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Tag: Paul Levy

What Would Issac Asimov Do?

The Three Laws of Robotics  are a set of rules devised by the science fiction author Isaac Asimov. The rules were introduced in his 1942 short story “Runaround“, although they had been foreshadowed in a few earlier stories. The Three Laws, quoted as being from the “Handbook of Robotics, 56th Edition, 2058 A.D.”, are:

  1. A robot may not injure a human being or, through inaction, allow a human being to come to harm.
  2. A robot must obey the orders given it by human beings except where such orders would conflict with the First Law.
  3. A robot must protect its own existence as long as such protection does not conflict with the First or Second Laws.

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A Home for Orphan Wearables

How many people do you know who’ve bought a Fitbit or similar device to track their exercise patterns–who have then let the whole venture lapse? The Fitbit now resides comfortably and peacefully in their drawer!

Well, there’s a useful way to recycle them, offered by Tufts University professor Lisa Gulatieri. As noted in this article:

Gualtieri started RecycleHealth in April with the goal of giving unused activity trackers — mostly Fitbits so far, but RecycleHealth accepts all devices — a second life. The company has collected about 20 devices so far and has plans to donate them to the Montachusett YMCA in Fitchburg, Massachusetts, where they will be used to help older and lower income individuals have access to devices, as well as to learn about how those populations interact with activity trackers.

Check out the Facebook page for stories on how the idea is spreading, plus more information, including how to get free mailing labels.

 Paul Levy is the former CEO of BIDMC and blogs at Not Running a Hospital, where an earlier version of this post appeared. 

Listen to People you don’t Like!

Agha Khan 2

The Aga Khan delivered the Samuel L. and Elizabeth Jodidi Lecture at Harvard University yesterday.  He has been a strong proponent of pluralism in the world and has devoted billions of dollars in resources from the Aka Khan Development Network to enhancing education, health care , culture, and economic development in the world’s poorest countries in Asia, Africa, and the Middle East. The full text is here, but I offer a pertinent excerpt, with lessons about an increasingly divisive level of political debate in the US and elsewhere:

In looking back to my Harvard days (in the 1950s), I recall how a powerful sense of technological promise was in the air — a faith that human invention would continue its ever-accelerating conquest of time and space. I recall too, how this confidence was accompanied by what was described as a “revolution of rising expectations” and the fall of colonial empires. And of course, this trend seemed to culminate some years later with the end of the Cold War and the “new world order” that it promised.

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The Network You May Not Like

Paul Levy 1This has been my week to discuss networks (Internet and electricity), but I would be remiss if I didn’t spend a few moments on the networks that are most likely to rob us of personal choice and increase costs: Health care networks.

Wait, didn’t President Obama promise us that the new health care law would preserve choice for us? Didn’t he promise us lower costs?  Well, in spite of much good that the law accomplished in terms of providing access to health insurance, these are two areas that have gone awry. For a variety of reasons–most of which have little to do with providing you with better care–the hospital world has grown more centralized. It’s done so to reduce competition and get better rates from insurance companies. It’s done so to create larger risk pools of patients under the “rate reform” that incorporates more bundled and capitated payments. It’s done so to keep you as a captive customer for your health care needs. It’s been aided and abetted by electronic health record companies that find a mutual advantage with their hospital colleagues in minimizing the ability of your EHR to be easily transferable to other health systems. As I’ve noted, we truly have created “business cost structures in search of revenue streams,” rather than a vibrantly competitive system focused on increasing quality and satisfaction and lowering costs.

Many people don’t even know they are part of a health care network until they discover its limitations. It might be that the insurance product they bought has different rates for in-network doctors and facilities from out-of-network doctors and facilities. It might be that their primary care physician subtly or not so subtly directs them to specialists in his or her network because they share in the financial reward of eliminating “leakage” to other systems. It might be that they discover that an MRI or other image taken in one health system cannot be transferred electronically to another, perhaps necessitating a second image and its accompanying cost.

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Why Watson May Not Be Quite the Great Civilizational Advance IBM Says It Is

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The joke goes like this:

Sherlock Holmes and Dr. Watson decide to go on a camping trip. After dinner and a bottle of wine, they lay down for the night, and go to sleep.

Some hours later, Holmes awoke and nudged his faithful friend.
“Watson, look up at the sky and tell me what you see.”

Watson replied, “I see millions of stars.”

“What does that tell you?”

Watson pondered for a minute.

“Astronomically, it tells me that there are millions of galaxies and potentially billions of planets.”

“Astrologically, I observe that Saturn is in Leo.”

“Horologically, I deduce that the time is approximately a quarter past three.”

“Theologically, I can see that God is all powerful and that we are small and insignificant.”

“Meteorologically, I suspect that we will have a beautiful day tomorrow.”

“What does it tell you, Holmes?”

Holmes was silent for a minute, then spoke: “Watson, you idiot. Someone has stolen our tent!”

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Shared Baselines as a Guide to Protocols

Paul Levy 1There have been some interesting and important discussions flying across the web in recent days on the issue of protocols in helping to reduce variation and reduce the incidence of harm to patients.  My mistake in the debate was assuming that medical leaders would be reasonable about how protocols should and should not be used.

A doctor friend, highly committed to patient safety, notes:

My point about the protocols is that I have been chastised for not following them in situations where it was blatantly obvious that they did not apply. (“The protocol is there for a reason.”)

The chastisement comes not from hospital administrators, but from clinician leaders in the doctor’s own department:

We just got another email scolding us for not following the “colorectal pathway” sufficiently. One of the provisions of that pathway, for example, is strict limitation of iv fluids, sometimes difficult to “comply” when patients are severely dehydrated from their bowel preps, particularly the elderly.

