Category: Uncategorized

My Patient Needed to Be Delivered

Jul 18, 2011• 12

By ALEXANDER FRIEDMAN, MD

My patient needed to be delivered. She had just developed eclampsia, a potentially fatal disease that afflicts women in the second half of pregnancy. She had suffered a seizure and dangerously high blood pressure, and was at risk for far worse, including a stroke. No one knows why this condition arises, but delivery sure clears it up in a hurry.

So we gave medication to start labor, and the nurses placed a fetal heart monitor.

Worn like a belt, but higher on the abdomen, the ultrasound monitor would play a crucial role in the hours to come. It prints a read-out strip of the baby’s heart rate, and the pattern would guide us in determining whether the delivery would be natural or through cesarean section.

As I suspected, the baby’s heart-rate strip showed worrisome changes soon after labor began, and I knew it would get worse as labor progressed. We would fight through the night to have a natural delivery. But ultimately that single heart-rate test, which is surprisingly unreliable, would be a key factor in whether my patient would get a C-section or not.

The Quantified Self: Making the Personal Public

Jul 15, 2011• 7

By SCOTT PEPPET

“Only the shallow know themselves.” — Oscar Wilde

Human instrumentation is booming. FitBit can track the number of steps you take a day, how many miles you’ve walked, calories burned, your minutes asleep, and the number of times you woke up during the night. BodyMedia’s armbands are similar, as is the Philips DirectLife device. You can track your running habits with RunKeeper, your weight with a WiFi Withings scale that will Tweet to your friends, your moods on MoodJam or what makes you happy on TrackYourHappiness. Get even more obsessive about your sleep with Zeo, or about your baby’s sleep (or other biological) habits with TrixieTracker. Track your web browsing, your electric use (or here), your spending, your driving, how much you discard or recycle, your movements and location, your pulse, your illness symptoms, what music you listen to, your meditations, your Tweeting patterns. And, of course, publish it all — plus anything else you care to track manually (or on your smartphone) — on Daytum or mycrocosm or me-trics or elsewhere.

There are names for this craze or movement. Gary Wolf & Kevin Kelly call this the “quantified self” (see Wolf’s must-watch recent Ted talk and Wired articles on the subject) and have begun an international organization to connect self-quantifiers. The trend is related to physiological computing, personal informatics, and life logging.

There are all sorts of legal implications to these developments. We have already incorporated sensors into the penal system (e.g., ankle bracelets & alcohol monitors in cars). How will sensors and self-tracking integrate into other legal domains and doctrines? Proving an alibi becomes easier if you’re real-time streaming your GPS-tracked location to your friends. Will we someday subpoena emotion or mood data, pulse, or other sensor-provided information to challenge claims and defenses about emotional state, intentions, mens rea? Will we evolve contexts in which there is an obligation to track personal information — to prove one’s parenting abilities, for example?

The Rationale for Developing Physician-Leaders

Jul 15, 2011• 3

By JAMES K. STOLLER, MD

The many challenges in healthcare today require great leadership. Access, affordability and quality are just a few of the overarching issues that call for and, in fact, demand great leadership from within healthcare.

Traditionally, the criteria for a physician to advance to a leadership position have included academic and/or clinical accomplishments, rather than the distinctive competencies needed to lead. Furthermore, traditional physician training and the unique characteristics of physicians — we tend to value autonomy and, outside of structured interactions (such as the operating room or intensive care unit), may have poorly developed team reflexes — can handicap developing leadership skills.

Though developing great leaders and embracing change are well-established characteristics of frontrunner organizations in many industry sectors, healthcare organizations have generally lagged behind. What’s more, many healthcare organizations are structured in silos or “fiefdoms,” which represent a challenging environment in which to lead. Only recently are healthcare organizations awakening to the importance of developing physician-leaders and, in this context, offering physician-leadership programs.

So Many EHRs. So Expensive.

Jul 15, 2011• 15

By MARGALIT GUR-ARIE

There are currently 386 software packages certified by an ONC approved certification body as ambulatory Complete EHRs, which means that the software should allow the user to fulfill all Meaningful Use requirements and possibly qualify the proud owner for all sorts of CMS incentives. There are 204 more software packages which are certified as ambulatory EHR Modules, and a proper combination of these packages could result in a Complete product, which if used appropriately could lead to the same fortuitous results.

