Category: Medical Practice

TECH: Just another EMR puff piece….on Cerner?

Anyone who’s ever read Fast Company won’t be surprised at the slightly breathless tones used in one of their typical "business gets new process, struggles a little at first, then succeeds beyond its wildest dreams" plot line. After all this was the magazine that was aped by a certain not quite so polite web-site also ending in "company", and beginning with an F.

What’s a little different is that this article, Record Time, is about a simple ObGYN adopting an ambulatory EMR, and then having all the usual crises of seeing his practice more or less collapse because of the extra time it took to figure out how to use it.

But apparently in this case the vendor sent donuts, and someone who built him templates and showed him how to use it. Repeat with me–a practice barely alive, but we can rebuild it, we have the technology, we can create the world’s first bionic physician’s office….it will be gooder than it was before…and all for slightly less than $6 million! (Look here if you’re too young to get it…)

Given that the vendor in question is Cerner, notorious for its not always quite as smooth as silk implementations, you’d be entitled to a little cynicism here. (and if you think I’m just relaying industry tattle here from HISTalk, you are of course right!). However, last year a very sharp IT consultant told me that his shop had done a real life performance comparison of the major ambulatory EMRs and Cerner’s Powerchart product (which was new and had little market penetration) had actually beaten out the big boys. So better product, with better customer service? Can it be true? Or is this just more "pie in the face for Neal Patterson" ammo?

Of course it would be nice if the article told us a little more about exactly how the physician got from near chaos to everything running as smooth as silk without avoiding total financial collapse. Several of his colleagues reported on in Medical Economics recently weren’t so lucky.

POLICY/PHYSICIANS: Another crazy doc in favor of single payer

Yet another crazy doctor decides that the hassle of dealing with 301 separate insurers is just too much and that he, was well as everyone else but the insurance industry, would be better off with a national single payer system. Nothing that hasn’t been heard before from a minority of docs.

The only noteworthy thing about this one is that the doc in question is Benjamin Brewer, who writes The Doctor’s Office column in that filthy commie rag The Wall Street Journal. Wonder how long he keeps that job?!

POLICY/PHYSICIANS: Mother of all comment threads

If you haven’t been reading, there are now some 46 long detailed and excellent comments in the article called Can the real HSA fan, please stand, please stand up?.

Speaking as someone who’s been through the academic mill, this comment thread provides about a semester and more’s worth of education on the entire topic of health management and health policy. Note Steve Beller’s excellent summary of the conversation so far at around comment #30!

Fantastic work—my hat is off to all the commenters


PHYSICIANS: Docs believing in God, not as many as you’d think

I’m the ultimate American outcast in that I’m an atheist (or as we’re known now secular humanist), who thinks that (as one old friend put it) "all religions from the Bhagwan Rajneesh to the Unitarians are only interested in putting their hand in your pocket".

But I accept that makes me pretty unusual in America where roughly 90% of the population reliably polls as believing in God  (although I’d fit in OK in Sweden and most of Europe).


What I fund pretty interesting was a survey that came out last summer but was just featured in Forbes. The authors seem to be all excited that they found that American physicians were likely to believe in God and have it influence their daily lives. That’s because they were comparing physicians to scientists, who have very low rates of religious belief.

But what I found interesting was that only 76% of physicians said that they believed in God. If we take that to include a wide meaning of "God", that means that in their beliefs about religion, physicians look more like Europeans than Americans.

But I have no idea what conclusions to draw from that for the health system.

PHYSICIANS/HOPSITALS/INDUSTRY: Customer service: are new market entrants showing the way?

Interesting piece from a marketing consultant called Chris Bevolo from boutique firm GeigerBevolo Inc., in Minneapolis. The report looks at new entrants into health care services and responses to improve the patient experience at Mayo and Park Nicollet.

The new entrants profiled are Steve Case’s Revolution Health, Best Buy’s eq Life ( a pharmacy with manicures while you wait), and MinuteClinics (nurse practitioners in shopping malls). The choice of Revolution Health is a little off, and its attempts (as well as the track record of its advisory board)  has been well slagged off on TCHB and by Joe Paduda before. But the other two are well worthy of a look.

