Category: Uncategorized

Informed Refusal

Aug 18, 2013• 9

By Richard Gunderman, MD

Before undergoing many health care interventions, patients are asked to give their informed consent. In most cases, it represents a mere formality. The patient has come to the healthcare facility for the express purpose of undergoing the test or treatment, and after a quick explanation, the patient signs the consent form. But not always – sometimes patients elect not to go through with it.

I know a woman in her late 70s, a highly accomplished health professional with a long and remarkably distinguished record of career achievement, who was recently diagnosed with cancer. Her physician advised a complete diagnostic workup to determine how far the disease has spread, to be followed by courses of radiation and chemotherapy. A vast and sophisticated medical armamentarium, unprecedented in the history of medicine, stands at the ready to take the full measure of her disease and then beat it back.

Yet after her oncologist carefully explained the benefits, risks, and alternatives to the recommended course, she declined to proceed further. Instead of launching into an arduous medical regimen, she has chosen to focus the remainder of her time and attention elsewhere, on matters outside of medicine. Why?

On hearing such a story, some of my medical colleagues question the patient’s soundness of mind. Could she be depressed? Might she be in the early stages of dementia? Could she have simply failed to grasp the full gravity of her situation? To them, the failure to take advantage of the wonders of modern medicine smacks of irrationality. The solution? Her physicians need to sit her down again and explain the situation more clearly. Should this fail to elicit her consent, perhaps a psychiatry consult would be in order.

Yet to those who know her, these explanations are unsatisfactory. We cannot attribute her decision to a lack of intelligence or sophistication about healthcare. She has spent her entire career in the field, and helped to care for countless patients with life-threatening conditions, many of whom eventually died. She knows what the care of such patients looks and feels like from firsthand experience. She understands the risks of declining further treatment at least as well as many of the health professionals caring for her.

#MomInHospital

Aug 17, 2013• 10

By Bob Wachter, MD

A few weeks ago, a middle-aged man decided to tweet about his mother’s illness from her bedside. The tweets went viral and became the subject of a national conversation. The man, of course, was NPR anchorman Scott Simon, and his reflections about his mother’s illness and ultimate death are poignant, insightful, and well worth your time.

Those same days, and unaware of Simon’s real-time reports, I also found myself caring for my hospitalized mother, and I made the same decision – to tweet from the bedside. (As with Simon’s mom, mine didn’t quite understand what Twitter is, but trusted her son that this was a good thing to do.) Being with my mother during a four-day inpatient stay offered a window into how things actually work at my own hospital, where I’ve practiced for three decades, and into the worlds of hospital care and patient safety, my professional passions. In this blog, I’ll take advantage of the absence of a 140-character limit to explore some of the lessons I learned.

First a little background. My mother is a delightful 77-year-old woman who lives with my 83-year-old father in Boca Raton, Florida. She has been generally healthy through her life. Two years ago, a lung nodule being followed on serial CT scans was diagnosed as cancer, and she underwent a right lower lobectomy, which left her mildly short of breath but with a reasonably good prognosis. In her left lower lung is another small nodule; it too is now is being followed with serial scans. While that remaining nodule may yet prove cancerous, it does not light up on PET scan nor has it grown in a year. So we’re continuing to track it, with crossed fingers.

Unfortunately, after a challenging recovery from her lung surgery, about a year ago Mom developed a small bowel obstruction (SBO). For those of you who aren’t clinical, this is one of life’s most painful events: the bowel, blocked, begins to swell as its contents back up, eventually leading to intractable nausea and vomiting, and excruciating pain. Bowel obstruction is rare in a “virgin” abdomen – the vast majority of cases result from scar tissue (“adhesions”) that formed after prior surgery. In my mother’s case, of course, we worried that the SBO was a result of metastatic lung cancer, but the investigation showed only scar tissue, probably from a hysterectomy done decades earlier.

Preparing for 2014: Questions for Obamacare’s Opponents

Aug 16, 2013• 25

By John R. Graham

As a confident critic of ObamaCare from its genesis, I’m impressed that the law remains unpopular and that the American people appear ready to scrap it and start again. Last March, a senior bureaucrat in charge of rolling out ObamaCare fretted about a “third-world experience“.