The initial goals were to decrease opiate use and decrease PACU LOS, both worthy goals, but we’re all annoyed at being beaten over the head with them and getting our hands slapped if we deviate, even with good reason.

It’s ironic that on the one hand we are extolling the virtues of gene-based individualized therapies, but on the other hand we are trying to pigeon-hole every patient into a standardized protocol.

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The Data Are Wrong. Our Patients Are Sicker!!!

People in health care don’t like it when numbers emerge that are uncomfortable.  Take these, issued today by the Massachusetts Health Policy Commission in its latest report on the drivers of the high cost of care in our state.

Variation, particularly when not correlated to quality of outcome, is particularly troublesome for some incumbents.  Academic medical centers often have their answer, but as the HPC explains, it doesn’t hold water:

One oft-cited theory for the cause of this variation is that certain types of hospitals, such as those that teach physician residents and fellows, must incur additional expenses to support their mission. However, the difference in median expenses per discharge between teaching hospitals and all hospitals ($1,030) was less than the difference between individual teaching hospitals ($3,107 between the 75th percentile and 25th percentile teaching hospitals). Moreover, there were a number of teaching hospitals that incurred fewer expenses per discharge than the statewide all-hospital median of approximately $9,000 per discharge.

So perhaps the high cost ones will now revert to the usual squawking: “This isn’t fair. The data are wrong.  Our patients are sicker.”

Except here, the data are the best that could be available–all the claims for all the hospitals and all the payers in the state–even adjusted for wages.  And the acuity of patients across the spectrum of academic medical centers does not vary widely–but, just in case, the numbers are case-mix adjusted.

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An Epic Voyage

Several months ago, I wrote a blog post comparing customers’ experience with Epic with the Stockholm Syndrome.

I reminded people of the syndrome:

Stockholm syndrome, or capture-bonding, is a psychological phenomenon in which hostages express empathy and have positive feelings towards their captors, sometimes to the point of defending them. These feelings are generally considered irrational in light of the danger or risk endured by the victims, who essentially mistake a lack of abuse from their captors for an act of kindness.

Then, I noted:

What is striking about this company is the degree to which the CEO has made it clear that she is not interested in providing the capability for her system to be integrated into other medical record systems.  The company also “owns” its clients in that it determines when system upgrades are necessary and when changes in functionality will be introduced.  And yet, large hospitals sign up for the system, rationalizing that it is the best.

I quoted an article by Kenneth Mandl and Zak Kohane in the New England Journal of Medicine:

We believe that EHR vendors propagate the myth that health IT is qualitatively different from industrial and consumer products in order to protect their prices and market share and block new entrants. In reality, diverse functionality needn’t reside within single EHR systems, and there’s a clear path toward better, safer, cheaper, and nimbler tools for managing health care’s complex tasks.

A year ago, Forbes noted, “By next year 40% of the U.S. population–127 million patients–will have their medical information stored in an Epic digital record.”

It is this last point that we must now address, as I hear from my colleagues in the EHR world—no, not Epic’s competitors– that Epic engages in practices that well help cement that market share for years to come.

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The Pain Index

A recent report by the New York Times contained an excellent graphic showing the current percentage of uninsured people in each state.  The range is from a high of 24.6% in Texas to a low of 4.4% in Massachusetts.I have combined this rate with the most recently reported CDC rate of obesity in each state to create what I call The Pain Index.  It is a simple sum of the two numbers. 

The theory behind the total is that obesity is a rough guide for the level of unhealthiness in the population.  My hypothesis is that, when insurance is made available to people, they will use it, roughly in proportion to the degree they are unhealthy.

Yes, I know this is a crude metric, but I think it will be a relatively good predictor of the rate of increase in health care costs in each state over the coming years.  This will show up in the insurance premium rates offered in the health care exchanges and will also affect the need for state appropriations to pay for newly eligible Medicaid subscribers.

States with a Pain Index in the top decile are: Texas, South Carolina, Louisiana, Mississippi, and Arkansas.  Others with scores over 45 are Nevada, Florida, New Mexico, Georgia, Alaska, Oklahoma, North Carolina, Kentucky, Alabama, and West Virginia.

My advice to policy-makers:  Get ready!  My advice to health care CEOs:  This would be a really good time to focus on quality, safety, and front-line driven process improvement as the most effective way to reduce your costs and improve efficiency.

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How to Stop a Future Cancer Epidemic

The theory of preventative care, including inoculations, is that we spend a little money now to offset big expenses later in life.  But sometimes behavioral friction keeps this from happening, even when the technologies and approaches are proven.  We are witnessing such a failure right now with regard to Human Papilloma Virus (HPV).

Here’s the story, from MGH’s James Michaelson, PH.D., arguably one of the most thoughtful, trustworthy, and sensible researchers in the field of analysis of cancer survival.  Jim and his team develop sophisticated mathematical methods for predicting the risk of local, regional, and distant recurrence.  He says:

There are a couple of good papers about Human Papilloma Virus (HPV), and the coming epidemic (yes, an overused term, but truly applicable here) of head and neck cancer. As Chaturvedi et al say in a recent paper: “If recent incidence trends continue, the annual number of HPV-positive oropharyngeal cancers is expected to surpass the annual number of cervical cancers by the year 2020.”

I get to see this problem from two angles: From my work as the the manager of the MGH/MEEI Head and Neck Cancer Database, and  from my experiments in using computer telephone messages to get patients in for preventive health services, such as the fabulous HPV Vaccines: Cervarix (from GlaxoSmithKline) and Gardasil (from Merck). The vaccines are incredibly underutilized. Only about 1% of eligible boys and only 50% of eligible girls get one shot.  Only about 25% of girls get all three shots.

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