Tag: Commentology


David Longstreet had this to say in response to Andre Blackman's post last week on the the increasing importance of technology in public health. ("Why Technology is No Longer Optional in Public Health."

"the biggest change in software technology is the growing trend of specialization along industry disciplines. The healthcare field is too complex for "generalist" software developers.  Those software organizations that specialize in healthcare have productivity and quality rates orders of magnitude higher than generalist firms.

This should not surprise anyone in the healthcare discipline because healthcare has understood the value of specialization for some time now.  Unfortunately there are still software firms whose employees work for a bank one week and a hospital the next week…."

Christopher George wrote in reply to Bob Wachter's piece on the implications of comparative effectiveness research.  ("Are We Mature Enough to Make Use of Comparative Effectiveness Research?")

"Because the only case which you discuss is one in which supposedly greedy doctors perform ineffective surgery for profit, one might be left with the impression that the principal problem in healthcare is restraining rapacious doctors.

It is well known in certain segments of the medical community that back surgery, and cardiac angioplasty are largely ineffective. It is also well known that regulators with government sponsorship have a limited grasp of statistics and science, and an uncanny tendency to target effective procedures as often as stupid ones. Don't be surprised if you don't like the result once a soviet style Supreme Extra-ordinary Medical Committee makes enforcable decisions about what heathcare is on your treatment menu.

Remember  an early target of those who would use government to eliminate medical progress: The CT scan. The assault on the Cat scanner was nearly successful. When you torture the data enough, a CT scanner can seem like a silly thing to use. Why not practice like they did at the dawn of time?"

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Helen Darling of the National Business Group on Health wrote in to comment on the thread on Robert Laszewski's post on the realities behind  the Obama health plan. ("For the Obama administration health care reform will require cost containment.")

We have known for many years that we have a wasteful health care system full of overuse, misuse and underuse. The system is not getting better and people are less healthy than ever. It is exciting and inspiring that we have political leaders  who are willing to fight the tough and thankless battles that they will have to fight to get us on the right track as a nation. While there will be plenty of specifics to make everyone unhappy about one element or another, can't we all pull together to have a much better, more effective and affordable health care system for the good of the country?

In the thread on MEDecision CEO David St. Clair's post over the brewing battle over privacy in Washington "Consumers Need All the Facts in the Privacy Debate" Inchoate but Earnest writes:

"At present "healthcare privacy" is a wraith, a boogeyman, & like most boogeymen, it is foisted upon the innocent by people, by institutions, that would retain power over them. The unknown deserves respect, but rarely fear …"

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Michael Millenson had this response to a commenter in the thread on his recent post looking at web sites that offer the public data about provider performance.   (' Just OK Quality or the Best? ')

"Why does HealthGrades get so many more visitors than HospitalCompare? I think you're correct that it's because of promotion, but the context is the magnitude. HealthGrades constantly promotes, via Google-sense ads, via press releases to the trade and mainstream media, via the ads taken out by hospitals touting their ratings and via search engine maximization. And they've done this for many years, acting as if their economic future depends on it (which it does). The government promotes its site kind of the way you see those "stop smoking" public service announcements.

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Joe Flower had this to say in response to criticism of comparative effectiveness research in the comment thread on his post ("Fear and Loathing Over the Stimulus Bill") examining the backlash against the Health IT provisions in the stimulus package …

"No one that I can see is saying that doctors and patients should not
be allowed to choose the best treatment. But there need to be some
bounds, some incentives to pay attention to what the best evidence
shows. Why don't doctors do bloodletting, as they routinely did 200
years ago? Why don't they whip out every kid's tonsils, as they did
when I was a kid? What happened to the idea that radical mastectomy was
the gold standard treatment for breast cancer? What about the fad for
high-dose chemo and bone marrow transplants for breast cancer, all
before studies showed little benefit and great risk? What about all the
routine things that are still done that have shown little benefit in
studies (like routine episiotomies, brain bypass surgery for patients
with warning signs of stroke, or HRT to prevent a second heart attack
in women)? What about the hundreds of thousands of spinal fusions still
being done, not for tumors or spinal fractures or congenital problems,
for which the surgery shows great benefit, but for chronic back pain,
for which repeated studies show little long-term advantage over
non-surgical techniques?