ObamaCare’s opponents have managed to keep Republican politicians unified against the law. The only tactical question is whether the GOP can credibly threaten to “shut down the government” during the forthcoming debate over the Continuing Resolution (the legislation that funds the government in the absence of a budget).

It’s been a good three and a half years for ObamaCare’s opponents. Nevertheless, outside the political realm, businesses and investors are behaving as if ObamaCare is hardened concrete. Although ObamaCare’s opponents have overwhelmingly succeeded in convincing society of the law’s drawbacks, it is not at all clear that society is ready to accept a more free-market alternative reform.

Indeed, some of the approaches used against ObamaCare might have unintended consequences that will appear in 2014, the law’s first fully operational year, which would make repealing and replacing ObamaCare extremely difficult.

Here are a few friendly questions for ObamaCare’s opponents:

First: We’ve spend a lot of effort convincing people that state-based health-insurance exchanges will be a disaster, and succeeded in blocking their establishment in many states. To be sure, they are an unnecessary bureaucracy, but do we really believe that enrolling in the New York Health Benefits Exchange or Cover California will be the worst thing since unsliced bread? It won’t be like shopping on Amazon.com, but I’ll bet it will be easier than doing business with the DMV. The New York Times recently reported on exchange outreach efforts in Colorado (a pro-ObamaCare state) and Missouri (an anti-ObamaCare state). The take-away: In Colorado, it’s almost impossible for people to avoid learning how to enroll in the exchange, while in Missouri it’s been extremely difficult to get information. Most people will not be interested in how much it cost taxpayers to set up and operate the exchanges. Do we really believe that when ordinary Missourians learn from their Coloradan friends that their state government has helped them get federal tax credits for health insurance, that they will reward Show-Me state politicians for trying to block them?

Pioneer ACO’s Disappointing First Year

Aug 16, 2013• 15

By Jeff Goldsmith

On July 16, the CMS Innovation Center reported the first-year results for the Pioneer Accountable Care Organization program: 13 Pioneers, or about 40 percent of the participants, earned bonuses. The program saved Medicare a gross $87.6 million before bonus distributions, cutting the rate of growth in Medicare spending by 0.5 percent, from 0.8 percent to 0.3 percent annually.

However, nine of the 32 members dropped out and press reports hinted at a contentious relationship between the Pioneers and a well meaning but green and overtaxed CMS staff. It was not an auspicious beginning for a program whose advocates believed would eventually replace regular Medicare’s present payment model. There immediately followed a blizzard of spin control from ACO “movement” advocates stressing the need for patience and highlighting first year achievements.

What was irritating about the Pioneer spin is it treated the ACO as if it were a brand new idea with growing pains. This studiously ignores a burned out Conestoga wagon pushed to the side of the trail: the Physician Group Practice demonstration CMS conducted from 2005-2010. The PGP demo tested essentially the same idea — provider bonuses for meeting spending reduction and quality improvement targets for attributed Medicare patients. The pattern of arrow holes and burn marks on the PGP wagon closely resemble those from the Pioneer’s first year, strongly suggesting more troubles ahead for the hardy, surviving Pioneers.

The PGP Precedent. Like the Pioneers, PGP participants were not ordinary community hospitals or freshly formed physician groups or IPA’s. Rather, most were “high functioning” organized clinical enterprises, some with decades of global risk contracting or health plan operating experience. Particularly in light of the degree of clinical integration and care management experience of its participants, the PGP results were extremely disappointing; only two of the ten participants were able to generate bonuses in each of the program’s five years, and one, Marshfield Clinic, earned half the total bonuses. Managed care veterans like Geisinger Clinic and Park Nicollet earned bonuses in only three of their ten program years. Two other high-quality multi-specialty clinics had even rougher sledding, with Everett Clinic getting one year of bonus ($126,000) and Billings Clinic completely shut out.

The pattern in the first Pioneer year is remarkably similar. While thirteen of the Pioneers earned bonuses, it appears from press reports that four of them generated 2/3 of the savings. It is likely not coincidental that three of those four participants (Massachusetts General, Beth Israel Deaconess’ physician organization, and New York’s Montefiore) either run or practice at some of the most expensive hospitals in the country, in two of the country’s highest per capita Medicare spending markets. Orchards full of low hanging fruit (e.g. very high levels of previously unexamined Medicare spending) appear to be an essential precondition of ACO success.

