Search results for ‘THCB Gang

HIMSSanity Preview


It’s time for my favorite busman’s holiday of the year, the HIMSS global conference, held this year in the cultural wasteland of Orlando, Florida (which given its cultural competition is Las Vegas is saying something!). But there are only 2 places in the US with enough hotel rooms to deal with 45,000 hungry and thirsty Health IT people and they’re it!

I think this is my 22nd HIMSS. First was in 1994, but I missed one when I was sick in the 90s, and 2-3 when I was taking a long post-dotcom bust sabbatical in the early 00s. Suffice to say I know my way around and have a decent party invite list. But this year is different. I’m both a HIMSS quasi-staff member, since Health 2.0 is now a HIMSS brand doing VentureConnect this year, AND I’m a vendor client with a booth for my advisory service program, which will be featuring several of our clients and a couple of special guests (or clients in waiting?).

So who will you see in booth #5594 at HIMSS?

First up the incomparable Jessica DaMassa will be interviewing all and sundry for her WTF Health specials. I’ll be stealing her camera for some THCB spotlights and we’ll also be recording segments for our forthcoming podcast HardCore Health. Then there’ll be a whole gang of super exciting tech companies and in no particular order with my (and not their quick summaries) here’s who they are:

  • SurveyorHealth — Super clever AI that optimizes medication management by fixing complex drug regimens, saving $$ and lives
  • BlueStream Health — Revolutionary, always-on telehealth network
  • CaptureProof — A visual medical record changing the game in ortho, derm, + + +
  • SAFE App — an STD lab test system hidden behind the coolest consumer app that will really help bring transparency to “dating” by sharing your STD status
  • Happego — Have you heard of psychological priming to create behavior change? This app does it at scale with no effort on the users part. Mindfulness made easy!
  • Ouchie – An app and community to help patients track, manage & beat chronic pain
  • Dot.Health — The home of the “.health” domain extension (come get yours!)
  • — Putting the power of data science into the hands of clinicians and researchers
  • InPharmD – “Siri for pharmacists,” bringing the most important lit searches to the end user
  • Visolyr — Interoperability-as-a-service for health care organizations

4 of these companies will be demoing at any one given time. Plus we will have the most fun furniture in the exhibit hall, and the only booth featuring a Unicorn Straddling during interviews. Come see us at booth 5594!

If you want to know more, the ringmaster is Zoya Khan.

Matthew is the Founder of The Health Care Blog and is the President of

Social determinants on becoming a physician


Poverty is known to be an important determinant of a person’s health and longevity. A person’s zip code is more relevant than genetic code. Does a physician’s zip code – that is where they were born and raised – have an effect on where they practice? Specifically, do rural born and raised physicians return to their rural roots? The story of Prashant, a physician raised in rural Bihar, India, is instructive.

When I first met Prashant, he was a second-year medical student in Patna Medical College and Hospital. Patna is the capital of Bihar, and Bihar is one of the poorest states in India.

Prashant brimmed with idealism and vigor. “I’ll practice in Purnea one day and serve the poor villagers,” he told me in broken English.

Prashant comes from a family of Bihari farmers who are also affluent landowners. He grew up near Purnea, a fourth-tier town in Bihar surrounded by villages. Visiting these villages is like stepping into a time machine – you can see people travelling by bullock carts but using mobile phones.

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The Ethics of Keeping Alfie Alive


Of my time arguing with doctors, 30 % is spent convincing British doctors that their American counterparts aren’t idiots, 30 % convincing American doctors that British doctors aren’t idiots, and 40 % convincing both that I’m not an idiot.

A British doctor once earnestly asked whether American physicians carry credit card reading machines inside their white coats. Myths about the NHS can be equally comical. British doctors don’t prostate every morning in deference to the NHS, like the citizens of Oceania sang to Big Brother in Orwell’s dystopia. Nor, in their daily rounds, do they calculate opportunity costs for keeping patients alive on ventilators.

Conversations such as this are vanishingly rare.

Administrator: “It’s costing an arm and leg keeping this sick baby alive – to balance the annual budget we need to stop dialyzing a granny.”

ICU doctor: “We’ll have to send poor Ethel to her grave. That’s a shame. She was beginning to grow on me.”

