The Health Care Blog – Page 437 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

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The Psephology of Early Diagnosis in Britain’s NHS

Feb 6, 2015• 17

By SAURABH JHA, MD

Consider this equation.

Early Diagnosis = Early Diagnosis + Overdiagnosis (1.1)

This sort of unequal algebra will fail high school mathematics. A new NHS initiative is arithmetic defying as well. Patients who think they have symptoms of cancer will be allowed to book medical imaging directly, without seeing their GP. This is to catch cancer early. The logic is impenetrable: early diagnosis of cancer saves lives.

Here is the problem. Cancer does not unequivocally announce its arrival. Early cancer presents with non-specific symptoms, such as an uncomfortable niggle in the back.

Tom

Let’s take Tom, who has advanced pancreatic cancer. He recalls that three years earlier he noticed a dull pain in his back during a misguided drinking binge. He would be correct in thinking that had he attended the emergency department and had a CAT scan of his abdomen, the cancer would have been smaller and would not have spread to other organs. He is right in contending that had the cancer been removed then, he would have a longer survival than presently.

The rationale has implications if extrapolated to everyone. To understand the consequences of extrapolation let’s visit a logical fallacy.

1) All Mr Smiths are over six feet tall.

2) He is above six feet tall so he must be Mr Smith.

This is affirming the consequent. Not all men above six feet in height are Mr Smiths. In fact, most are not.

3) Early pancreatic cancer presents with back pain.

4) All patients with back pain have early pancreatic cancer.

Similarly, (3) doesn’t imply (4).

Cancer often presents with non-specific symptoms, such as a vague discomfort, early on. But the majority of people with a vague discomfort do not have cancer. That is, the chance that someone with pancreatic cancer has dull back pain should not be confused with the chances that someone with dull back pain has pancreatic cancer. The chances of the latter are much lower than the former.

Computers Replacing Doctors, Innovation and the Quantified Self: An Interview with Atul Gawande

Feb 5, 2015• 49

By ROBERT WACHTER, MD

Atul Gawande is the preeminent physician-writer of this generation. His new book, Being Mortal, is a runaway bestseller, as have been his three prior books, Complications, Better, and The Checklist Manifesto.

One of the joys of my recent sabbatical in Boston was the opportunity to spend some time with Atul, getting to see what an inspirational leader and superb mentor he is, along with being a warm and menschy human being. In my continued series of interviews I conducted for The Digital Doctor, my forthcoming book on health IT, here are excerpts from my conversation with Atul Gawande on July 28, 2014 in Boston.

I began by asking him about his innovation incubator, Ariadne Labs, and how he decides which issues to focus on.

Gawande: Yeah, I’m in the innovation space, but in a funny way. Our goal is to create the most basic systems required for people to get marked improvements in the results of care. We’re working in surgery, childbirth, and end-of-life care.

The very first place we’ve gone is to non-technology innovations. Such as, what are the 19 critical things that have to happen when the patient comes in an operating room and goes under anesthesia? When the incision is made? Before the incision is made? Before the patient leaves the room? It’s like that early phase of the aviation world, when it was just a basic set of checklists.

In all of the cases, the most fundamental, most valuable, most critical innovations have nothing to do with technology. They have to do with asking some very simple, very basic questions that we never ask. Asking people who are near the end of life what their goals are. Or making sure that clinicians wash their hands.Continue reading…

Random Evil Policy Cancellations

Feb 5, 2015• 3

By THCBist

Suspicious in Michigan writes:

I am really upset. Our ACA coverage was cancelled without my knowledge or permission. When I contacted the help line I was informed that I had cancelled the policy myself, which is ridiculous! During a conference call with BCBSM and the marketplace, I was told that only a consumer could cancel a policy. Since neither myself nor my wife would have cancel I inquired what proof did they (the marketplace) have to verify it was in fact one of us that cancelled the policies. They don’t have that capability in their system. … The Market Place needs to be able to document who, when and where and the phone number used in canceling a policy. I can assure you we never had anything to do with effecting a policy cancelation. This needs to be investigated. Has anyone else experienced the Healthcare Marketplace canceling their policy especially with Blue Cross Blue Shield of Michigan? Please respond.

Where Does the ACA Go From Here?

Feb 5, 2015• 6

By DAVID DRANOVE and CRAIG GARTHWAITE

Barring a Republican landslide in 2016, it looks like the Affordable Care Act (ACA) is here to stay. By and large, we think that is a good thing. While there are many things in the ACA that we would like to see changed, the law has provided needed coverage for millions of Americans that found themselves (for a variety of reasons) shut out of the health insurance market.

That being said, since its passage the ACA has evolved and the rule makers in CMS continue to tinker around the edges. We are especially encouraged by CMS’ willingness to relax some of the restrictions on insurance design, but remain concerned about some of the rules governing employers and the definition of what is “insurance.” In the next few blogs we will examine some of the best, and worst, of the ongoing ACA saga.