Health 2.0 Introduces Big Players in Big Data

Aug 15, 2013

Bob Rogers isn’t just the Chief Data Scientist at Apixio, he’s also a physicist, prior hedge fund manager, and now an instructor for Health 2.0 EDU’s joint three-day executive education course with UC Berkeley on digital health startingOctober 3rd. Bob’s career shift to health care gave what he references as “a sense of intrinsic value” to his work in a time where the value of health care technology is only increasing:

EDU: What are you focused on right now at Apixio?

BR: My number one goal right now is to help health care organizations get seamless, simple access to all of their data, including structured data, textual documents, and images. The business and financial challenges to health care organizations to simultaneously increase efficiency and improve care are impossible to overcome without reliable data. Studies show that over two-thirds of key clinical information is missing from the coded layer of EHRs, so we are developing technology that surfaces the information hidden in clinical narrative and scanned documents. Given the number and diversity of the documents generated by health care systems, this is truly a big data problem.

EDU: Your work in application and algorithm development seems like a hard concept to grasp: How do you explain something so new but fundamental to people in health care without a tech background?

BR: The goal of information technology is to answer questions and to solve problems: The underlying technology is secondary. I like to focus on specific examples and use cases and analogies that everyone in the industry can understand and appreciate.

EDU: Why do you think it’s important for executives in organizations like hospitals and pharma companies to understand big data?

BR: Decision makers in health care and pharma need reliable information to run their businesses, but many have been burned by clunky, expensive technology that has not met expectations. Health care data is big and requires big data techniques to make it useful, so a good understanding of the opportunities and risks of big data is crucial to navigate successfully.

EDU: What new application of big data in health care are you most excited about?

BR: There are two areas that are exciting to me. In the therapeutic arena, it has become possible to make meaningful discoveries about the safety and applicability of drugs by mining clinical narrative. For example, Stanford professor Nigam Shah is doing some very impactful work in this area. On the clinical care side, it is now possible to construct a network model of an entire health system using big data techniques. This creates opportunities to empower care coordination, chronic disease management and cost management for populations.

EDU: What are you most looking forward to in your upcoming UC Berkeley course with Health 2.0 EDU, and what do you hope your students will take away?

BR: I’m looking forward to learning about the challenges and use cases that are impacting my students. I hope they will come away with the confidence and knowledge to embrace the aspects of big data analytics that can help them run their organizations successfully.

Registration for the executive course ends September 1, 2013. The full agenda is available HERE.

The Federal Health Data Services Hub Hubbub

Aug 15, 2013• 17

By Adrian Gropper, MD

Secrecy breeds suspicion. The role of secrecy in health care is practically non-existent so when we see examples of secrecy, as in the operational details of the Federal Data Services Hub, we get the recent outcry from a range of politicians and journalists waving privacy flags. For Patient Privacy Rights, this is a teachable moment relative to both advocates and detractors of the Affordable Care Act.

There’s a clear parallel between the recent concerns around NSA communications surveillance and health care surveillance under the ACA. Some surveillance is justified, to combat terrorism and fraud respectively, but unwarranted secrecy breeds suspicion and may not help our civil society.

“The Hub” is described by the government as:

“For all marketplaces, CMS [the Centers for Medicare and Medicaid Services] is also building a tool called the Data Services Hub to help with verifying applicant information used to determine eligibility for enrollment in qualified health plans and insurance affordability programs. The hub will provide one connection to the common federal data sources (including but not limited to SSA, IRS, DHS) needed to verify consumer application information for income, citizenship, immigration status, access to minimum essential coverage, etc.

CMS has completed the technical design, and reference architecture for this work, is establishing a cross-agency security framework as well as the protocols for connectivity, and has begun testing the hub. The hub will not store consumer information, but will securely transmit data between state and federal systems to verify consumer application information. Protecting the privacy of individuals remains the highest priority of CMS.”

Here’s where the secrecy comes in: I tried to find out some specific information about the Hub. Technical or policy details that would enable one to apply Fair Information Practice Principles? Some open evidence of privacy by design? Some evidence of participation by privacy experts? I got nothing. Where’s Mr. Snowden when we need him?

