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Tag: Quality

QUALITY: The herniated disk story

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Medpundit has a pretty good explanation of the recent study about herniated disk surgery. Basically it works, but if you wait two years, then the results are about the same as non-surgical treatment—roughly 70% of people get better, and there doesn’t appear to be any long-term harm from delaying surgery. As I have someone very close to me with a current case of extreme back and leg pain from a herniated disk, I’m very interested in the study, and actually more inclined to suggest surgery (especially arthroscopic) sooner rather than later. But in this case the patient, doctor and other advisors are more in favor of waiting it out.

So on a global level it’s more cost-effective not to do the surgery. But on an individual level it probably lessens the pain—and the pain is close to unbearable, and if you have to put up with it for several months, then surgery is probably an option the patient will want.

Note that this is only the case for herniated disks and not lots of the other back issues for which surgery is probably ineffective–but still done at a very high rate.

The good news is that ten years after AHCPR (the forerunner to AHRQ) was decimated by daring to discuss back surgery, we’re getting studies out about this type of issue. Even, as Medpundit points out, it’s not a great study and it’s very, very hard to do studies about this type of intractable medical problem.

CODA: One slightly disquieting anecdote. I asked a local back specialist (non-surgeon) what the best way of doing surgery was (open or athroscopic). He said that the choice depended mostly on the training of the surgeon! Er…shouldn’t the surgeon be trained in the most advanced manner? (I expect those who know to chime in here)

TECH/HEALTH PLANS/QUALITY: Lonny Reisman, Active Health Management transcript

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Here’s the transcript from the podcast I did with Lonny Reisman, a week or so back. Really interesting stuff for those of you interested in the future of patient care management.

Matthew Holt: So welcome to another forecast here at The Health Care Blog. I’m Matthew Holt, and today very exciting that we’re talking with somebody’s who’s really been a technology pioneer and a medical pioneer in developing tools for active health management, and surprising enough, his company is called Active Health Management and I’m talking with Lonny Reisman. Lonny, how are you today?

Lonny Reisman: I’m well, thank you. How are you?

Matthew: We’re doing pretty well over here. One of the first fall and somewhat foggy days in San Francisco, but at least we’re not going to endure that terrible New York winter you’re going to have to go through [laughter]. Anyway, let me very briefly give a sense to, in essence, what your organization does. And there are a couple of things that people who may or may not necessarily have heard of Active Health Management should know. First off is that you are in the business of taking data, all kinds of different data about medical information about patients, putting it all together and spitting it back out and using it to try and help and inform and change medical decisions by those patients and physicians. And the second one is that you’ve been so successful at that, that last year, Aetna decided to write a very big check, $400 million to buy you, and now you’re part of that large insurance company. So with that it’s a very brief introduction. why don’t you say a little bit about what Active Health Management does, how you got started, and what kind of impact you’ve been having in the healthcare system and the part of it you’re specializing in.

Lonny: Sure. Why don’t I start with my background, which will give you a sense of how we have come to be here. I’m board-certified in internal medicine in cardiology, I’m a physician, and during the 1990s I was leading a bit of a dual existence. I was practicing clinical medicine here in New York City, had a fairly typical practice, but I also was consulting with a large human resources consulting firm, William M Mercer, and was charged with evaluating health plans around the United States, mostly from my perspective on the basis of quality but obviously the premiums and the costs associated for those health plans was a consideration as well. In considering what I was experiencing as a practitioner and what I saw as a consultant evaluating health plans, saw an opportunity to better take advantage of clinical data that were available in the managed care world which weren’t being fully exploited. So specifically as I visited health plans I saw that they had the capacity to collect drug information, laboratory results, information about procedures and diagnoses and basically had the thought that if in fact that information could be used to support doctors and patients in making decisions, that in fact we’d be able to raise the bar with regard to the level of clinical excellence being provided to patients all over the United States. So fundamentally, the observation that I made, which ended up being relevant to what I was experiencing as a practitioner was that to the extend that the care that was being provided by me and others was fragmented, specifically I didn’t necessarily know what other doctors were doing to my patients or for my patients, to the extent that all of the information about a patient or much of it could be aggregated at the health plan level, we decided to take advantage of that.

The other component of Active Health, which again sort of derives from my own experience and perhaps insecurity, is that I recognized early on in my career that it’s very, very difficult to keep up. So there are thousands of articles, relevant articles, published yearly and the issue is how does one not only read and assimilate and remember those articles, but how does a physician relate the information in an article that they’ve read to the particulars that relate to a patient sitting in front of that doctor during the course of an office visit.

Matthew: They can’t is basically the answer, correct?

