it.
In the medical space, this has fostered conflicting aims. The promise afforded by collecting and analyzing digital health data for insights into population health and personalized medicine is tempered by haziness on who owns and leverages that data.
But even as government actors struggle with the question of how to regulate data, technological progress marches on. Given the dizzying array of technological products claiming medical benefits hitting the marketplace, regulatory agencies have had to contemplate, and take, drastic steps to keep up. For instance, in the past two years the FDA has taken the following steps:
In July 2016, the FDA clarified what constituted a “low-risk” device such as fitness trackers or mobile apps tracking dietary activity.
In June 2017, new FDA Commissioner Scott Gottlieb outlined his vision for a more streamlined process for digital technologies which moves from a “case-by-case” approach to one that allows developers apply consistent safety standards to innovation.
Just a month later, the FDA announced the pilot for a digital health pre-certification program for individual companies which allows those firms that demonstrate a “culture of quality and organizational excellence” and the need for minimal regulation to introduce products to be marketed as new digital health tools with less information communicated to the FDA, sometimes with no “premarket submission at all”.
By September 2017, nine companies, including tech heavyweights Apple, Samsung and Alphabet-backed Verily, had been selected for the pre-cert process.
On February 13, 2018, the FDA further specified that low-risk products would be evaluated by looking at the firm’s practices rather than the product itself and announced its intent to create a new Center of Excellence on Digital Health which would be tasked with establishing a new regulatory paradigm, evaluating and recognizing third-party certifiers and hosting a new cybersecurity unit to complement new advances.
With this flurry of activity, the FDA is clearly moving toward a principles-oriented and firm-based approach to regulating digital technologies. This means moving away from certifying medtech products to the producers.
You may have heard that before you pick a doctor you are supposed to look them up online and see what other people have to say about them before you set up an appointment.
In the Age of Amazon this makes sense. Why wouldn’t you?
Allow me to give you a little insider information. While they may well be a good idea in theory, Yelp.com and other online physician review sites have evolved in recent years to become the bane of my and fellow doctors existence.
This past summer, Physicians Working Together, a non-partisan physician organization, started a petition on Change.org requesting Yelp remove online reviews of doctors.To date, more than 30,000 physicians have signed it but I doubt Yelp will pay much attention.
Recently, the highest-level court in Germany ruled Jameda, an online physician rating site, must remove the name of a disgruntled physician. A dermatologist from Cologne filed the case in the Federal Justice Court demanding Jameda remove her name due to the fact the anonymous nature of the rating site inspires the public to leave spiteful, vindictive comments.Interestingly enough, in 2014, a gynecologist asked to be removed from Jameda, however the Court ruled the right of patients to be “well informed” about their doctor took precedence over freedoms of the physician.
What is the value of rating physicians online?Are consumers becoming “well-informed?”
Americans on average will visit a care provider about 300 times over the course of their lives. That’s hundreds of blood pressure readings, numerous diagnoses, and hundreds of entries into a patient’s medical record—and that’s potentially with dozens of different doctors. So it’s understandable, inevitable even, that patients would struggle to keep every provider up-to-date on their medical history.
This issue is compounded by much of our healthcare information being fragmented among multiple, incompatible health systems’ electronic health records. The majority of these systems store and exchange health information in unique, often proprietary ways—and thus don’t effectively talk with one another.
Fortunately, recent news from Apple points to a reprieve for patients struggling to keep all of their providers up-to-date. Apple has teamed with roughly a dozen hospitals across the country, including the likes of Geisinger Health, Johns Hopkins Medicine, and Cedars-Sinai Medical Center, to make patient’s medical history available to them on their phone. Patients can bring their phone with them to participating health systems and provide caregivers with an up-to-date medical history.
Empowering patients with the ability to carry their health records on their phone is great, and will surely help them overcome the issue of fragmented healthcare records. Yet the underlying standardization of how healthcare data is exchanged that has made this possible is the real feat. In fact, this standardization may potentially pave the way for innovation and rapid expansion of the health information technology (HIT) industry.