The Good Doctor Calls For Backup

Aug 15, 2013• 8

By Rob Lamberts, MD

My mom is great.

Unfortunately, like most mothers, she relishes telling funny (usually embarrassing) stories about us kids. I, unfortunately, seem to be the subject of the vast majority of those stories. But my big brother gets the leading role in one I will now tell. I guess it’s a small way to get back at him for…well, for lots of stuff. One day he came home from school all excited (unusual for my half-vulcan brother). ”Mom! Mom! I learned how to swim today!” he said. ”Oh?” my mother answered, not sure how and where he learned this new skill. Bill got a very pleased expression as he explained, “Steven V. taught me on the bus!” This is where my mother guffaws and my father chuckles and we kids look at each other with the well-worn “when will this story get old?” expression. He’s probably making that expression at his computer right now.

Sorry, Bill.

But the naïveté expressed by my brother at the nature of learning how to swim is similar to my confidence going into this project. Certainly it helps to know you can’t breathe underwater, and that swimming in a suit of armor is a bad idea, but this knowledge does not substitute for the first-hand experience of keeping afloat while the water seems to be trying to drown you. Similarly, I could read books, make a business plan, and impress people with my thought and insights, but that does not substitute for the first-hand experience of building a new business from scratch. It does nothing to keep me financially afloat while unseen forces try to pull me under.

Which brings me to my current situation. Would I have taken the plunge had I known what it’s taken up until now? It has been hard.

I hesitate to write about this, because:

I hate to sound whiney.
I don’t want people to worry that things are worse than they are. Especially my patients.
I don’t want to get a lot of advice from well-meaning people who don’t know the details of my situation.

But I want to give a realistic picture of what this journey is like, not just throw you the vaporware version. Besides, my world right now has significant stress and pressures that I didn’t anticipate.

The first sign of trouble came very early, in the renovation of my office. My goal was to start seeing patients in mid-December, and officially opening around the first of the year. Unfortunately, the office wasn’t ready until February 6th, and the construction cost twice what I expected. For those who can’t see the implication: I spent more money and lost a month of earning it. More money out, less money in. Maybe swimming’s a little harder than Steven said it was.

Then came the EMR debacle.

Of the areas I was most sure of, my ability to use computers to improve care was at the top. After all, I had won national awards and much acclaim for my use of electronic records to improve care. Two months and five EMR products later, I was beginning to see just how far the health IT industry had moved away from patient care. I din’t know what to do; I was at an impasse. Each system I tried either lacked some basic element of organization I required (such as management of outside documents) or was unable to generate anything but the voluminous documentation which succeeds only in two areas: getting physicians paid and hiding useful clinical information.

Health 2.0 and Enspektos Market Intelligence Webinar TODAY

Aug 15, 2013• 1

Enspektos and Health 2.0 have come together to implement a unique market intelligence partnership. It will combine:

Groundbreaking insights on how digital content can be used to change health behavior – based on a novel consumer research tehchnology
Deep intelligence about the shape and future of digital health from a technology and company perspective.

Health 2.0 and Enspektos are holding a Webinar TODAY August 15 at 2pm ET where we’ll not only talk about these offerings, but also provide a sampling of the kind of big picture intelligence and analysis we’ll be delivering. You’ll also learn how you can access our unique insights and much more 24/7. Click here to spend an hour with us learning about the new breed of health technology market intelligence Health 2.0 and Enspektos will deliver — Fard Johnmar, Enspektos & Matthew Holt, Health 2.0

Average Care at a Typical Hospital on an Ordinary Sunday in August

Aug 14, 2013• 25

By Ashish Jha, MD

The Bike Path:

On a warm and sunny August Sunday, I was rollerblading with my kids on the Shining Sea Bikeway. On mile nine on the trip, I hit a tree root, went flying, and landed on my shoulder. I could tell immediately that something was wrong — I couldn’t move my arm and was in the worst pain of my life. Feeling for my left shoulder, it was obvious that I had dislocated it. What happened next was that I received some of the best care of my life – unfortunately it was not from our healthcare system.