What do we do with such information? Do we just shrug our shoulders
and do nothing about it? Do we wonder whether such over-treatment with
unproven or even disproven therapies has anything to do with the fact
that we spend roughly twice as much per capita as every other major,
medically modern economy, whether socialized or mixed, for worse
outcomes, and still can't seem to afford to offer even basic care to
all Americans?"


John Haughton MD left this thought-provoking follow up to his original post on the Obama administration's health IT plans. ("Stimulus Bill Offers Docs Incentives, But Demands Effective Use")

"Since writing the post 2 weeks ago, the Stimulus bill has now passed.  It does offer the $40K + bonus for "effective use" of a "qualified EHR" (DISTINCT FROM CURRENT DEFINITIONS OF EMRS / EHRS) – The bill specifically targets FIVE AREAs (which by the way are the evidence-based areas associated with HIT and care improvement):  1) Patient Info / History and Problem lists (Structured Data); 2)Clinical Decision Support.  3) Quality Reporting (performance measurement)  4) Ordering (including prescribing)  5) Interoperability (exchange and integrate with other sources).

All of the above can ENHANCE workflow and health by saving time and improviing care.  There is no push in the bill to completely change office workflow – there is a push to enhance patient care. 

The days of the $40K EMR are numbered.  Here's a prediction:  most physicians will spend no more than $10K each over a 3 or 4 year period (2010 – 2013) to acquire and use a qualified system – leaving an increase of dollars flowing into primary care – a great stimulus. What do you think?


MToubbeh, MD wrote us in response to Eric Novack's slightly incendiary post. ("The Expansion of the Federal Healthcare Bureaucracy Bill")

I don't think that when we built the Highway system
in the country that people were worried that the Government was going
to control the flow of travel.  The ONC was established under the Bush administration, is headed up by
a provider and the new advisory board (NeHC) has at least 8 physicians
on it including many who post on this blog regularly.  

bill in fact has blocked the power of many lobbying groups (ie it isn't
a vendor dominated organization) and is only one small part of the
total amount of money that needs to be implemented in health IT. The
private sector has been catering to their clients (hospitals) and both
providers and consumers have been left out of this process up until

Bev MD had this comment on David Kibbe's landmark post on Clinical Groupware:

a former medical laboratory and blood bank director, I have seen every
conceivable(and some inconceivable) way that a patient's identity can
be mistaken and incorrect information entered in a patient record. This
is one reason why every blood bank will re-draw a patient's blood on
every admission to confirm their blood type is really the same as what
is in their record. And no, one cannot rely on the patient himself to
verify the information, for a variety of reasons. Please do not
overlook the critical necessity for at least one, preferably two,
unique patient identifiers in any type of system that is developed – or
you may literally kill someone."

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Jay wrote in on Dr. John Haughton's post on the health IT provisions in the latest version of the stimulus package. ("Stimulus bill offers docs big incentives for technology, but demands effective use.")

"While a move to EMR is a necessity to reduce medical costs for the
country, I don't believe that providing purely financial incentives for
individual doctors is going to bring about the desired change. So many
doctors are already operating as small business owners so going through
the selection, procurement, integration and ongoing maintenance of an
EMR system is going to be both time consuming and expensive, much more
so than the $40K in incentives.

How many doctors are going to be a position to effectively wade
through the sea of EMR systems to find one that will integrate as
painlessly as possible with their clinical activities. By my judgment,
not that many. At the same time, what happens when a particular system
fails to meet expectations or fails outright; is the doctor paying
someone to be on the phone to work through the technical issues? How
much support is the doctor going to receive as just one small user of a

In my mind, a far better solution and use of the funds would be for
a centralized application commissioned by the federal government."

