Category: Medical Practice

PHYSICIANS: An Open Letter to Harvard Medical School By Dr. Terry Bennett

Doctor Terry Bennett
became the focus of national attention two years ago when he brusquely told an
overweight patient that she was fat, warning that unless she changed her
lifestyle she faced serious healthcare problems. The woman complained to the state Medical Board.  Last year, the New Hampshire
physician  fought off the attempt to punish him. The
experience convinced Bennett that the practice of medicine in America
must change.

Like many physicians he
believes that doctors are treated unfairly and that the healthcare system is on
the verge of collapse.  He argues that
out-of-control HMOs, high malpractice rates and the financial burden of earning
a medical education
are ruining the  practice of medicine, creating a generation of
young doctors that has forgotten what makes a doctor a doctor.

Instead of sitting in
his office in
Rochester, New Hampshire  and watching it happen, Dr.
Bennett has decided to do something about it by nominating himself for one of the highest profile jobs in
medicine. He recently launched a "write-in" campaign to interview for the Dean’s
job at Harvard Medical School, generally considered the cultural heart of
the medical profession in America.
What follows is his open letter to the Harvard
search committee requesting an interview.  For the record, THCB neither
endorses nor opposes his candidacy. We
believe, however, that the views Dr. Bennett expresses are important and worthy of very careful
examination. He also turns out to be a gifted writer, which makes this piece a very compelling read. An insider at Harvard Medical School who must remain anonymous calls Dr. Bennett’s letter "one of the most beautiful pieces of writing on medicine I have ever read." I fully agree. —  John Irvine

To the search committeeHarvard Medical School

I would not press for the job of Dean of Harvard Medical School, at my age, and at my station in life, if I did not think the Dean’s job did not need a rethink, a change from, an inarguably good man, the present Dean and most of his predecessors, to a zealot, of sorts, with a considered and announced, very public, totally non-secret, pro patient anti "money only" agenda, one which will change the life/lives of the man/people on the streets of America, and by extension, the world.

Humor me a little:

Ask the first one hundred people you meet on the streets of Boston if they know the name of the present Dean of Harvard Medical School, or what, if anything, has he stood for, while he has been Dean, and how has his tenure positively impacted/affected their lives and those of their families?

What has the Dean of Harvard Medical School caused in the way of useful change in their lives? What has he changed, for the better, or at all?

I will be surprised if one person in one hundred knows his name, or thinks his existence in any way affects their lives, and so will you.

It is my belief that so much has changed for the worse in American Medicine, that the HMS Dean’s name should be a byword, his/her positions clearly known, and the positions inarguably pro bono publicum, as he/she struggles publicly to change the status quo, tries get the 45 million uninsured into a universal healthcare program of some kind or another, tries publicly to get US drug prices within the reach of patients, tries to get American community hospitals to return to full and fully charitable services offered to their communities, and vows to be producing debt free zealot "gonna go out and change the world" physicians from HMS to go out and effect the necessary change(s), before all is lost, forever.

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PHYSICIANS: Bennett YouTube Interview

It turns out that Dr. Bennett is also a supporter of
universal healthcare.  He recently attended
a  rally for John Edwards, where Daily Kos caught up with him.

PHARMA/PHYSICIANS: ESRD centers having the curtain pulled back

The NY Times shows that apparently doctors owning ESRD centers and others running chemo-infusions centers reap millions for Anemia drugs .
Who knew? OK, anyone reading THCB for the past few years knows all about this, but now that it’s hitting the NY Times (which got a former clinic director to open his version of the books showing that docs in a 6 person group made about $450K a year each on their sale of the drugs) and now that hearings have already been held, and the FDA’s issued a warning, perhaps something may change…

PHYSICIANS/PHARMA: Fool me once-shame on you. Fool me twice… won’t get fooled again? by The Industry Veteran

So there’s been a fair amount of fuss about a new paper by two academics, one a former drug rep, about the tricks big Pharma uses to “fool” physicians when it details them. You may not be impressed and may be willing to blame Pharma with its cheerleader sales reps and beauty queen detailers. The Industry Veteran, in his usual gentle style, assigns blame elsewhere. You have, as usual, been warned!