There are 423 distinct manufacturers of ambulatory EHRs and EHR modules on the federal list. Most are software vendors, or wannabe software vendors, but a fair amount are facilities that developed an EHR for in-house use and had it certified. These are not really available for purchase. A very large number of listed vendors offer niche products for distinct specialties, such as optometry, oncology, behavioral health, etc. All that said, there is still an inordinate number of EHR “choices”, or so the story goes. By comparison, since we all love car analogies, there are 1,310 individual trims currently sold in the U.S., and around50 car manufacturers overall. If you ask an average citizen on the street to name their top 10 cars, chances are that you will get a Honda Accord, Toyota Camry, a Caddie, maybe a Ford truck, a Beemer, a Porsche and perhaps even a Beetle. You are not likely to hear anything about a Tesla or a Coda and rarely will anybody mention a Scion. Automotive modules are not widely sold for home assembly, so there is no parallel lesson there. One way or another, we manage to find our way when it comes to automobiles.

Innovation and Competition

Jul 14, 2011• 1

By FRANK PASQUALE

Last year I published a piece called “Beyond Innovation and Competition,” questioning the dominance of those values. Economists celebrate innovation and competition as the main source of future growth. Innovation has become the central focus of Internet law and policy. While leading commentators sharply divide on the best way to promote innovation, they routinely elevate its importance. Business writers have celebrated search engines, social networks, and tech startups as model corporations, bringing creative destruction and “disruptive innovation” in their wake. Maximum innovation is the goal, and competition is billed as the best way of achieving it. Players in the vast and dynamic tech marketplace are supposed to constantly strive to innovate in order to attract consumers away from rivals.

In the piece, I explain how both competition and innovation can be as destructive as they are constructive. There are many social values (including privacy, transparency, predictability, and stability), and companies can compete for profits in ways that erode those values. In an era of inequality and hall-of-mirrors stock market valuations, innovations of marginal or negative impact on society at large can be vastly overvalued by a stampede of fickle investors.

The shortcomings of the innovation and competition story also play out in health information technology. Stimulus legislation in 2009 provided many carrots and sticks for doctors to digitize their recordkeeping systems, ranging from bonuses now to reimbursement haircuts later this decade if they fail to implement the technology. Congress structured the incentives to encourage a competitive and innovative marketplace in health information technology. But many doctors are shying away from implementation, in part because they fear that the fast and loose ethics of the market can’t mesh with a medical culture of constant commitment to quality care.Continue reading…

If Doctors Lead, Will Health Care Costs Follow?

Jul 14, 2011• 1

By NAOMI FREUNDLICH

Can doctors and other health care providers be the driving force in achieving cost-effective health care? In their commentary in the New England Journal of Medicine, Stanford professors Victor Fuchs and Arnold Milstein, call this the “$640 billion question.” That figure represents the savings to the national health care bill if all U.S. physicians and health care organizations could follow the example of individual providers who already deliver high-quality care at a costroughly 20% lower than the average.

The authors ask “Why don’t cost-effective models diffuse rapidly in health care, as they do in other industries?” The answer, according to Fuchs and Milstein, is that a long list of stakeholders has interests that are effectively blocking the “diffusion of cost-effective care.” These include drug and medical device-makers who tout their new, more expensive products as always better than older (and cheaper) alternatives; insurance companies with high administrative costs; employers who offer just one or two benefit plans to workers; legislators who accept donations from health industry insiders, academic health centers that tolerate cost inefficiency as the price of training residents; and others whose vested interests keep them from fully embracing cost-effective care.

The media is also to blame, write the authors, by publishing articles that tout miracle cures and treatments to boost newsstand sales and failing to convey risk/benefit information accurately.

Trying to cut health care costs has often been compared to squeezing a balloon; pinch the air out of one end and it will fill up the other. Or as the Canadian economist Robert G. Evans recently told a Group Health audience, “look carefully at so-called ‘waste’ in the U.S. health care system. ‘Nothing is ever wasted… Every dollar ‘always goes somewhere, which is what makes it so difficult to bend the (cost) curve.’ In other words, one person’s waste is another person’s income.”