As I was lying on the bike path, nearly everyone stopped and asked how they could help. A pediatric nephrologist offered to pop my shoulder back into place. I declined. This wonderful couple on a two-person reclining bike stopped and insisted on pedaling me to the hospital. We were far from the road and knew that calling an ambulance was not straightforward. So I sat with my left arm dangling, in excruciating pain, while David rode the bike to Falmouth Hospital. It was a 20 minute ride finishing with a very steep hill. David apologized after each bump on the road as he heard me swear and wince.

The Emergency Room:

We finally made it to the ER, and, ironically, it was then that my care stopped being so wonderful.

It started off well enough – a triage nurse saw me walking in holding my arm, in distress. She got me a wheelchair and brought me into triage. I explained what happened, gave my name, date of birth and described the pain as the worst of my life. I was then shuttled to registration, where I was asked to repeat all the same information. It felt surreal: I had moved all of 10 feet and yet somehow my information hadn’t followed me. The registration person asked me question after question. Initially, the same ones: name, address, phone #, etc. Then, my Social Security number (presumably so they could go after me if I didn’t pay my bill), my primary care physician’s name, his address, his phone #, my insurance status, my insurance #, my insurance card, my emergency contact, their address and phone #, etc. etc. etc.

I told her I was in excruciating pain and needed help. A few more questions, she said. She needed the complete registration.

I was wheeled to radiology and sat in a hallway for what felt like forever, groaning in pain. I couldn’t find a comfortable position. Six or seven people walked by – and as they heard me groan, they would look down and walk faster. The x-ray technologist avoided eye contact. It was hard — I was right outside her room. Finally, I asked a passerby if she could help. Caught by surprise (I must have sounded human), she stopped. She looked at me. She then went into the x-ray suite. A few minutes later, a second technologist came out, saw my arm, and was the first to acknowledge that my arm looked painful. He told me the ER was pretty quiet and he would get me in right away.

Nurses Will Play a Vital Role in the Enactment of the Affordable Care Act

Aug 14, 2013• 12

By Kathleen Potempa

While in the care of a nurse, patients have a champion: a health care professional working to assure timely tests, procedures, and rehabilitative activities that foster better and faster recovery. Prior to discharge from a health facility, it is often the nurse who assesses a patient’s self-care ability (or access to home caregivers) to provide the type of treatments and medications needed to prevent relapse or even costly return to a hospital.

Responsibility for optimal recovery is of course shared by all health team members, but the unique position of nurses at the patient’s bedside (literally and metaphorically) gives us many avenues to influence care and cure.

Though nurses already play a central role in cost containment, care quality, and patient safety, current trends in nursing education have us poised for even greater contributions. That’s because good baccalaureate and graduate programs in nursing increasingly incorporate quality improvement in care settings. Through attention to ‘microsystem’ processes, we work toward better outcomes not only for individuals but also for health systems as a whole. Nursing prepares leaders, administrators, and researchers who can improve care processes and related analytics around outcomes and cost.

The coming enactment of reforms included in the Affordable Care Act will increase the opportunities for nurses to make both individuals and care systems as healthy as they can possibly be. Patient communication, preventive care, and navigation across the vast medical landscape are well-established foci in the curriculum at major U.S. nursing schools. These areas of expertise could not be more essential now that new insurance options and Medicaid expansion are bringing millions of individuals into a national primary care system already taxed by provider shortages.

Nurse navigators and transitional care nurses are stepping up to central coordinating roles within Accountable Care Organizations—the model wherein participating health care providers are collectively responsible for their enrollees’ care, and also can share savings resulting from efficiency and improvements in that care.

Nursing as a profession actively engages in leading efforts to improve patient care and reduce costs; this is integral to our professional values, knowledge base, and skills. We have earned the trust of Americans (we’re voted most ethical and honest in Gallup polls), and will use that trust, along with our health promotion expertise, to communicate with patients about the best prevention, timely care, and most efficient ways to get needed help as they navigate together through America’s evolving system of care.

Kathleen Potempa, PhD, RN, FAAN, is the Dean of the University of Michigan School of Nursing and a national leader in health promotion, nursing education, and research. Dr. Potempa is the immediate past president of the American Associate of Colleges of Nursing and recently concluded a four-year term on the NIH’s National Institute of Nursing Research Council.