A long and detailed story about Steve Case and Revolution Health is up on Bloomberg.com. It was kind of weird, I vaguely thought I recognized some stuff in it, then found myself being quoted. Then I remembered that I’d been interviewed about it ages ago by the author Bob Van Voris. If I remember rightly I was mostly grouchy about the name. I mean, they may turn out to be good businesses, but is what he’s doing Revolutionary?
TECH: LinuxWorld – Healthcare Day
For those of you who believe in Open Source at LinuxWorld in San Francisco on Aug 15 there is a Healthcare Day. Sometime THCB commenter and contributor Fred Trotter is on at 2pm running a panel on innovation.
HEALTH PLANS/PHYSICIANS/TECH:Health care, the way it should be (or How to stop worrying and learn to love the bomb), by Pat Salber
Pat Salber writes The Doctor Weighs In. She is a doc, an ex-med director at California blue shield, and a Kaiser Permanente member. And she loves them. This is why, and it’s quite an advertorial for Kaiser and an indictment of how everyone else does it. So if this becomes the standard, and people find out about it (and with $80m of advertising budget a year behind it, they will find out) can the rest of the US system compete?
Health care, the way it should be or (How to stop worrying and learn to love the bomb)
I have to tell you again about what great health care I get from Kaiser Permanente Northern Cal. 
(Yeah, I know, they screwed up on the transplant service). But, they are doing a lot of the things we, the wonks, have been hollering about for years. Read this.
Sunday night I noticed new “floaters” in the right visual field of my right eye. They were different from the run of the mill floaters – those little dark circles — most of us have. These were like long lines and they only moved on the right side of the visual field. The next day, I started having sparkling lights, again in the right visual field. Now, even an emergency physician knows this could indicate a retinal detachment (serious indeed). So mid-afternoon, when I had convinced myself it would be stupid to miss my own diagnosis, I called KP. The woman on the phone in the opthalmology department clearly had been trained. When I talked about the sparkles, she put me on hold and got a nurse.
The nurse tried her best to get me in the same day. She had an appointment available, but being rush hour, there was no way I could make it. She carefully went over the symptoms of retinal detachment and compared them to what I was experiencing. Together we decided it was OK to wait until the next am for an appointment. She carefully explained that if certain symptoms occurred (e.g., a sensation of a curtain coming down over the eye), that I needed to go to the emergency department right away as that could indicate a retinal detachment.
The next day (today) I showed up at the opthalmology department. The receipt I was given for my $15 co-pay listed the dates I had had all of my age/gender specific preventive services and the dates the next ones were due.
There was no wait to see the doctor. I was put in an eye exam room and saw a nurse right away. She explained everything she was going to do. She anesthetized my corneas, she tested my vision (with glasses and with pinholes), she used the slit lamp to look at the corneal surface, and then she put in drops to dilate my eyes.
After about 15 minutes (waiting for the eyes to dilate), Dr. Prusiner, chief of the department came in to see me (he is the brother of Stan Prusiner, the Nobel Prize winner who discovered prions). He did a very thorough exam of both retinas using a variety of techniques. He explained that I had a vitreous detachment (annoying, but otherwise, no big deal). He showed me a color picture of an eye with a vitreous detachment. He answered all of my questions. He did not seem rushed (because the nurse had done a lot of the early work for him).
We were finished, he gave me a 4 x 6 piece of paper with his name, his photo and the URL of his home page. Here’s the link so you can see how nice it is. This is, I think, the new KP Connect. It also showed all of the stuff (by major categories) that he had on his home page. He wrote down the diagnosis “vitreous detachment” on the paper and drew an arrow from it to name of the link where I would find the information he had chosen for his patients to read about this condition. He urged me to read it. I went on the site, found the condition, and, lo and behold, everything he told me was what was on the site.
He then told me, in detail, what symptoms would require me to call or go to the ER right away. But he assured me that the symptoms represented complications highly unlikely to occur.
By the way, he said as I was leaving. Be sure to make an appointment with the optometrist. I think we can improve the correction of your left eye.
I challenge you to find one single thing you would want that I didn’t get. This is the way health care should be.
TECH: Is Continua the work of the devil
You and I might have thought that Continua was a sensible business led approach to get medical devices and remote monitoring systems operating together. But looking at this photo of Intel’s Dave Whitlinger who runs the Continua Health Alliance over at Tim Gee’s blog, maybe more sinister forces from far below are at work?
(Yes, I’m kidding)
TECH/QUALITY/PHYSICIANS: Healthcare and The Long Tail – Searching for help when you’re on the wrong-end of the curve by Jim Walker
Two things have got my attention recently. The first is the concept of the long tail in medicine, which I’ve thought about alot since my fiancee got an odd condition (shortness of breath) that didn’t match any of the symptoms the text books said were the symptoms of the usual shortness of breath. She endured several doctors diagnoses of diseases that went from the wrong to the ridiculous (panic attacks that lasted for weeks?). After much, much digging around on the web she found a patient testimonial from someone who had long term shortness of breath and related it to caffeine. Yup, drinking coffee was causing the problem. But because it was a rare symptom of what’s not normally a medical problem she had to go through the annoyance (and worry) of being wrongly diagnosed and put on drugs she didn’t need, and now she can’t drink coffee or eat chocolate—her life must barely be worth living!