Lonny: Can’t do it, right, exactly. It’s just too much. So the basic notion and this is as true today as it was in 1998 when we started the company was if in fact you could provide the treating physician with more clinical data on the member than they have access to—again the patients frequently see multiple doctors—and then if you could expose those data to thousands of clinical rules that represent incontrovertible standards of clinical excellence and use technology to highlight discrepancies between what was actually happening to the patient as manifested in their data as opposed to what should be happening as displayed in the literature, we in fact could pinpoint changes that needed to be applied to individual patients by doctors that related to everything from preventive care to diagnostic services to therapeutics to follow-up, and basically started the company with the notion that we would have those data, have a technology that would analyze those data and communicate first with doctors and then over the years with patients in order to again introduce this level of consistency to the healthcare system. And from there we’ve evolved into other sort of disease management like capabilities which I’ll elaborate on. But the fundamental premise behind the company is what I’ve articulated.

Continue reading…

QUALITY/PHYSICIANS: OBGYNs are scientists, scientists I tell you

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Interesting long article in the New Yorker by Atul Gawande about How childbirth went industrial. Briefly it’s about how we stopped using all kinds of techniques for getting kids out that required a lot of skill because we started measuring the results on a universal scale. And the result is a lot, lot more C-Sections. In the UK they don’t use so many C-Sections, so I asked a recently retired British OBGYN I know rather well for his opinion. Here’s what my dad has to say about the article:
It shows yet again that the worst way to deliver a baby is by C/S following a long failed labour. If you could guarantee a normal labour then that would probably be best for mother and baby, at least at the time. This doesn’t allow for the increase in prolapse and Sphincter Weakness Incontinence (Stress incontinence)in later life. It also shows that female doctors are the poorest judge of how they should deliver!

PODCAST/TECH/QUALITY: Don Kemper podcast

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Here’s the transcript from the recent podcast with Don Kemper. Interesting stuff from a real pioneer.

Matthew Holt: So welcome to another THCB podcast. Today we’re very lucky to have Don Kemper, who is the President, CEO and certainly the joint founder of Healthwise, and also, although he’d be too bashful to say it, probably the main individual in America who has been behind the information therapy movement, which now has its own separate Center for Information Therapy, the one that Don I believe founded. So Don, welcome to The Health Care Blog.

Don Kemper: Thank you, Matthew. I’m pleased to be here. You’re very kind.

Matthew: Those of you who’ve been reading the blog have noticed that over the years I’ve both been to a couple of information therapy conferences, partly because they’re held in Park City, Utah, which is a beautiful and lovely place to go where I have friends (even though I left most of my left knee there in the trees some years ago and am just steadily getting it put back together) but also because I’m pretty convinced and a firm believer that the concept of information therapy is one that is going to be of significant importance no matter what happens in the future health care reform debate. And it’s something that, as people are developing new and different forms of information technology to support those patients and physicians, information therapy is going to be an important part of that.

So, with that, Don, why don’t you take us back to the early days. Tell us a little about what Healthwise does, how that started, how the Healthwise Handbook got going, and then perhaps just tell us a bit about Information therapy to start off with.

Don: It all started, Matthew, when I was a lieutenant in the U.S. Public Health Service back in 1970, and I heard a talk by the assistant secretary for health education and welfare in those days, Vern Wilson. He said the greatest untapped resource in health care is the consumer. And that was at a time when nobody was thinking about what a patient could do for themselves, and I though, "That’s a good idea." I had a little baby at home and somebody had given me a Dr. Spock, and I thought, "Well, what the world needs is a Dr. Spock for the whole family," and began to try to get the federal government to write a basic self-care book that they could give to every family in America.

That idea didn’t get very far in my two year tenure with the Public Health Service, but I held onto the idea, and a few years later landed in Boise, Idaho with a pretty open book on what I could do, and we started to develop that idea. And so Healthwise was formed in 1975. We published the first copy of the Healthwise Handbook through Doubleday in 1976. And we have been growing toward the same mission that we established right then, which was to help people make better health decisions.

So over the last 31 years, we have been continually looking for ways to enrich this mission of helping people make better health decisions by giving them books, giving them workshops, giving them good web based information, and now finding ways to prescribe information to meet their specific needs in every moment of care.

Do you want to know more?

Matthew: Sure. Let me ask you some more specific questions. Healthwise is founded as a non-profit, and I guess that perhaps the first time I ran into Healthwise was back in early ’90s. Somewhere around that time you convinced the folks at Kaiser Permanente to give that book to every member, I believe. Maybe that was just Northern California. The thing that I as a health care economist policy guy that I sort of sat up and took a notice, was that actually, they showed that emergency room visits declined dramatically amongst people who had these books.

So tell me a little bit about how that evolved, and how, apart from being sort of a worthy organization giving out information to people, Healthwise started evolving into being a place where the health care system realized it could start having a positive impact on savings, as well as outcomes.

