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The Second to Last Mile

May 18, 2016• 5

By AKASH RANDHAR and JAAN SIDOROV, MD

flying cadeucii Thanks to the ubiquity of cable, fiber and wireless internet, the “last mile” telecommunications gap that has long separated the consumer from the wide world web is finally being bridged. According to Pew Research, 84% of Americans now regularly use the internet, and 68% use smartphones to access increasingly available broadband services.

The impact on healthcare has been considerable. More than half of all Americans have already uploaded their vital signs, benchmarked their fitness levels, co-managed their medications, communicated with their providers or researched health-related information. No wonder the “mHealth” market could grow to $60 billion by the end of the decade.

Yet, as more and more patients have rushed into this growing ecosystem of apps, wearables, home devices and other gadgets, a considerable body of research suggests that U.S. health care providers are not keeping up. The poor second-to-last mile fit between consumers’ personal health technology and the providers’ incumbent information systems is turning out to be an important barrier to fully realizing the full potential of mHealth.

How should mHealth leaders respond?

Everyone agrees that healthcare technology is beset by unfriendly interfaces, poor clinical fit and opaque “black-box” programming logic. In addition to this, physicians are also well aware of the perils of inbox data overload.

Resolving these technical challenges is well within reach. Yet, healthcare leaders who are sponsoring mHealth initiatives should also consider three lessons that address the very human dimensions of connecting the second-to-last mile:

Why Medicine?

May 18, 2016• 2

By SAURABH JHA, MD

flying cadeucii Cross posted with Quartz.

When I was applying to med school some 20 years ago in the UK, I was advised not to say at the interview: “I want to be a doctor because I want to help people.”

The answer was considered too dull back then. And in any case, I was asked “Why medicine?” only once.

“I’m not sure, but it’s not because my parents forced me.” I hesitatingly answered.

The interview panel giggled at my honesty, and for breaking a stereotype about Indians. I was accepted. But I doubt that this answer would cut it today.

Showing a sense of altruism is practically mandatory today for would-be doctors – one wonders if functional MRI will soon be used to prove empathy. But when I was 17 (the age when we typically applied to study medicine) that wasn’t the case. My curriculum vitae had little evidence that I wanted to help people.

The Quality of Virtual Visits

May 17, 2016• 3

By JOE KVEDAR, MD

Joseph Kvedar Virtual visits are increasingly the rage amongst forward-thinking healthcare providers that want to jump on the telehealth band wagon. Extending the office visit across distance, using the same technology we use to keep in touch with loved ones (videoconferencing such as Skype and FaceTime), is a safe and logical way for providers to venture into a new tech-enabled world that may still be scary for some.

One way to think of this trend is to consider virtual visits an extension of the brick and mortar care model made famous a decade ago by companies like Minute Clinic. Offer convenient access to a care provider for a limited number of conditions.

Virtual visits can take place by either video or voice connection. These interactions are most often for indications that are non-life threatening, acute problems such as sore throat, ear ache, urinary tract infection and the like. There is also a role for this technology in follow up care for conditions such as diabetes and hypertension, but for this post we’ll focus on acute care.

Slavitt’s “Data Paradox”

May 16, 2016• 6

By KIP SULLIVAN

flying cadeucii Andy Slavitt began his statement at the Datapalooza conference with encouraging words for those of us who believe that the measurement craze has been a disaster and that MACRA will make it worse.

Slavitt claimed to be in favor of electronic medical record “reform” that “works with doctors, not against them.” He seemed to say he understood MACRA could aggravate the damage that “meaningful use” and the pay-for-performance fad have already inflicted on doctors.

He even accurately summarized the lousy results to date of the measurement craze. He said doctors feel all the data entry “took time away from patients and provided nothing or little back in return.” “[P]hysicians are baffled by what feels like the ‘physician data paradox,’” he said. “They are overloaded on data entry and yet rampantly under-informed.”

Playing Doctor

May 16, 2016• 5

By AL LEWIS

flying cadeucii In a deep dark recess of today’s Federal Register, large corporations just quietly received permission to “play doctor” with their employees. They can now impose even more draconian and counterproductive wellness schemes on their workers than they already do. Their hope is to claw back a big chunk of the insurance premiums paid on behalf of employees who refuse to submit to these programs, or who can’t lose weight.

A Bit of Background on Wellness

The Affordable Care Act (ACA) allowed employers to force employees to submit to wellness under threat of fines. Specifically, the ACA’s “Safeway Amendment” — named after the supermarket chain whose wellness program was highlighted as a shining example of how corporations could help employees become healthier — encouraged corporations to tie 30% to 50% of the total health insurance premium to employee health behaviors and outcomes. (As was revealed while ACA was being debated, Safeway didn’t have a wellness program. The fictional Safeway success was a smokescreen for corporate lobbyists to shoehorn this withhold into the ACA.)

Rethinking MACRA Part II

May 15, 2016• 10

By JOHN HALAMKA

John Halamka In my blog posts, I speak from the heart without a specific political or economic motivation. Although I’ve not written about highly controversial subjects such as religion, gun control, or reproductive policy, some of the topics in my posts can be polarizing. Such as was the case with MACRA.