The second is a plethora of people writing to me telling me about XYZ product that is the greatest since sliced bread and would I please praise it on THCB. One such person is Jim Walker from new physician social networking site MyMedwork. Usually when I request that said person writes a piece putting their service in context I get self-serving marketing jargon, and when I request that they instead really write a general interest piece I never hear from them again. In contrast Jim wrote an excellent explanation of the Long Tail in health care. Here it is:
Healthcare and The Long Tail
My neighbor brought her son to the doctor this summer for a rash that
wouldn’t go away. “The doctor had never seen anything like it,” she
explained. “In fact, he brought in the other doctors to take a look at
it, and none of them had ever seen it either.” Now I don’t know about
you, but listening to her reminded me of my worst medical nightmare of
things I don’t ever want to hear from my doctor: “Excuse me, do you
mind if I bring in some of the residents? We’ve never seen a case like
yours before.”
In a recent THCB post,
author Maggie Mahar writes that “Ambiguity haunts medical care”. She
goes on to quote Dr. Atul Gawand – “Uncertainty is the core predicament
of medicine . . . the thing that makes being a patient so wrenching,
being a doctor so difficult and being part of a society that pays the
bills so wrenching."
It’s important to note that for a great
many cases, ambiguity is not really an issue. This is because the
distribution of medical ailments follows a curve very similar to Chris
Anderson’s “Long Tail”,
with a great many common “blockbuster” ailments stacked up high on the
left-hand side of the curve. For those not familiar with the Long Tail,
Anderson describes how Amazon, Netflix, and other online retailers sell
lots of the usual blockbusters, but actually derive more total volume
from 100s of thousands of niche products. In healthcare, it is the
left side of this distribution curve which inspires (for better or
worse) Wal-Mart, Target, and others to offer “Doc In A Box” services –
Allergies, Bladder Infections, Bronchitis, Ear Infections, Pink Eye,
Sinus Infections, and a full battery of vaccines – all served up for a
fixed price while you wait.
On the right hand end of the
curve though, the NIH Office of Rare Disease classifies over 6,000
conditions, each afflicting fewer than 200,000 Americans. Along this
part of the curve, things do indeed get very ambiguous in a hurry –
both for patients and physicians. Specialization is a response to this
range of ailments (“nichefication” in Anderson’s terms), and brings
physicians repeated cases of a particular nature – giving them the
confidence that they can routinely diagnose and treat a high percentage
of these patients. However, even within a particular specialty area,
cases will naturally follow a distribution curve from typical to
atypical. Unto themselves – atypical cases are just that – one of a
kind aberrations that force physicians to go outside their typical
“comfort zone” of diagnosis and treatment. For each individual
physician, these atypical cases feel like the exception rather than the
rule. What the Long Tail suggests though, is that taken in their
entirety, these rare cases actually compromise a large percentage of
all medical cases. In fact, over 25 million Americans suffer from a
“rare” condition.
This is problematic, because in general,
physicians – and the healthcare system as a whole – are not well
prepared for dealing with the many and inevitable rare cases. In fact, statistics show
that the median time to diagnosis of a rare condition is six months,
and the average is almost three years! When faced with an atypical
case, most physicians will begin to consult the literature, and/or
confer with their colleagues. Ironically, it is at this moment that the
Long Tail shows up again in a quite surprising and often detrimental
fashion. This is because recent studies in social and information
analysis reveal that our network of professional contacts and
information sources follows the same type of distribution curve. In
other words – we all generally tend to connect with the same 15 or 20
trusted colleagues on a regular basis, and we all gather our
information from a limited stream of trusted sources. Beyond this
trusted core lies an entire world of other people and sources we rarely
connect with, if at all – our own social and information “long tail”.
Generally, using a network of trusted sources (while tuning out most
everything else) is actually very efficient at handling a majority of
our day to day needs. For the atypical situation though, just when we
really need to break out of our habitual way of doing things – our
trusted sources generally don’t deliver. They’ve all been drinking from
the same information punch bowl.
So, we have to head out to
the right-hand side of the curve – and begin finding and evaluating
people and sources we don’t really know. For a student or researcher,
this type of research can become a time consuming, challenging, but
often rewarding journey. But, for a patient and physician confronted
with a puzzling and life threatening illness, the stakes are much
higher and time is at a premium. In today’s system, the physician often
must address this dilemma by referring the patient to some other
specialist – with the hope that maybe they will have the knowledge or
connections to form a proper diagnosis and treatment protocol in a
timely manner. The patient of course, must continue to move from
specialist to specialist, their rare case still in hand.