This newswires and every health care site in the blogosphere carried a story about a former Lilly rep who published an article about the sales tactics that pharma reps use to influence physicians’ prescribing. I’m shocked and horrified — NOT! So pharma reps have been taught Sales Skills 101. What the hell, are physicians such delicate flowers that they must not be subjected to the lures of salesmanship? Sorry if I appear obtuse, but I don’t see anything disreputable if a rep assesses the type of physician he’s seeing and tailors a pitch to that type.

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PODCAST/CONSUMERS/TECH: Interview with Joseph Kvedar, Partners’ Connected Health guru

Joseph Kvedar wrote a piece for THCB a couple of weeks back on Connected Health and its potential. As I’m in Boston I dropped in on him in his office at the center of the world’s greatest collection of medical ivory towers in downtown Boston, just near Mass General. What he’s doing is preparing for a world in which doing more of the same may not be an option, and his employer is at least thinking about what it’s role might look like in that future.

But Joseph isn’t some other start-up whiz-kid with a few ideas. He’s the Director of the Center for Connected Health at Partners, and he has some very interesting things to say in depth about the promise of using technology to improve health and reduce costs of the very sickest patients–and the roadblocks and incentives along the way. And he’s, just perhaps, threatening to radically disrupt his own organization from the inside.

Here’s the interview.

TECH/PHYSICIANS: The real state of play in eRx, by Jonathan Pearlstein

The very careful reader will have noted that I met a very smart (and, to a rapidly becoming old fogey like me, disturbingly young!) THCB reader, Jonathan Pearlstein at HIMSS. Jon works for the academic survey firm NORC and has been heavily involved in the AHRQ/CMS assessment of ePrescribing that I’ve featured on THCB here, here, and here. John has written a commentary specially for THCB on the studies just done. He tells me that these are of course his opinions not those of the organizations he works for or with—but he has to say that! Those of you involved in eRx should particularly pay attention to the issue around re-keying data into pharmacy systems in the section End to End Transmissions but overall this is a fascinating read.

From September 2006 to March 2007, I participated in an evaluation of five electronic prescribing (eRx) pilot projects, sponsored by AHRQ and CMS, and mandated as part of the Medicare Modernization Act. All told, the evaluation cost the government over $7 million and involved the heaviest hitters in eRx and health IT evaluation—SureScripts, RAND, and Brigham & Women’s Hospital, to name a few.

The product of our labors is available here. My commentary on the study follows:

Our primary charge in evaluating the pilot projects was to investigate the effectiveness and interoperability of proposed standards for eRx messaging. These proposed standards enable some of the more advanced features of eRx, such as sending automatic notifications when a patient has filled a prescription, or allowing prescribers to access patient medication histories and formulary information. Other advanced aspects include digital methods for requesting prior authorization, representing drug dictionaries, and writing sigs (patient instructions for taking medications, such as “by mouth”).

A lot of what we found falls in line with what Matthew commented on early this month regarding the HSC article on eRx in Health Affairs. Although our study probably is more different than it is similar to the one in HA, I think a comparison is worthwhile. Their methods mainly involved qualitative interviews of doctors using eRx in 2005. Ours, on the other hand, took place in 2006 and involved a panoply of methods including interviews, surveys, expert panels, observational studies, medical chart reviews, and technical testing of the standards. Here is how some of our findings stack up:

Medication History

One year after HSC conducted their eRx study, Medication Histories are still not complete. RxHub and SureScripts represent two competing solutions for compiling Med History information, gathering data from payers/PBMs and pharmacies, respectively. Neither one works (i.e. neither generates a comprehensive list). Further interoperability among standards is needed to integrate Med History from a number of different sources. And, as was discussed in the HSC paper, until physicians are confident that the medication history they get through eRx is complete, they will not use it.