Continue reading…

TECH/QUALITY/THE INDUSTRY/HOSPTIALS: Transforming patient care, with UPDATE

Cisco has produced a video on transforming patient care which includes discussion from “Crossing the Chasm” author Geoffrey Moore, Jeff Rideout, Cisco’s head honcho Medical Director, several hospitals execs, and a cameo from me. Go to this site to register and take a look. I’ll also be answering questions in the discussion segment for the next week.

UPDATE: Now I’ve seen it. So here’s my take! I may look wooden and my answers are sometimes to questions that I wasn’t asked (oh, the  magic of editing!), but you only have to put up with literally a minute or two of me. The rest of the session is really interesting–everyone else is much more eloquent than I am and the technology featured-especially the instant translation services at San Mateo County hospital–is very interesting. Yes it’s product placement for Cisco, but well worth watching nontheless. Interesting that video-conferencing and PACS are what the hospital people view as the important changes, while I was talking mostly about IP telephony, automating vital signs recording (telelmetry) and location tracking. I must still be a futurist!

BLOGS/TECH/QUALITY: HealthTrain, the Open Healthcare Manifesto

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Yesterday saw the official launch of HealthTrain, the Open Healthcare Manifesto. Dmitriy Kruglyak has been working on this for some time with a large group of collaborators, and I have joined several others to sign on. The manifesto lays down some principles for how the new media of social networks and open access to publishing technology (e.g. blogging) ought to be used within health care. It’s an interesting and common sense filled set of guidelines which I hope will give the concept of “open healthcare” some visibility and some direction.

So instead of perusing my blog today, I hope that instead you’ll read the manifesto (It’s only about 12 pages).

QUALITY: Does DM save money? The old chestnut rears its ugly head

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Poor Chris Selecky of Lifemasters. I had a brief chat with her at a DM conference in August and she was heading to the beach (happily) after selling the company to Healthways. Or so she thought. But then that merger fell apart, mainly because LifeMasters was making less money on a contract than it thought it would.

Now things have gotten much worse. As reported by Vince Kuratis at Better Health Technologies. Selecky announced that Lifemasters has pulled out of its Medicare Health Support project in Oklahoma.

A central factor in their decision was the unexpected medical needs of the Oklahoma project population. These are "really, really sick patients. It takes a lot more to get them under control." She explained that the Oklahoma population included many patients with five or more comorbidities. She pointed out that the rural nature of the population led to unexpected results. Lifemasters found that the population was significantly medically underserved — people had not been receiving appropriate medical care in the past. Arranging for needed care would lead to higher medical costs for Medicare and would prevent Lifemasters from achieving required cost savings.

The entire DM industry is hanging on Medicare Health Support and has really been talking it up. More importantly an even bigger industry is sitting behind MHS expecting that Medicare will start paying for in home monitoring as a consequence. Remember that Forrester thinks that’s going to be a $35bn market in less than 10 years, with Medicare paying most of the freight.

But several studies over the years have suggested that DM improves quality but has found it hard to prove that it saves much money. The response of the DM industry has been, to quote Al Lewis, “let’s go surfing”. in other words, do it anyway and let the academics worry about the savings.  And they’ve convinced some health plans that this works.

But to get Medicare, the big kahuna to pay for DM , they’re going to have to persuade the taxpayers’ agent that spending money on DM will reduce the amount spent elsewhere in the system. If the answer is that we’re not spending enough on health care, and we should spend more, and DM will help us do that, then it’s hard to imagine that DM will get the positive response it’s looking for in a world in which everyone’s budget in Medicare is under pressure.

(Hat tip to the ever wonderful Jane Sarasohn Kahn for pointing this one out to me!)

QUALITY/TECH/PODCAST: Interview with Don Kemper, CEO of Healthwise

Don Kemper from HealthWise essentially invented the concept of information therapy–the idea that every contact between patients and the medical system should come with an actual prescription for information. I think it’s an incredibly important concept, so I talked with Don in this podcast
about how it got started and where we are, as more and more technology becomes available. (Trascript available in a few days)

TECH: The best treatments for heart disease?

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I’d never heard of EECP as a treatment for heart disease. Apparently it works, according to this UCSF analysis.  But Debra Braverman’s letter to the NY Times says it all (other than mistaking the drug industry for the medical device business):

A full course of EECP costs Medicare a fraction of one stenting procedure and offers physicians and hospitals very little and the pharmaceutical industry nothing.  EECP does, however, offer patients substantial relief and improvement in quality of life without risk of heart attacks or death, unlike the drug-coated stents in widespread use, despite the little scientific evidence of long-term benefits.

Meanwhile does anyone know if Dean Ornish’s program is routinely reimbursed by Medicare? Because if the tax payer is buying stents that dont really work as advertised, perhaps we should also be funding alternatives.

Meanwhile, apparently the latest wisdom is that angioplasty is essential within a few hours of a heart attack. And where did this inspired piece of medical wisdom come from? It was developed in the socialized health care havens of Denmark and Sweden. But we’re told that patients there are left to die; apparently not necessarily so!

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