And the message seems to be a) provide shopping while people are waiting to see the doctor as Americans like shopping, and b) do it in Minnesota, because those Minnesotans like innovation. I actually think that Chris has missed a third option which is edutainment while patients are waiting.  But I’ll have more to say about that when I finally get around to discussing Phreesia’s in-office tablet entertainment/patient history service again.

But while I’m more than half-joking, I am full serious. The level of customer service in health care remains abysmal, and whether or not the market forces plans and providers to do something about it sooner rather than later, it surely can’t hurt for them to get out ahead of this trend.

PHARMA/PHYSICIANS: Reimbursements Sway Oncologists’ Drug Choices, by Greg Pawelski

Greg Pawelski is not exactly surprised about the latest revelations about oncologists and their use of chemotherapy.

A joint Michigan/Harvard study confirms that medical oncologists choose cancer chemotherapy based on how much money the chemotherapy earns the medical oncologist. Just published in the journal Health Affairs is a joint Harvard/Michigan study entitled “Does reimbursement influence chemotherapy treatment for cancer patients?” In a study of 9,357 patients, the authors documented a clear association between reimbursement to the oncologists for the chemotherapy of breast, lung, and colorectal cancer and the regimens which the oncologists selected for the patients. In other words, oncologists tended to base their treatment decisions on which regimen provided the greatest financial remuneration to the oncologist  This study adds to the ‘smoking gun’ study of Dr. Neil Love on the subject. The results of his survey show that for first line chemotherapy of metastatic breast cancer, 84-88% of the academic center-based oncologists prescribed an oral dose drug (capecitabine), while only 13% prescribed infusion drugs, and none of them prescribed the expensive, highly remunerative drug docetaxel. In contrast, among the community-based oncologists, only 18% prescribed the oral dose drug (capecitabine), while 75% prescribed infusion drugs, and 29% prescribed the expensive, highly remunerative drug docetaxel. The existence of this profit motive in drug selection has been one of the major factors working against the individualization of cancer chemotherapy based on testing the cancer biology. Once a decision to give chemo is taken, physicians receiving more-generous Medicare reimbursements used more-costly treatment regimens.

POLICY/HOSPITALS/PHYSICIANS: Wennberg found wearing concrete boots at bottom of Lake Michigan

No, not really. But Wennberg’s disciples at Dartmouth are coming out with so many uncomfortable facts for the medical-industrial complex that it’s hard to keep count. Starting by introducing the notion of practice variation 30 years ago, the group is now turbo-charging its research production, and basically all of it is bad news for anyone pretending that “American health care is the best in the world”. To paraphrase Uwe Reinhardt, how can the American healthcare not be as good as American health care?

In just the last couple of years not only has the Dartmouth crowd found that care delivered in areas with fewer doctors, and using less advanced technology, leads to better outcomes at lower costs, but they’ve also found that academic medical centers vary threefold in their efficiency of inputs (and costs) to get the same outputs, and most recently that hospital system and location is a better indicator of resource use than population acuity.

And, for the medical establishment, the news gets worse. For the last five or so years, those of us who think that we’ve already got plenty of doctors per head, as we doubled the number in medical school in the 1970s and 1980s and are still waiting for the smaller generations trained in the 1960s to retire, have been drowned out by hysteria from the medical establishment about an impending “physician shortage”. That is of course code for the taxpayer (via Medicare which funds most medical education) to support the creation of new physician residency slots, creating more specialists, who’ll then start applying more medical technology to all of us, which will contribute to more flat of the curve medicine. But I won’t give you a potted Fuchs/Enthoven class here (although you can search around plenty in THCB if you want more).

Today in Health Affairs (or you can read the potted version in Forbes), Dartmouth researcher David Goodman and his team (including Wennberg) cry bullshit on the “we need more doctors” meme. While the big academic centers which get the money from training them would love to have more residents, by examining one type of intensive medical process — caring for patients at the end of life in ICUs — Goodman et al shows pretty logically that many major academic centers use far too many physician resources. In other words we could provide equally good (or probably better) care while using many many fewer physician “inputs”. Hence overall we need fewer physicians, more efficiently used.

