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#Healthin2Point00, Episode 227 | Maven, Carrot Fertility, Cricket Health & Sharecare

It’s the return of #HealthIn2Point00 after an overly long summer break (well, I went to HIMSS and Jess didn’t last week!). We have deals with Maven raising a big round, Cricket Health (from a few weeks back) filling its coffers and another fertility play, Carrot Fertility, getting $75m. Finally Sharecare gets its checkbook out — again–and buys a home care company. We have more to catch up on tomorrow–Matthew Holt

Cityblock Health & The ‘At-Risk’ Disruption of Medicaid Care

By JESSICA DaMASSA, WTF HEALTH

Innovation in Medicaid is HAPPENING – and not only is it capable of creating better, less expensive healthcare for Medicaid members, but Cityblock Health is proving that it can also be the underpinning of a business worth over $1B dollars.

Dr. Toyin Ajayi, Cityblock’s co-founder & President, walks through the company’s novel business model, which goes AT-RISK to take care of some of the highest risk patients in all of healthcare. Here’s how it works: the startup contracts with health plans that provide Managed Medicaid services, helps them identify groups of patients that are of highest risk or rising risk, then takes over the financial and clinical accountability for that group. Cityblock then envelopes those members in a suite of highly personalized services that address both their healthcare needs and the social care challenges that are connected to them. In short…Cityblock is a medical practice built at the bustling intersection of value-based care and social determinants of health.

Toyin talks through some examples of the unique challenges facing the 75,000+ members Cityblock works with, particularly what they are learning about what it takes to “earn the right” to provide this population with care. But, is the high-touch, tech-infused core of their model defensible? What stops a huge national Managed Medicaid health plan like Centene or Molina from simply replicating this within their own multi-billion-dollar enterprises? Competition, expansion, funding, and outcomes – we get into it all, and hear Toyin’s near-term vision for Cityblock as it puts the nearly $500M its received in venture funding to work on “transforming the healthcare ecosystem for those who need it most.”

George Halvorson HIMSS Changemaker Lifetime Achievement Award Acceptance Speech, Part 1

Former Kaiser Permanente CEO George Halvorson has written on THCB on and off over the years, most notably last year with his proposal for Medicare Advantage for All post-COVID. This month he was given a lifetime achievement award by HIMSS and we are running his acceptance speech in two parts. Here’s part one — Matthew Holt

Thank you for giving me this first ever HIMSS Changemaker In Health Care Lifetime Achievement Award.

You are honoring an extremely impressive set of other current changemakers at this particular national meeting for 2021 and I am very honored and pleased to be the first person to be given the Lifetime Achievement version of this Changemaker award.

Changemaking is a good thing.

Changemaking is actually happening at a massive level for health care systems right now and that is good for health care and it is good for health care patients.

We are actually at the dawn of a golden age for health care systems, and I deeply appreciate being recognized for having done several fun, useful, and interesting things over time to help get us to where we are now.

As you pointed out, I have personally had a chance to work very directly on rolling out full electronic medical record systems in a couple of real and functional care systems to tens of millions of people.

It worked well.

We ended up with care sites in those settings that literally had no internal paper flows and that had and still have instantly available medical information for thousands of caregivers about their patients.

That tool kit worked extremely well.

Those care sites ended up with the highest ratings in the country for both quality of care and service and that high level of performance happened because the sites had both a culture of continuous improvement in their care settings and the highest levels of continuously available data for the caregivers in those sites about the patients they served.

“All-All-All.”

That was a mantra, a goal, and a strategy — and it became an actual functional capability.

Having All of the information about All the patients All the time — All-All-All is a good mantra, an extremely practical goal, an extremely functional strategy, and a very solid working practice for the delivery of care — and that data strategy worked even better than we had hoped it would work when we started down that path.

Having full electronic data on every patient improved diabetic care, chronic heart disease care, and stroke and heart damage prevention — and it created major reductions in the complications of care for chronic care patients in every category of care in all of those settings.

The data about patients was expanded at Kaiser Permanente to be the first major site and system in the world to add race and ethnicity to the care data for millions of patients.

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Trendspotting with Optum’s Direct-to-Consumer VP: Behavior Change Science in Healthcare

By JESSICA DaMASSA, WTF HEALTH

It’s interesting enough that Optum’s Vice President for Direct-to-Consumer is not only a serial digital health entrepreneur, but she’s also a behavior change scientist. Dr. Kate Wolin stops by to share some background on behavior change science, and how healthcare companies large and small are looking to drive health and wellness outcomes by integrating its principles and techniques into product design strategy.