Not
surprisingly, the Internet has proved both boon and bane in this
situation. Patients and their families are using the Web to dig into
the latest medical research. However, matching a worried patient or
family member against 1,706,532 Google results is usually a
prescription for both confusion and high blood pressure.
On
a more encouraging note, patients stuck along the right-side of the
curve with a “niche disease” are using the extraordinary reach of the
Web to discover that they are not so atypical after all. It’s probably
no surprise to THCB readers that patients are banding together around
wikis, chat rooms, blogs and social networks to offer each other
information, empathy, and inspiration. (This is not so different in
network theory terms from when fans of a niche band find each other on
MySpace). Some of these disease state patient networks are sponsored by pharma marketing, while others are grass-roots efforts, usually led by a parent or family member related to one of the patients.
Physicians
are also turning online in large numbers. Manhattan Research reports
that more than 600,000 physicians are using search engines to find
medical information. Are they searching about how to treat their
day-to-day typical cases? Very unlikely. Chances are, they are
researching an atypical case. However, if two physicians search – for
example, on “phylloides tumors” at Google they each receive the same
list – but have no easy context by which to evaluate the 13,600 +
search results!
Social network software may be one way to
help physicians overcome this “search result overload”, allowing them
to move faster and more confidently outside their circle of trusted
sources and down the long tail, especially when faced with a “rare”
condition (which as we’ve noted – is not such a rare occurrence in the
aggregate). For example, within MyMedwork
, search priorities start with the individual physician’s network of
trusted colleagues and work outward from there. In other words – each
physician gets a totally unique list of search results based on who in
their own extended network is likely to possess useful information.
Because the medical community is so small, it turns out that physicians
are usually quite closely linked to any given article or study, they
are just not aware of the connection. By viewing the social network
connection within their search results – they are then in a position to
more accurately judge the quality of the information – either by
checking with the in-between link (i.e. “Hi Dr. Jones, I notice you’re
connected to Dr. Watson – what do you think of his study on phylloides
tumors?”) – or by contacting the physician directly (i.e. “Hi Dr.
Watson, I see you went to medical school with my colleague Dr. Jones,
do you mind if I ask you a few questions about your study?).
The
implications of The Long Tail and social network analysis for
healthcare are just beginning to be explored and understood. It is
already clear though, that as the entire healthcare field continues to
undergo dramatic change, and “atypical” rare disease states become ever
more typical, ambiguity and uncertainty will continue to impact medical
decision making. In this environment, the need to develop richer and
more varied sources of information, and the value of far-reaching,
online social trust networks will become increasingly apparent for
patients and healthcare practitioners alike.
YOU’VE GOT MAIL
Or we’ve got mail. Or we’ve all got mail. Or something …
After much late night heroism by THCB’s trusty (and highly
sensitive) tech staff, the THCB email list is up and running. If you’d
like to get a quick email in your inbox with a rundown of new posts –
with news flashes for important stories – you can sign up here.
If you subscribed to the list in its earlier incarnation, there’s no need to do so again.
TECH/HEALTH PLANS: JSK on Health IT After the Employer-Sponsored Health Era
JSK is up on iHealthbeat about Health IT After the Employer-Sponsored Health Era.
Go read.
TECH: Cerner stock heading up again?
Following almost a 30% fall from its heights late last year, Cerner’s stock seems to be on the move again. Its numbers had lower profits than the analysts guessed but higher revenue, and then they raised guidance for profits and revenue for Q3. After so many months of bad news the stock was up over 14% on Friday. It’s still 20% of its all time high, but the UK may start delivering (as in cash—as no one there’s got paid yet) and sales in the US still seem to be chunking away. Perhaps the people who piled in today know something?
TECH: Why we love HISTalk
Every so often Mr HIStalk reminds me why he’s the best blogger in Healthcare IT and possibly far beyond:
Kaiser Permanente’s Northwest region president resigns, seemingly because of computer problems that hurt earnings. "Kaiser launched a computer system to govern billing for its high-deductible health plan and for Medicare enrollees, but halted billing for both products in June 2005 due to a technical glitch." If you had all the money that various tentacles of Kaiser have spent on botched IT projects, you could be up there on the dais with Bill Gates and Warren Buffett, giving it away to the less fortunate, which would be just about everyone.
TECH/POLICY: All Oprah’s fault
You just thought she just plugged crappy books. But no, apparently the medical arms race is all Oprah’s fault!
TECH: IOM reccomends ePrescribing by 2010
The IOM is out with another report on medication errors in which it recommends the use of ePrescribing for all scripts by 2010. And it’s made it into the news, at least into the AP Headlines where the tale is told that drug errors hurt 1.5 million.
Perhaps someone should let whoever took the ePrescribing mandate out of the final language in the MMA in 2003 (after it made it through in the House version of the bill) know that they’re killing people and costing payers a fortune. But then again I wouldn’t want to point fingers at anyone in particular.