Unlike the HSC study, we did find that there is a glimmer of hope for Med History. There were a few devoted prescribers who frequently used the function and expressed high satisfaction. Even so, a new problem we encountered was that most of the physicians in our pilot testing did not even realize that their eRx system had Med History available. Can someone say “user training”?

Formulary and Benefit Information

Here we have a similar story to the Med History. Due to the complexity of formulary information and the wide variety of formularies, information presented by the eRx systems may not be complete. As a result, physicians in our study, as in HSC’s, doubt the information’s reliability and do not use it.

A noteworthy challenge in this area is the dynamic nature of benefit information, which makes it difficult to know the extent to which a specific patient will be covered. Think Medicare Part D. Ideally, a prescriber would know whether the patient were approaching the “donut hole,” in order to avoid racking up some major bills. We still need to investigate further how the Formulary & Benefit Standard will incorporate real-time, patient-centered data sources.

End-to-End Transmissions Still a Challenge

The HSC study found that most sites were not actually engaging in e-prescribing, but rather, e-faxing. What we found is that one year later, things look similarly bleak. Of the five pilot sites we evaluated, only one achieved full end-to-end transmission of new prescription information. The problem was not the technical standard itself (NCPDP SCRIPT New v8.1 worked fine, for those who care). The problem was manipulating the data to be usable on the pharmacy information systems.

At most of the pilot sites, pharmacists had to re-key, or re-enter at least some of the information they received through the eRx system. Their pharmacy information systems simply could not use the data to auto-populate forms for dispensing and filling prescriptions. Although this type of transmission—Electronic Data Interchange + Re-Keying—may be a step up from e-faxing, it still seems a far cry from the ideal of true end-to-end eRx. We still don’t know the extent to which re-keying information contributes to medication errors or lost efficiencies. My suspicion, however, is that the losses will be enough to merit getting eRx to work on the back-end.

Surrogate Prescribing

The use of the eRx system by nurses, MAs, and PAs rather than by physicians—described as “surrogate prescribing”—was endemic across all our pilot sites. The HSC study vaguely alluded to this finding in their paper; however, we found it to be a ubiquitous practice. Some of our sites recorded that as many as 77% of all prescriptions were entered into the system by surrogate prescribers, not physicians. Moreover, this workflow pattern did not appear to be a transitional stage; rather, it was the preferred workflow across all five sites.

The implications of surrogate prescribing are ambiguous. On the one hand, it seems to undermine eRx’s much-touted decision support functionalities. Prescribers won’t react to a drug interaction alert if they never see it. On the other hand, the efficiencies it creates may drive adoption and help create a business case for eRx.

The key to success is in careful implementation. Tech vendors and health systems can choose to embrace surrogate prescribing and may be rewarded for it. One of our pilot sites built surrogate prescribing into their system, constructing a queue for physicians to sign off on prescriptions originally written by nurses. The potential for eRx to shift work away from the physician—and at the same time to create efficiencies—represents a good example of “commoditizing the caregiver” through technological innovation, discussed recently by Clayton Christenson.

Final Thoughts

All pessimism aside, it’s worth noting that in our study we endorsed the technical standards for three types of eRx messages: Medication History, Formulary & Benefit, and Prescription Fill Status Notification. Now, with the likely promotion and promulgation of these standards by Congress and HHS, it’s probable that we will see accelerated efforts in this arena. Widespread use, coupled with our recommendations for improvement, will facilitate more comprehensive Med History and Formulary & Benefit information.

In addition, the outlook for physician adoption looks good. Supposing that we decide surrogate prescribing can be safe and effective, the real need now is to get eRx working on the pharmacy back-end. For if we want eRx to be the “killer app” that drives health IT adoption, rather than just plain “killer,” we must cautiously approach all new types of potential errors.

PODCAST/PHYSICIANS/QUALITY: Interview with David Seligman, CEO of Best Doctors

Here’s the transcript of the interview earlier this week with David Seligman, CEO of Best Doctors. Pretty interesting especially for those of you thinking about how to improve health care quality on a national and perhaps nationally branded level. (By the way, the transcriptionists at Castingwords are getting really quick! They only got this 36 hours ago). For those of you who prefer listening to reading the audio is here.