Behavior change science appears to be having a “moment” here in healthcare, peppering conversations about everything from business models and consumer engagement strategies to product design, particularly in the chronic care and mental health spaces. Optum obviously has an interest in the discipline, with Kate in such a critical leadership role. And, our friends at life sciences giant, Bayer, also seem keen on exploring the approach, as it’s both the focus of one of the sessions of Bayer G4A’s free digital health forum, Health for All, on September 9, AND the reason Kate’s here to provide a deep-dive into the subject as a special prequel to the event.

So, what are the key takeaways? Well, it turns out there are a lot of misconceptions about behavior change science. Kate sets us straight, explains why she’s NOT a fan of the term “nudges,” and talks about what digital health companies usually get wrong (and right) about incorporating behavior change techniques into their products and services. Does behavior change require human intervention in order to make it sticky? Or, can technology be just as effective in achieving the right levels of personalization needed to make an ongoing impact on a person’s behavior? We get smart on this trending approach, and Kate gives us her prediction for how healthcare will be looking to increasingly incorporate this science into its future.

Special Note: To hear more from Kate and a host of other healthcare experts during Bayer G4A’s special global event “Health for All – A Digital Health Forum” on September 9, 2021, register at www.g4a.health.

Yes, Shit

By KIM BELLARD

The Conversation had a provocative article by Stanford professor Richard White about how America has a bad pattern of wasting infrastructure spending.  In light of the surprisingly bipartisan $1 trillion infrastructure bill recently passed by the Senate, this seems like something we should be giving some serious thought to. 

I’ll posit that we’re doing it again, by not adequately addressing the potential that our excreta, to be polite, offers to detect health issues, including but not limited to COVID-19. 

No shit: excrement can be an important tool in public — and personal — health. 

Take wastewater monitoring.  It is not a new concept – for example, to track polio – and has been used during much of the current pandemic.  According to the COVIDPoops19 dashboard, run by UC Merced’s School of Engineering, there are 55 countries with 89 dashboards monitoring the wastewater in 2,428 sites for signs of COVID-19.  The project even has its own Twitter handle (@CovidPoops19). 

According to Kaiser Health News, the University of California San Diego’s program has identified 85% of COVID-19 cases over the last year, using a largely automated monitoring system.  Infected people shed virus particles long before they show symptoms, allowing such programs to act as an early detection system. 

“University campuses especially benefit from wastewater surveillance as a means to avert COVID-19 outbreaks, as they’re full of largely asymptomatic populations, and are potential hot spots for transmission that necessitate frequent diagnostic testing,” said UCSD study first author Smruthi Karthikeyan, PhD.  Any university debating vaccine or mask mandates in order for students to return to campus should seriously be considering this kind of monitoring mechanism.

Similarly, the University of Minnesota has been sampling the wastewater of 65% of the state’s population, and has correctly predicted the rise and fall of each of the three waves in the last year.   North Carolina has also had success. 

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EHRs Are Workarounds, Rerouting the Way Physicians Work

By HANS DUVEFELT

IT GUY: Hey, Doc, don’t make up workarounds, use the EHR the way it was designed.

DOCTOR: Listen, your whole EHR is a workaround itself – around the way medicine is practiced.

– Hans Duvefelt, MD

This was a tweet I posted a while ago. I expected it to either go viral among doctors or catch the ire of administrators and IT folks. Neither happened. So I’m back on my soap box:

Imagine creating a computer simulation or video game that people expected to prepare them for or refine their skills in any given sport. Then, assume that this game altered the rules of the game – using a volley ball instead of a hockey puck, scoring goal attempts rather than goals, rewarding slowness rather than speed and so on.

Then, imagine you, the programmers/code writers, went to the team owners and proposed athletes and coaches should abandon the time-honored rules of the game and instead play like it plays out on the pixelated imitation you just created. And just to be clear: You, the programmer, actually never played the game yourself.

You’d get shown the door and sent back to the digital drawing board.

But that’s not what is happening in medicine.

FIRST: Is finding the clinically relevant information easier than, or at least as easy as, the regulatory information? (The cumbersome ways we have to enter information is a big topic, better covered separately.)

Here’s a silly example: One of the EMRs I work with displays prominently that the smoking assessment requirement has been satisfied, but I’ll be darned if I can see whether the patient smokes or not. Whom does the Holy Grail serve here?

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The Backstory of a Photo That Went Viral

By MIKE MAGEE

“People might not treat you the right way or they may stare at you. But the way that you treat people is going to go way further than anything else.”