Health Ethicist: “Wait, let me check with National Institute of Clinical Excellence, the rationing experts, who should be relieved of intensive care first. Perhaps it should be Winston, not Ethel – because Winston is an alcoholic. We need to make rationing scientific and fair.”

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Donald Trump’s Healthcare Problem

Screen Shot 2016-02-23 at 12.05.28 PMWhether you are elated, appalled, or just plain amazed that Donald Trump is the Republican primary front runner by a considerable margin, one thing should be clear: he’s not a policy guy.

So far, The Donald’s lack of policy specifics seems not to have hurt him. He’s successfully deflected the more searching debate questions, provided vague generalizations or given incomprehensible responses, and—when all else failed—insulted the debate moderators or his fellow Republican candidates.

So far, so good, for the Trump campaign. But is it time to change tactics?

As the number of competing candidates dwindles(So long, Jeb!),the focus in debates and interviews becomes sharper. With the original crowded field winnowed to just a handful,interviewers and debate moderators have time to probe a lot more deeply.And even if the questioners are relatively gentle, every other surviving candidate will be eager to pour scorn on policy statements that lack either substance or rationality.

Like Donald Trump’s healthcare proposals so far.

He’s said he wants the government to negotiate Medicare drug prices, he likes health savings accounts, he wants to be able to buy insurance across state lines, and he wouldn’t cut Medicare. And that’s pretty much it, except for one very big thing: he would “repeal and replace” Obamacare. But by what? “Something terrific” he says.

It’s easy to mock, but all of us – liberals and conservatives — should worry that we might just find ourselves with an incoming president trying to impose such an incoherent healthcare vision that our present system would look like a paragon of rationality.

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The Stanford Lectures: So, Is Software Really Eating the World?

Here at THCB  we really can’t think of many lectures we’d rather sit in on than Peter Thiel’s Stanford course on entrepreneurship. And we can’t think of a better guest to catch than Netscape co-founder Marc Andreeson.  In this talk, Andreeson talks about how healthcare IT is changing in the Facebook and Big Data Era era, the privacy issue and how the cloud may or not be eating software.

Is Software Eating the World?

Marc Andreessen’s most famous thesis is that software is eating the world. Certainly there are a number of sectors that have already been eaten. Telephone directories, journalism, and accounting brokerages are a few examples. Arguably music has been eaten too, now that distribution has largely gone online. Industry players don’t always see it coming or admit it when it arrives. The New York Times declared in 2002 that the Internet was over and, that distraction aside, we could all go back to enjoying newspapers. The record industry cheered when it took down Napster. Those celebrations were premature.

If it’s true that software is eating the world, the obvious question is what else is getting or will soon get eaten? There are a few compelling candidates. Healthcare has a lot going on. There have been dramatic improvements in EMR technology, healthcare analytics, and overall transparency. But there are lots of regulatory issues and bureaucracy to cut through.

Education is another sector that software might consume. People are trying all sorts of ways to computerize and automate learning processes. Then there’s the labor sector, where startups like Uber and Taskrabbit are circumventing the traditional, regulated models. Another promising sector is law. Computers may well end up replacing a lot of legal services currently provided by humans. There’s a sense in which things remain inefficient because people—very oddly—trust lawyers more than computers.

It’s hard to say when these sectors will get eaten. Suffice it to say that people should not bet against computers in these spheres. It may not be the best idea to go be the kind of doctor or lawyer that technology might render obsolete.

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The Fall of Berwick?

When President Obama named Dr. Donald Berwick to head the Centers for Medicare and Medicaid (CMS) last March, I wrote this:

“Most who know Berwick describe him a ‘visionary’ and a ‘healer,’ a man able to survey the fragments of a broken health care system and imagine how they could be made whole.  He’s a revolutionary, but he doesn’t rattle cages. He’s not arrogant, and he’s not advocating a government takeover of U.S. health care.”

To understand what I meant, view these clips from the film, Money-Driven Medicine, where Berwick speaks about the need for healthcare reform. Soft-spoken and charismatic, Berwick is as passionate as he is original. His style is colloquial, intimate, and ultimately absolutely riveting. He draws you into his vision, moving your mind from where it was to where it could be.

And now, it appears that we are going to lose him. Thursday, 42 Senators delivered a letter to President Obama demanding that he withdraw his support for Berwick to head CMS. The Boston pediatrician and co-founder of the Institute for Health Care Improvement (IHI) had received a temporary appointment in July while Congress was on vacation. President Obama re-nominated him in January. But Berwick still needs to be confirmed by the Senate, or he will have to leave his post at the end of this year.