Some agreed with my initial analysis that clinicians will have a hard time translating complex MACRA payment processes into altered clinical behavior. Others felt I was overharsh, negative and inappropriate. It’s never my intent to criticize people, instead I want encourage dialog about ideas. In that spirit, here’s my opinion on how we should evolve from fee for service to pay for value/outcomes.

1. Humans can never really focus on more than 3 things at a time. Although we sometimes believe multi-tasking is efficient, in reality we do work faster with less quality. Instead of 6 or 8 dimensions of Meaningful Use performance combined with a large number of quality indicators, why not delegate each medical specialty the task of choosing 3 highly desirable outcomes to focus on each year, then reward those outcomes? For example, I have glaucoma. Asking my opthalmologist to record my smoking status or engage in secure messaging with me is probably less important than ensuring my intraocular pressures are measured, appropriate medications are given, and my visual field does not significantly worsen. The cost to society of my blindness would be significant. Keeping my sight intact represents value. Care Management software could ensure I’m scheduled for pressure check appointments, given medications, and have my visual field checked once per year. Some percentage of reimbursement could be withheld until those outcomes are achieved. How software does that is not important and innovative workflow would be left to the marketplace where clinicians will choose applications based on usability, cost, and time savings instead of regulatory oversight.

Independent Decision Support at the Point-of-Care for Both Patients and Physicians

May 13, 2016• 9

By ADRIAN GROPPER, MD

flying cadeucii “We did not spend $35 Billion to create 5 data silos.” This was said by Vice President Biden at the beginning of Datapalooza on Monday and repeated by CMS’s Andy Slavitt on Tuesday. On Wednesday, at the Privacy and Security Datapalooza at HHS, I proposed a very simple definition of electronic health record (EHR) interoperability as the ability for patients and physicians to access independent decision support at the point of care regardless of what EHR system was being used.

Over the three days of Datapalooza, I talked to both advocates and officials about data blocking. In my opinion, current work on FHIR and HEART is not going to make a big dent in data blocking and would not enable independent decision support at the point of care. The reasons are:

A Free Market Repudiation of Evidence-Based Medicine

May 13, 2016• 14

By MICHEL ACCAD, MD

Michel Accad In a recent article entitled “A Hayekian Defense of Evidence-Based Medicine” Andrew Foy makes a thoughtful attempt to rebut my article on “The Devolution of Evidence-Based Medicine.” I am grateful for his interest in my work and for the the kind compliment that he extended in his article. Having also become familiar with his fine writing, I return it with all sincerity. I am also grateful to the THCB staff for allowing me to respond to Andrew’s article.

Andrew views EBM as a positive development away from the era of anecdotal, and often misleading medical practices: “Arguing for a return to small data and physician judgment based on personal experience is, in my opinion, the worst thing we could be promoting.” Andrew’s main concern is that my views may amount to “throwing the baby with the bath water.”

On those counts, I must plead guilty as charged. I have been trying to sink that baby for a number of years now, attacking it from a variety of angles. I have made a special plea in favor of small data and I have even questioned the intellectual sanity of EBM. On the question of the coexistence between EBM and clinical judgment, I have been decidedly intolerant, relegating EBM to second class citizen status. In other words, I’m an unapologetic EBM-denialist which, as I found out yesterday on Twitter, puts me in the same category as climate change skeptics.

Hillary’s Pivot Left on Healthcare

May 13, 2016• 10

By INDUSTRY MOLE

Is Hillary Clinton really moving to the left on healthcare, as the NY Times and many others have asserted, pushed by continued pressure from Bernie Sanders to endorse the public option? It is a strange claim. First of all, her campaign’s explicit support of the Public Option goes back to at least February, when her site was updated with language backing it, and which seems essentially identical to the language the campaign uses today. She hasn’t moved left in the last three months due to the lingering strength of the Sanders campaign.

Has she changed at all from previous years? There isn’t any indication of that, either. If anything, her plans today are scaled back from her 2008 presidential campaign, in which the public option, based on Medicare, figured prominently.

Datapalooza: MACRA, EHR Reform and Working with Doctors – Not Against Them

May 12, 2016• 11

BY ANDY SLAVITT

Screen Shot 2016-05-12 at 8.45.31 AM There’s a bit of a checklist for speaking at Datapalooza. Thank Niall. Mention Todd Park. Remark at how big the event has gotten compared to last year. Recap how much progress has been made. Refer to yourself as a “data geek” . Also, have in my notes “Good not to follow Farzad or Aneesh” . Perhaps even make some news with an announcement or grant or contest. Several of my colleagues did this and I share their excitement.

But I’m not going to make news. Instead, I’m going to relay a bit of my personal experience with health care innovation and technology as my goal is to leave this job with nothing really left unsaid. Twitter, by the way, seems to be helping with that.

Lately, we’ve been contemplating a significant transformation of the Medicare program by implementing the bi-partisan MACRA legislation. Legislation to make a wholesale change in the Medicare payment system to pay for quality. This has caused me to begin an obsession with the plight of independent physicians, knowing as we all do that if we don’t invest in primary care, we’ll invest double or triple when people get unnecessarily sick. And as a steward of programs where people with the lowest incomes and in the most remote locations get care, I know that without access, it will be people that can afford it the least that suffer first and most.