Carson Pickett, NWSL/Orlando Pride/NC Courage

In the summer of 2017, Colleen and Miles Tidd were told that their third child would be born without a left forearm. Colleen later reported that she cried at first, but not for long. They had two other children, girls age 2 and 12, to consider. In preparation for their son Joseph’s birth, they reached out to an advocacy organization, “Lucky Fin”, for information and support.

The name derives from the 2003 Disney classic, “Finding Nemo”, and its’ animated star clownfish, Nemo. He was born with one short fin, the result of a barracuda attack that killed his mother and sister, and cracked his egg while he was still in development. The little fish was left with an over-protective father who, out of fear, tried to limit his future. Nemo resisted and found his strength and purpose, in part, by redefining what other sea creatures saw in him. They saw an unfortunate fish with an abnormally shortened limb. He saw adventure ahead, powered by his “lucky fin.”

Carson Pickett, the soccer star, has her own story. She was born in 1994 near Jacksonville, Florida, with a missing left forearm, nearly identical to Joseph (nicknamed Joe-Joe). Her parents, Treasure and Mike were former college sports stars, committed to expanding rather than limiting their daughter’s horizons. Carson’s mantra became, “Control what you can control”, her own variation of Nemo’s famous, “Just keep swimming.”  At age five, her father introduced her to soccer and she never looked back. She was a standout at Florida State University, and was drafted by the National Women’s Soccer League team, Seattle Reign. In 2018, she was part of a three-person trade to the NWSL Orlando Pride.

Colleen and Mike Tidd immediately took notice. Joe-Joe and Carson were both born in Florida, loved soccer, were athletic, and had partially formed left arms. Their limb defects placed them among 2,250 U.S. babies born each year with the condition. By the time their photo was taken in April, 2019, Joe-Joe was 21 months old and had taken to wearing a purple Pride jersey with Carson’s #16 on the back.

The famous photo was taken by Joe-Joe’s mother at a home game when Carson jogged over to the family after hearing their cheers. As reported, “She repeatedly tapped her arm against his as he shrieked with glee.” After the game, the two spent time in the locker room playing their version of peekaboo – pulling up their shirt sleeve to expose their left arms. As Colleen recounted, “It took a minute for him to realize, ‘Wow, we’ve got the same arms,’ and then he just giggled. You could see it hit him, and then they were best friends after that…She’s like me.”

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Morning Distort

By MARTIN A. SAMUELS

A 35-year-old woman complains of weakness of the right side of her face and pain behind the right ear.  She lives in an urban environment and denies any recent illnesses.  She is not vaccinated against COVID-19 but is COVID negative. 

What do you think, I was asked at our Morning Report?  Well, I said, it sounds like a straightforward Bell palsy.  The pain around the ear suggests swelling of the VIIth cranial nerve in the facial canal and the stylomastoid foramen, a very common historical point, I opined; so much so that its absence would make me doubt the diagnosis and make me consider other causes of facial palsy such as sarcoidosis or Borreliosis, though the urban environment argues against that tick born disease.  Then we went around the room, expanding the differential diagnosis (as this exercise is often called) to include tumors of the parotid gland, leptomeningeal metastases and many more.  At one minute before the end of the thirty- minute conference, a photo of the patient was shown.  There was only one problem.  There was no facial weakness, but rather she had a definite Horner syndrome on the right with a smaller pupil and subtle ptosis due to weakness of the Muller muscle, a small circular sympathetically innervated muscle that acts as a minor controller of the palpebral fissure.  The patient’s pupils were not tested in bright and then dim light, nor was sweating tested because why would one do those things in someone with facial weakness and pain around the ear.  In fact, this patient had nothing like a Bell palsy but rather Raeder syndrome, a painful oculosympathetic (Horner) syndrome, which implicates a disease of the carotid artery.  Once this was discovered it was learned that the patient had hyperextensibility of the joints and hadn’t suffered any neck trauma.  Now a spontaneous dissection of the right carotid artery becomes the focus of thought with a very different implication for therapy and prognosis.