Stuart wrote in on the same thread, with an alternative suggestion:

Omitted in the "stimulus" bills is EHR using very secure, patient-carried EHR smart cards. They are well-proven, safe, easy to use, effective and in wide use in the EU. The French card system gets especially high marks.
But why ask our EU friends for a proven system when we can waste $20B screwing around for years with web-based systems that are so insecure that Americans will never agree to their use?

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Former Medscape and Journal of the American Medical Association Editor Dr. George Lundberg had this response to Dr. John Haughton's opinion piece on government Health IT spending. ("Stimulus Bill Offers Docs Big Incentives but Demands Effective Use.")

"There are many reasons why physicians in general (excluding
pathologists, radiologists, intensivists, anesthesiologists,large
multi-specialty groups) have not yet embraced healthcare information
technology. I refer interested readers to for Blake Lesselroth's unique take
on the barriers to full clinician adoption of HIT
and how to overcome
some of them.

 Dr. Robert Rowley's post  on his company's advertising based  electronic medical record system ("Freenomics and Healthcare IT') prompted this response from Scott Shreeve MD

I was an early critic of Practice Fusion when I first heard of their business model. However, I have come around for many of the reasons that Dr. Rowley and Dr. Kibbe mention. In fact, I would suspect that I am the only commenter on this section that has actually used the software in to take care of patients (Crossover Health personal health advisory service).  Getting a tool (an EMR) into the hands of providers (much better than paper) who can use it to improve patient care is a good thing. The fact that the tool comes with some branded messaging is tolerated because the price (free) and the ease of use is so compelling (installed in minutes).

In terms of software, I have found the features/functionality of the software to be sufficient for now, the look and feel to adequate, and the rate of ongoing development to be intriguing (several key updates over last several months). There are definitely some holes that need to be plugged, some functionality that needs to be added, but overall I find it from an EMR perspective to be "good enough".

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The anonymous eDoc had this to say about Merrill Goozner's report that Obama may be considering Emory's Ken Thorpe as a replacement for Tom Daschle: 

"As a member of the Emory community, I know Ken Thorpe as a mover and a shaker in the area of public health with strong ties to the CDC (his office is literally next door to the CDC). He has Washington experience as Deputy Assistant Secretary for Health Policy during the early years of the Clinton administration, and has testified before Congress a number of times on public health issues. There is no stronger advocate for public health and preventative care than Thorpe."

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Intermountain CIO Marc Probst had this response to John Halamka's post "Five reasons for Hope"

"As a CIO in an integrated delivery system I have had my eyes opened to see the wisdom and benefit of following proven informatics principles.  Although we may not be perfect, our organization has achieved some amazing results by using data and knowledge.  HIT will not save healthcare, but as an integral component with operations and organizational leadership, HIT can help in this transformation. 

Please let's not waste this
opportunity.  $20 billion properly spent will provide great
improvements.  $20 billion spent as it appears it may be spent will
just raise costs and make getting to where we need to be harder."

Tcoyote wrote in on the same post:

"Agree on the quality of the people.  Can you please tell us where the 200 thousand new jobs estimate you gave NPR for $20 billion in healthcare IT spending came from?"

Virginia Mason CEO Gary Kaplan, the author of "An Urgent Shared Commitment to Change," had this reply to commenters who asked a number of tough questions.

"It's very important for me to chime in about a few comments here on the role of a not-for-profit board. Let me be the first to say our board and executive team are very focused on fulfilling our mission and vision on behalf of our patients and our community. This is our primary fiduciary responsibility.

Also, profitability is not the goal, but a net margin is an essential ingredient. Our patients and community count on us to provide high-quality care; stay up-to-date with treatment and technology; employ smart, skilled medical professionals; and keep our doors open. We simply cannot do any of these things without diligence and prudence — and a net margin allows us to invest in our mission to improve the health and well being of the people we serve and our vision to be the quality leader in health care."


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