Trying Too Hard to Save Medicare

Jul 14, 2011• 29

By DAVID DRANOVE

In the latest edition of Health Affairs, Dr. Francis Crosson, chair of the Council of Accountable Physician Practices and senior fellow at Kaiser Institute of Health Policy, offers an impassioned defense of Accountable Care Organizations. Crosson’s main point is in his title: “The Concept is Too Vitally Important to Fail.” He adds:

“The accountable care organization model is intended as an option both for Medicare and for non-Medicare, commercial health care services. However, the general model and the specific shared savings model proposed for Medicare have come under criticism. Much of the criticism is valid and should be addressed. However, none should serve to prevent the evolution of this model.”

If the concept is “It sure would be nice to hold down costs and improve quality” then how can I argue? Who wants to argue against God, Mother or Country? But if the concept is “The only way to save the healthcare system is to organize everyone into ACOs,” well forgive me for disagreeing.

Why This Lawyer Won’t Sue Me

Jul 13, 2011• 2

By MICHAEL KIRSCH, MD

I spent the entire last weekend with an attorney, not a desirable circumstance for most physicians. However, I wasn’t being deposed or interrogated on cross examination. This was a rendezvous that we both sought with enthusiasm.

Lewis is my closest friend, a bond that was forged since we were eight years old. We are separated now only by geography, and we meet periodically because we both treasure the friendship. Earlier this year we rolled the dice in Vegas. Last weekend, we sweated in the sweltering heat of the Mile High City. Next stop? Back to Denver with a few youngins’!

Lewis is the managing partner in a prominent west coast law firm that specializes in tax evasion. (Or is it tax avoidance? Am I confusing my terms here, Lew?) He has been redrafted to this position because he has earned the respect of his colleagues. Clearly, both Lewis and I have ascended to the highest strata of our professions. Lewis is in charge of a large law firm that has global reach; he travels all over the world cultivating business and negotiating deals; and he navigates clients through complex and labyrinthine legal conundrums. I, an esteemed community gastroenterologist, perform daily rectal examinations and counsel patients on flatulence.

Myths about Medical Malpractice: Part 2 Crisis or Hoax?

Jul 12, 2011• 56

By MAGGIE MAHAR

Conservatives call it the “malpractice crisis.” Public Citizen, a liberal non-profit consumer organization based in Washington D.C., calls it “The Great Medical Malpractice Hoax.”

No doubt you have read that ambulance-chasing lawyers have escalated their assault on health care providers, and that as a result, malpractice insurance premiums have been levitating, along with malpractice suits, further hiking the cost of medical care.

Various solutions have been floated, including “caps” on compensation for pain and suffering; “health courts” where expert judges replace juries; immunity for doctors who follow “best practice guidelines;” and “full disclosure” policies which urge doctors and hospitals to move quickly to disclose errors, apologize, and offer compensation.

In the end, the best solutions would make malpractice reform part of heath care reform. Our malpractice system should be redesigned to reduce medical mistakes, fully compensate patients who are injured by human error, reward doctors and hospitals that disclose errors, and penalize those that try to “cover up.” When it comes to the cost of malpractice, reform should slash the exorbitant administrative costs built into an adversarial process that moves at a snail’s pace, while subjecting both plaintiffs and defendants to what a recent report from the American Enterprise Institute rightly describes as “inhumane.”

Continue reading…

Let’s Stop Bashing Profits and Business In Healthcare

Jul 12, 2011• 167

By MERLE J. BUSHKIN

I’m tired of profit-bashing and business-bashing in healthcare. And every American should be, too!

Well-run, profitable businesses, along with our sense of decency, democratic institutions, education and free enterprise systems, and adherence to the rule of law, have made the United States the most extraordinary nation in recorded history. Together they have unleashed the talents, creativity and productivity of our people, generated enormous sums of capital, and created unheard of social, economic, scientific and political advances.

Is there anything nobler than providing the environment and opportunity for people to fulfill their potential and achieve their dreams, and for providing the goods and services that enable people to raise their standard of living? Not even the practice of medicine can do so much good for so many people. But that’s precisely what businesses do. (That also may explain why far more Americans today are interested in job creation than restructuring healthcare.)

In our system, an individual has an idea, attracts capital, and hires people to build a product or provide a service. When they meet a need, they prosper – and attract more capital and hire more people. Everybody wins. If they fail, they alone suffer the consequences. That’s what capitalism is all about and that’s what has made America great.