Of course any English surgeon, whose workloads and consequently surgical speed massively exceed those of their American counterparts, could have told you that. And my father frequently did every time he came back from a “fact-finding” trip over here. And when Goodman et al invoke the most famous name in American medicine, it’s pretty hard to argue with their conclusions:

"We have benchmarks. We have academic medical centers which are highly successful in terms of the care they provide, and we need to start looking to those places as our examples," Goodman said. "We need to study them and understand them and emulate them. The Mayo Clinic has been studied very extensively and is fairly well-understood," he continued. "We should be at a point where we can emulate some of those systems."

Mayo of course has fantastic outcomes at relatively low cost. In this study it used 8.9 physician full-time equivalents per 1,000 patients in the six months before death, while at the other end of the spectrum New York University Medical Center had 28.3. Of course the system-wide implications of all of the Dartmouth research are too awful for the medical establishment to contemplate, because they in the end mean 20 of the 28.3 doctors at NYU going away – and there are enough cab drivers in New York City as it is. And it’s not just New York city doctors that suffer when you extrapolate:

Applying the Rochester standard to the nation’s elderly, the United States has an excess of physician input; it needs 30,163 fewer FTE inputs than were allocated in 2000. Indeed, the current rate of supply growth along with excess capacity is sufficient to accommodate the 56 percent increase (in the number of elderly-MH add) predicted for 2020, with 49,917 physicians to spare.

All this research of course reminds organized medicine, and the industries that feed off its members prescribing more and more technology without caring about the cost, of something Lenin said back in 1923 about “Better fewer but better”. And you know how the American medical establishment hates them commies. On the other hand, it also invites memories similar to what Maggie Thatcher did to the British steel-workers in 1980 — she basically fired 70% of the workforce, but the amount of steel produced stayed the same. Are they going to call Maggie a commie? I think not, but you may have noticed lots of major industries taking the same approach.

So this research will stay ignored. We spend too much on high-tech medicine, we have too many specialists doing too many heroic procedures, and everyone’s very happy about that. Until that is that we notice that we have a health care system that does a shitty job of basic primary care, doesn’t cover 45 million people and costs way too much.

But if word somehow sneaks out that the two sides of that equation might per chance be related, then the pillars of the medical establishment might choose to move to other tactics. And perhaps the Dartmouth crowd might find themselves wearing concrete boots and hanging with Jimmy Hoffa instead.

CODA: And in a quick reminder that doctors are doctors whatever their
passport cover says, this article explains how spending more on health care in
Canada has not
shortened waiting times

In the five years up to 2002-03, the number of angioplasties (to open
arteries) and bypass surgeries increased 51 per cent, the number of joint
replacements rose 30 per cent, and cataract surgeries 32 per cent. But demand
for care seems to have increased just as much, and it’s not just because the
population is aging. "We’ve got way more activity beyond what the demographics
would dictate," said CIHI Chairman Graham Scott:More research is needed
to understand the phenomenon, he said but new technology is probably a factor.
If there are new tools available, such as MRIs, doctors are likely to use them.
If techniques for a certain kind of surgery improve, the procedure will become
more popular.

Duh! They don’t need more research. When the NHS was introduced in
the UK in 1948, the politicians thought that demand would fall after the initial
rush from those who hadn’t had coverage before wound down. But it didn’t. 50
years of data tells us that in health care supply creates its own demand, and
the way to deal with that is to restrict supply.

PHYSICIANS/TECH: Why diagnostic radiologists won’t make $400K a year forever

One of the smartest observers of the medical scene, UCSF’s Bob Wachter had an interesting article in the NEJM on The Implications of Medical Outsourcing. Here’s the key point:

By severing the connection between the "assay" and its interpretation, digitization allows the assay to be performed by a lower-wage technician at the patient’s bedside and the more cognitively complex interpretation to be performed by a physician who no longer needs to be in the building — or the country.

Of course they’ll be lots of resistance to this — and if anything Wachter understates the extent of the war that’s about to happen (think specialty hospitals). But eventually collaboration software (as being plugged by Microsoft and Nortel) will remove the need for much direct physical connection between patient and physician, and skilled technicians and lower-paid clinicians will mediate between them.

Until of course the availability of lower-paid physical physicians re-disintermediates that trend. If you have no idea what I’m talking about, do yourself a favor and read Eric Schlosser’s fantastic article on why it’s cheaper to hire people than machines to pick strawberries.


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