Matthew Holt:  This is Matthew Holt. I’m here with The Health Care Blog, and I’m talking with David Seligman. David is the CEO of Best Doctors, based in Boston, Massachusetts, and is also a locational contributor to the Boston Globe, as I noticed the other day‑‑and I’ve just found out, a regular reader of The Health Care Blog, which always is a pleasing thing.

David Seligman:  [laughs]

Matthew:  David, good morning. How are you?

David:  Good morning, absolutely, Matthew. I enjoyed being with you down at the World Health Care Congress, and I understand you’re going to be there again this year.

Matthew:  I’ll be looking forward to it. Anybody that’s listening can come by. I’ll be doing some blogging from there all three days.

David:  Excellent.

Matthew:  Let’s start with the real basics. I know that Best Doctors is a referral service and a second opinion service, and it’s obviously a lot more than that, but that’s, I believe, what it is at its core. For those readers of The Health Care Blog who are a bit more casual, can you just give the basic introduction to what you do, what problem you’re solving, and how you solve it?

David:  Yes, absolutely. Best Doctors is a global organization located with a presence in 30 countries around the world. It was originated by physicians from Harvard Medical School in the late 80s. What these physicians were seeing were many patients coming from around the US, and from other countries, to the Boston area, in search of the best information or the best medical care. They realized, back in the late 80s, that nine out of 10 of these patients could’ve, should’ve, stayed home with their local providers. Again, what they were looking for was what they thought would be access to better a quality of care and treatment. What we pioneered was a database of 50,000 of the world’s leading physicians in over 420 sub‑specialties of medicine. We tap into these physicians to really help us provide a comprehensive clinical review of serious or complex medical cases, and we really identify a correct diagnosis or course of treatment over 60 percent of the times in the cases that we’re doing, particularly here in the US. Once again, Best Doctors, we’re a global resource‑‑a trusted resource‑‑to help people with serious illnesses access the best medical care, without having to leave their local physician or local environment.

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PODCAST/PHYSICIANS/QUALITY: Interview with David Seligman, CEO of Best Doctors

This is an interesting podcast (well aren’t they all?). I interviewed the CEO of Best Doctors, David Seligman, about his network of second opinion providers and a whole lot more. They’re having quite a bit of success selling the service, which essentially is a combination of a medical advocacy service, expert review, and second and third opinion service for people with major medical problems. They already have on the way to $40m in revenues, 50,000 doctors on the list, and a significant number of employer and insurer clients.  Are they a model for the future of high end acute and even chronic care management? Well listen in and see.

PHYSICIANS: Roy Poses–Academia and used car sales

Roy Poses at Health Care Renewal explains the economics of faculty medical practice. It’s like used car sales—minus the integrity. Used care dealers have a goal (to get their sales people to sell cars) which their methods actually may work towards—in that the best salesmen make the most money for themselves and the dealer. Whereas the goals of academic medicine (to create the most rational system of care, and to provide services to the poor and the huddled masses) are in direct contrast to the medical faculty’s financial goals. Well worth reading the whole piece—and if Roy’s not on your RSS feed, well he should be.

POLICY: Is Healthcare a right? By Eric Novack

Food for thought for
the weekend… and beyond. Should the immoral in the rest of the business
world be trumped by the needs of some people?

Would it be ethical for an employer to require overtime and not pay
employees for the work? What if it is just really a busy time and the
public needed access to the store? What would happen if the employer
instituted this policy? Would it be easier or harder for the employer
to find people willing to work there?
The answer, of course, is that employers cannot force employees to
work without pay. And employees would look for other places to find
work and make a living – quickly!
Yet, when we talk about health care, what we know to be morally
repugnant – forcing people to work without pay for fear of sanction –
does not seem to apply.
Some in government – elected officials and bureaucrats – and some
activists believe that health care is a “right.” They see a need for
specialty coverage in emergency rooms that are currently lacking. They
believe that physicians have a moral obligation to be available to
provide care that is needed. 
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