This experience vividly emphasizes two traps in the diagnostic process:  thinking fast and framing.  As Daniel Kahneman and the late Amos Tversky have articulated and summarized in their book, Thinking Fast and Slow, there are two subsystems within the nervous system that they dubbed system one and system two.  System one is a very rapidly acting, involuntary system which estimates the likelihood of a given circumstance and reacts to it.  System two is a voluntary, tedious, slow system that weighs evidence, considers the frequency of a likelihood in the environment according to The Reverend Bayes’s prior probability.   In neurology, system one is the autonomic nervous system (or the reptilian brain as it was called by the late Paul MacLean in his triune brain).  System two is the cerebral cortex with its complex networks that facilitate various aspects of awareness, an aspect of consciousness.   Neither system is good nor bad, as both have their place.  The first presumably survived the rigors of evolution because it allowed our ancestors to react to potential threats rapidly (i.e. a movement in peripheral vision is not analyzed; it is rather escaped as if it were a snake, even though Bayesian reasoning would predict that it was probably a stick).  System two allows for more accurate conclusions in less time sensitive circumstances.  What happened to me in the conference was that my system one rapidly generated a theory, but this was based on incorrect data (it was a snake; not a stick).  If a mistake is made early in the diagnostic process, the processes thereafter are all distorted and there is virtually no way to reach the correct answer.  Recall Conrad Waddington’s epigenetic landscape, wherein he used a metaphor (marbles rolling down a hill) to describe how mistakes early in a developmental process have enormous effects on the ultimate outcome, whereas errors later in the process are less destructive.   In addition to my system one error, I was also taken in by the framing shortcut (heuristic).  The person who presented the case had a theory of his own, which was promulgated in the headline:  a woman with a painful facial palsy.  In fact, it was a woman with a painful Horner syndrome.  The moral of the story is that I should have looked at the photograph first.  That would have avoided the futile task of elaborating an expanded differential diagnosis which, after all, is a nothing but a list of wrong answers followed by the right answer. 

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Digital Health: A Promise of Health for All

SPONSORED POST

In this interview Sophie Park, Chief Strategist at Bayer G4A, talks about the pandemic’s effect on the digital health landscape, digital health’s promise of Health Equity and Bayer G4A’s upcoming Digital Health Forum.

G4A is Bayer’s digital health partnerships and investments team dedicated to scaling digital health companies to change the experience of health. To attain this goal, G4A works with startups, innovation groups, commercial partners, thought leaders, health systems, and public institutions to accelerate and expand digital health innovations. In that context, G4A is offering opportunities for early stage to advance digital health companies to partner with Bayer.

Sophie, Covid-19 has clearly opened everyone eyes on the need to better our healthcare systems and raised awareness for digital health solutions. From your perspective, did the pandemic accelerate digital health on a long-term basis?

Clearly, the Covid-19 crisis spurred a momentum for digital health. During the crisis, I have observed two dynamics which advanced digital health in a never before seen pace.

On the one side, the needed adoption of digital health tools led to a mindset shift and more openness among health consumers and providers. The pandemic was a great chance for many people to get familiar with digital health tools and acknowledge their value. Covid-19 made it clear to individuals that their own health is a personal responsibility as well. Therefore, people more actively took care of their own health(care) and became more open to collect and securely share healthcare data. I believe that all these factors will lead to increasing use of digital health tools also in post-Covid times.

On the other hand, the pandemic exposed the pain points of our healthcare systems. The quality of care one gets is determined by social determinants- where you live, where you are from, what education you receive and what job you have. The pandemic left no doubt that there is still a long way to go to reach health equity and better health access. At Bayer G4A we believe that digital health can and should play a vital role in closing existing care gaps and ensuring health for all.

“Health for All” – that is the goal. Not only is it Bayer G4A’s leading vision it also is the title of this year’s Digital Health Forum hosted by G4A on September 9th. Why did you choose that theme for this year’s event?

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Health Care You Do Not See

By KIM BELLARD

Within a mile from my home in one direction, there are two pharmacies and a primary care office.  In another direction, there’s a multi-specialty physician practice, complete with lab and pharmacy.  And in a third direction, an urgent care center.  Widen the circle another mile, and there are more physician offices, a plethora of other health care professionals, another urgent care, a retail clinic, and an imaging center.  Add a couple more miles and hospitals – plural – to start show up.

I’m not sure that’s a good thing.

Admittedly, not everyone has so many options.  If you live in a rural area or a disadvantaged neighborhood, there may not be so many choices.  Chances are, though, even in those places, whenever you find retail activity, some portion of it is probably healthcare-related.

Retail clinics helped blur the lines between retail and healthcare, and early moves by retail giants like Walmart or Kroger to incorporate first pharmacy, then primary care, into their stores made getting care easier for millions.  All in all, probably a good thing.

Still, though, you know when you’ve gone from shopping for home goods or groceries to getting your healthcare.  You know because there’s more waiting.  You know because there are more forms to fill out.  You know because you don’t know what will happen to you. 

And you definitely know when you are getting health care services.  You get an injection, you take a pill, you have an image taken, your body is invaded by a tube or a scalpel.  That’s why we go, isn’t it?  We go because we fear something may be wrong and we want someone to do something about it.  Advising us to make lifestyle changes is all well and good, although usually not effective; we want some concrete treatment.

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