With 42 out of 100 Senators firmly opposed to him, it appears that Berwick’s supporters won’t be able to muster the 60 votes needed to clear the Senate floor. Reportedly, Senate liberals already have given up. According to’s Brett Coughlin: “At a meeting with Senate staffers Friday, health care lobbyists and advocates were told that there will be no confirmation hearing and that they’ll soon be discussing ‘next steps’ for CMS.”    If this is true, Berwick is now a lame-duck CMS director without power—as of today.Continue reading…

A NY Times guest (inadvertently) spanks its professionals

A couple of weeks back two New York Times reporters (Abelson & Harris) decided to take on the orthodoxy of the Dartmouth school. Frankly their efforts reminded me of England’s performance in the world cup so far—abject and inept and leaving the fans hoping for much better. Within a few hours the mainstays of Dartmouth (Fisher & Skinner) responded correctly accusing Gardiner and Harris of shaky reporting. Although that original article was particularly muddled, there are indeed legitimate questions about some of the Dartmouth research, raised by serious academics (including on the august pages of THCB), but few of those made their way into the hodgepodge that was that original article. And now in their response to the response, Abelson & Harris have descended further into the mire.

The new argument is basically this. Yes, the Dartmouth academics have done all the corrections to regional data that the NYTimes duo accuse them of not having done. But they’re not available on the website within a click, not always portrayed in the maps in the Atlas, and (horror of horrors) you’d have to read Health Affairs to find out what they’d done. And that some of the academics who read Health Affairs hadn’t carefully looked at the maps which showed unadjusted data.

So now it’s not an academic issue or a misstatement. It’s an issue of poor user interface design! Well I guess we’re used to that in health care!

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Making (sh)it up as they go along

So today’s news is that the gang of ten have come up with something. (If you haven’t been following along, the gang of ten are the five “liberal” Democrats and the five DINOs asked by Harry Reid to come up with something to break the deadlock and get some type of compromise that will pass the Senate).  More details are here from Brian Beutler at TPM

So it might vanish like a Clinton-era trial balloon, or it might be a stayer, but the core of the new concept is to allow the 55–64 crowd to buy into Medicare, and to ask/allow/mandate a non-profit insurer(s) to provide a substitute public option. Exactly what the second point means is unclear to me. It may turn out to be some collapsing of Kent Conrad’s notion of the cooperative with an extension of the Federal Employees’ Plan (presumably minus the for-profit carriers) and somehow cramming that into the exchange. Of course providing something like the choice among private plans that Federal Employees now get was at the heart of Ron Wyden’s plan. We’ll see if it can last a couple of days scrutiny, or the wrath of the House Democrats.

The Medicare buy-in seems both sensible politics and half-decent policy.

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Silly Season: Monty Python Policy Making

Editor’s Note: Ian Morrison today makes his first contribution to THCB. Ian was President of Institute for the Future where I learned my health care consulting trade in the 1990s. A more amusing boss one couldn’t have hoped to have and he never minded me (or half of health care) shamelessly stealing his jokes–although his Scottish brogue always gave them a zing none of us can quite match. Ian’s now a full time speaker/writer/futurist and he gave THCB his view of the health care debate, interpreted logically through the lens of Monty Python’s Flying Circus–Matthew Holt

Now we are down to the really fun part of healthcare reform, when they actually write the final bill and figure out ways to pay for it.  And to honor the 40th Anniversary of Monty Python’s Flying Circus’s debut, Congress and the Administration have entered the silly season where final policy is turned into law.

I love the American healthcare system, not because it is the best in the world, but it is the funniest. The laughs keep coming.  Here are a couple of my latest favorites.

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Is Hospital Peer Review a Sham? Well, Mostly Yes

Dr. Sidney Wolfe, healthcare’s answer to Ralph Nader, spends most of his days unhappy with somebody.  Pragmatic, see-both-sides types like me naturally recoil from Wolfe’s reflexive indictment of institutions ranging from the FDA to Medicare.

But Wolfe’s blistering condemnation of medical staff peer review contained in the new report, Hospitals Drop the Ball on Physician Oversight (co-written by Alan Levine, both of Public Citizen’s Health Research Group) is timely and, I believe, largely correct.