Six years ago Ezekiel Emanuel and Jeffrey Liebman made the foolish prediction that ACOs would eat the insurance industry’s lunch. “By 2020, the American health insurance industry will be extinct,” they wrote. “Insurance companies will be replaced by accountable care organizations….”This would happen, they argued, because ACOs are just so darned good at lowering costs compared with insurance companies.
The first Medicare ACO programs began in 2012. Today there are 800 to 1,000 ACOs in business.  But ACOs aren’t even close to displacing the insurance industry. The most obvious reason is they don’t want to be insurance companies – they don’t want to bear full insurance risk. And the reason for that is they can’t cut costs. The performance of the Medicare ACOs, which are the only ACOs for which we have reliable data, illustrates both problems: Very few want to accept “downside risk” (the risk of losing money if they can’t cut costs); and they are incapable of cutting costs.
ACO hype confronts reality: Reality wins
Anyone paying attention to the research knew even before 2012 that ACOs wouldn’t cut costs for a general population (as opposed to a small slice of the population that is very sick). The Physician Group Practice Demonstration, which was widely seen as the first test of the ACO concept, raised Medicare spending. According to the final evaluation of the demonstration, the ten participating ACOs raised Medicare’s costs by 1.2 percent over the five years the demonstration ran (2005-2010), and it might have been worse if the ACOs hadn’t upcoded.  This failure to cut costs occurred despite the fact that the ten participating “group practices”/ACOs were very experienced in managing risk. They had names anyone who studies health policy would recognize, including Dartmouth-Hitchcock Clinic, Geisinger Clinic, and Marshfield Clinic. According to the final report on the demo, “Seven of the ten participants had currently or previously owned a health maintenance organization ….” (p. 15)
Here’s the third episode of Health in 2 point 00, hosted by Jessica DaMassa. This week the tech and parties of HIMSS18 are looming on the horizon and she asks me as many questions as I can answer in two minutes. Hope you enjoy it! And if you have questions please leave them in the comments–Matthew Holt
Amazon has many puzzled about its plans for healthcare. Arguably, Amazon is just as puzzled, but is – in effect — running a massive Delphi process to sort out the plan. Amazon is, after all, the Breaker of Industries, Destroyer of Margins. Allow rumors to float, hire some people, have meetings, seek a few regulatory approvals, start a vaguely missioned non-profit with other business titans. Fear and greed do the rest.
Stock prices gyrate as investors bet and counter bet on who is vulnerable, incumbent CEOs promise cooperation or competitive hostility, analysts speculate, “old hands” pontificate, and consultants send megabytes of unsolicited slide decks to South Lake Union. All that information gets exposed without any material commitment.
Disrupting the roadblocks to healthcare innovation
Proper strategic planning requires consideration of a few disruptive (if less likely) scenarios. Amazon getting into hospital supply or creating yet another benefits buying group is easy to imagine but conservative in scope. And we know Bezos thinks long-term and that profits are secondary to platform building.
The 80 year-old woman lay on her mat, her legs powerless, looking up at the small group that had come to visit her. There were no more treatment options left. The oral liquid morphine we had brought in the small plastic bottle had blunted her pain. But, she would be dead in the coming days. The cervical cancer that was slowly taking her life is a notoriously horrible disease if left undetected and untreated and that is exactly what had happened in this case.
We had traveled hours by van along dirt roads to this village with a team of health workers from Hospice Africa Uganda, the country’s authority on end-of-life care, to visit the woman. She was the second patient of a similar condition I would see that afternoon.
Back home, seeing an 80 year-old woman with advanced cervical cancer, let alone two in the same day, was exceedingly rare. In high-income countries, cervical cancer is a largely treatable disease, especially when caught in the early stages. And it is now preventable thanks to a widely accessible vaccine against Human Papillomavirus (HPV), the infectious agent that causes most cervical cancers, called Gardasil, which is recommended for all pre-teens in the United States.