The report focuses on the National Practitioner Data Bank (NPDB), established in 1986 to collect data about problem physicians, mostly to help credentials committees make informed decisions about medical staff privileging. The legislation that established the NPDB requires hospitals to submit a report whenever a physician is suspended from a medical staff for over 30 days for unprofessional behavior or incompetence. Although the public cannot access NPDB reports on individual physicians, healthcare organizations (mostly hospitals) ping the database about 4 million times per year. When it was inaugurated, the best estimates (including those of the AMA) were that the NPDB would receive 5,000-10,000 physician reports each year.

Not so much. Since its launch two decades ago, NPDB reports have averaged 650/year, and nearly half of US hospitals (2845 of 5823) have never reported a single physician! The most extreme case is that of South Dakota, where three-quarters of the hospitals have never reported a single case to the NPDB. I’m sure South Dakota has some wonderful doctors, but the idea that the state’s 56 hospitals have never had a physician who needed to be suspended for incompetence, substance abuse, sexual harassment, or disruptive behavior since the Reagan presidency is a bit of a stretch, don’t you think?

Public Citizen chronicles several cases of egregious behavior by physicians who dodged NPDB reports  – the cases either received no peer sanctions or were dealt with in ways designed to skirt the reporting requirements, such as – wink-wink – leaves-of-absence and 29-day suspensions. Most famously, a cardiologist and CT surgeon at Redding Medical Center in Northern California performed hundreds of unnecessary cardiac procedures but were not reported to the NPDB – largely because Redding’s medical staff and hospital were cowed by the physicians’ power and reluctant to kill two geese who laid many golden eggs. (Interestingly, the Joint Commission whiffed on this one too, a major reason why Congress removed its near monopoly on the hospital accreditation business last year.)

Levine and Wolfe recommend powerful medicine to fix the NPDB system, including much more vigorous legislative oversight, substantial fines to hospitals for failing to report, and linking NPDB reporting practices to accreditation standards and to Medicare’s Conditions of Participation.

A few years ago in our book Internal Bleeding, Kaveh Shojania and I described the limits of peer review; the Public Citizen report provides statistical confirmation of our observations. We wrote,

It is undeniable that hospitals do have a tendency to protect their own, sometimes at the expense of patients. Hospital “credentials committees,” which certify and periodically recertify individual doctors, are toothless tigers. Most committees rarely limit a provider’s privileges, even when there is stark evidence he presents a clear and present danger to patients. Instead, they assign a committee member to “have a chat” with the physician in question, perhaps gently suggesting he or she shouldn’t do a particular procedure anymore. They might even ask another physician, not on the committee but in a similar specialty, to “keep an eye on old Doug” and let them know if he continues to screw up, even if patients or other staff members don’t report it….

It is not that hospital credentials committees never take action. They do – removing a physician’s privileges at a hospital or recommending to the state board that a doctor’s license be suspended – when there is clear, repetitive evidence of gross negligence and incompetence. But when this happens – and it is really rare – it comes only after an orgy of soul-searching, handwringing, buck-passing, second-guessing and second chances that is painful, and sometimes embarrassing, to watch. In most cases, committee members just swallow hard and – unless the physician is under felony indictment or is so stewed that he can’t walk down a corridor without banging into both walls – the credentials are rubber-stamped.

Kaveh and I offered three reasons why medical staff self-policing is so wimpy. The first is the “fraternity of medicine” thing – no gang members like to “rat out their pals,” and in this regard, we’re no different from the Crips. The second is that credentials committee members are acutely aware of the amount of time and effort that it takes to become a practicing physician, which makes them reluctant to take away a doc’s livelihood.

A third reason, we wrote,

is simply that doctors aren’t very good organizational managers. Their people skills are usually confined to bedside chats and working with colleagues and support staff in task-oriented jobs; they aren’t particularly adept at managing conflicts and confrontations, so they avoid them. This is a pretty dumb reason to let an error-prone doctor continue to prowl the hospital wards, but because litigation… lurks behind any challenge to professional competence… many physicians are reluctant to go into that particular swamp unless the trail is awfully solid.

The fear of litigation is undoubtedly one of the major reasons why peer review doesn’t work. Although the statute establishing the NPBD provides immunity to physicians who perform good faith peer review, many hospitals and reviewers lack confidence in these protections. An American Hospital Association analysis of the NPDB concluded, “The specter of baseless, time-consuming and expensive litigation serves as a powerful disincentive to effective peer review.” If peer review is to be strengthened, these protections must be unambiguously robust.

Writing in his book Complications, Harvard surgeon and bestselling author Atul Gawande sees in the medical profession’s failure to perform aggressive peer review something understandable, even a tad noble. When it comes to disciplining a basically good but troubled doctor, “no one,” he says, “really has the heart for it.” Atul writes:

When a skilled, decent, ordinarily conscientious colleague, whom you’ve known and worked with for years, starts popping Percodans, or becomes preoccupied with personal problems, and neglects the proper care of patients, you want to help, not destroy the doctor’s career. There is no easy way to help, though. In private practice, there are no sabbaticals to offer, no leaves of absence, only disciplinary proceedings and public reports of misdeeds. As a consequence, when people try to help, they do it quietly, privately. Their intentions are good; the result usually isn’t.

There are still other reasons for the failure of peer review. When questions of clinical competency arise, there are often insufficient data to refute the inevitable arguments that “my patients are older and sicker.” When the issue is disruptive behavior, unless there has been documented scalpel throwing (by a surgeon with good aim), finding the bright line that separates the behavior of an aggressive, passionate, patient-advocate-of-a surgeon from the surgeon whose disruptive behavior creates a hostile work environment or places patients at risk can be elusive. Finally, peer review conducted by professional colleagues is fundamentally tricky – one the one hand, how could one’s practice be dispassionately reviewed by a golfing buddy? On the other, peer reviewers might well be competitors of the physician-in-question, with a financial stake in the outcome.

Is it any wonder that medical staffs kick this particular can down the road so often?

Layered on top of these traditional impediments is a new one: the paradigm shift introduced by the patient safety field. Remember, our patient safety mantra has been “no blame,” which is unlikely to be in the first verse of the Peer Review Fight Song. Haven’t we just finished convincing ourselves that most errors are due to dysfunctional systems and not bad apples? If that’s the case, who really needs peer review, anyway?

But this represents a fundamental misunderstanding of “no blame.” I struggled with this tension while writing Internal Bleeding, and went to The Source for guidance: Dr. Lucian Leape, the father of the patient safety movement. Lucian, I asked, how can we reconcile systems thinking with the necessity of standards and peer review? His answer was spot on:

There is no accountability. When we identify doctors who harm patients, we need to try to be compassionate and help them. But in the end, if they are a danger to patients, they shouldn’t be caring for them. A fundamental principle has to be the development and then the enforcement of procedures and standards. We can’t make real progress without them. When a doctor doesn’t follow them, something has to happen. Today, nothing does, and you have a vicious cycle in which people have no real incentive to follow the rules because they know there are no consequences if they don’t. So there are bad doctors and bad nurses, but the fact that we tolerate them is just another systems problem.

I’m proud to say that over the past five years, my hospital (UCSF Medical Center) has taken Leape’s challenge to heart, withdrawing clinical privileges (and filing accompanying NPDB reports) in several cases for behavior that, I’m quite confident, would have been tolerated a decade ago. This is progress. As Kissinger once said, “weakness is provocative.” As more hospitals take this tougher stance, I think we’ll see the boundaries of acceptable behavior shift everywhere. And patients will be safer for it.

A profession is group of individuals with special knowledge, who are granted privileges by society in deference to their expertise and in exchange for self-regulation. When thousands of hospitals can go 20 years without disciplining a single physician on their medical staff, our status as a profession is called into question.

In the end, peer review is about answering one deceptively simple question: Is it more important to protect problem physicians or vulnerable patients? If we can’t answer that question correctly, we should not be surprised when the Sid Wolfes of the world call us to task, nor when we find ourselves under an unpleasant media, legislative, and regulatory microscope. Professions don’t need that kind of outside scrutiny to do the right thing, but we just might.

Dr. Robert Wachter is widely regarded as a leading figure in the modern patient safety movement. Together with Dr. Lee Goldman, he coined the term “hospitalist” in an influential 1996 essay in The New England Journal of Medicine. His most recent book, Understanding Patient Safety, (McGraw-Hill, 2008) examines the factors that have contributed to what is often described as “an epidemic” facing American hospitals. His posts appear semi-regularly on THCB and on his own blog “Wachter’s World.”


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