We start with one of CMS’s best moves—encouraging reference pricing. The term reference pricing was first used in conjunction with European central government pricing of pharmaceuticals. Germany and other countries place drugs into therapeutic categories (such as statins or antipsychotics) and announce a “reference price” which insurers (either public or, in Germany, quasi-public) that insurers will reimburse for the drug. Patients may purchase more expensive drugs, but they were financially responsible for all costs above the references price. Research shows that reference pricing helps reduce drug spending both by encouraging price reductions (towards the reference price) and reducing purchases of higher priced drugs within a reference category. Other research has found suggestive evidence of similar results for reference pricing for medical services.

While the ACA does little to govern pricing in the pharma market, the concept of reference pricing can and should be extended other medical products and services. In particular, insurers can establish reference prices for bundled episodes of illness such as joint replacement surgery. Under the original ACA rules set forth by CMS, insurers were free to establish a fixed price for bundled episodes. They could even require enrollees to pay the full difference between the provider’s price and the reference price. But there was a catch. It wasn’t clear if any spending above the reference price would count to the enrollees by enrollees out of pocket limits (currently $6,600 for individual plans and $13,200 for family plans). Obviously, allowing the out of pocket limit to bind on reference pricing would limit the effectiveness of this cost control measure.

Health is Life

Feb 5, 2015• 7

By ALEXANDRA DRANE

We’ve all experienced the crushing agony of a heartbreak, or the deep foundational stress of worrying about how you’ll pay all your bills, or the isolating and bleak reality of a mum or dad or loved one whose health is failing in a way you can’t figure out how to stop – or fix. Life is hard. Now – how hard is all relative … but for most of us, our days are consumed on some level with a pretty significant level of worry. Did you overextend when you bought that house? Is so-and-so gunning for your job? Is it wrong that you secretly and deeply resent your partner because you’re sick of them “never doing anything”?

And how about the real worries – will you have food, electricity, heat, clothing, safety…the worries that consume more people than any of us would care to imagine (The Shriver Report has 1 out of 3 women living ‘on the brink’ – in other words, right smack dab in this reality). For fun – let’s try an exercise marriage counselors use for marriages that are in trouble…they have each of you sit down and write on a piece of paper what matters to you, and what you think matters to your partner. Then they compare the two. And what do you think stands out in stark testament to the current state of the relationship? Pretty much zero overlap. You don’t understand what matters to me, and I don’t understand what matters to you.

Let’s extend that analogy to the healthcare space…picture a typical day for many of us in the health communication space, for example. How are we spending our days? Dreaming up new and more imaginative ways to lecture about the importance of getting a colon cancer screening, or eating well, or taking your blood pressure medication, or getting in for your annual Medicare wellness visit, or or or…

And a question for those of us working on this stuff. If you turned all that passion and intensity you bring with you to work, and to the task of telling others how to live in a way that complies with HEDIS this or STAR that or [insert any other traditional health quality metric here]…if you turned that lens on yourself – how are you doing? Do you eat the way you should? How’s your weight? Do you sleep the recommended 7 to 8 hours of sleep a night? How are you on your preventive screenings – are you up to date? Did you exercise at all in the last week?

I’d bet the answer to all those questions is “no”. Continue reading…

How the Advent of Propofol Changed the Meaning of the term “Sedation”

Feb 4, 2015• 1

By KAREN SIBERT, MD

“Twilight! She has to have twilight,” insisted the adult daughter of my frail, 85-year-old patient. “She can’t have general anesthesia. She hasn’t been cleared for general anesthesia!”

We were in the preoperative area of my hospital, where my patient – brightly alert, with a colorful headband and bright red lipstick – was about to undergo surgery. Her skin had broken down on both legs due to poor circulation in her veins, and she needed skin grafts to cover the open wounds. She had a long list of cardiac and other health problems.

This would be a painful procedure, and there would be no way to numb the areas well enough to do the surgery under local anesthesia alone. My job was to figure out the best combination of anesthesia medications to get her safely through her surgery. Her daughter was convinced that a little sedation would be enough. I wasn’t so sure.

“Were you asleep the last time your doctor worked on your legs?” I asked the patient. “Oh, yes,” she said. “Completely asleep.”

“But she didn’t have general,” the daughter interrupted. “She just had twilight.”

Health IT: Glass Half Empty? Half Full? Shattered?

Feb 4, 2015• 5

By JACK COCHRAN, MD and CHARLES KENNEY

Technology occupies an unusual place in health care. Some people say that electronic health records are clumsy barriers between patients and their doctors. Others suggest that technology is a kind of secret sauce.

In many places physicians and other clinicians are stymied by awkward technology. In other organizations — Kaiser Permanente included — electronic health records enable some of the finest individual and population health care ever.

This humorous equation speaks volumes about technology and health care:

NT + OO = COO

New technology + old organization = Costly old organization. In other words, technology doesn’t change an organization. Change is about leadership and culture. It is about thinking in new ways and asking new questions.

For example, rather than ask how many patients can you see, let’s ask how many patients’ problems can you solve?

Instead of asking how can we convince patients to get required prevention, let’s ask how can we create systems that significantly increase the likelihood that patients get required prevention?

Instead of asking how often should a physician see a patient to optimally monitor a condition, let’s ask what is the best way to optimally monitor a condition?

When we begin asking these kinds of questions, we see technology as a tool — not a solution by itself, but as a powerful tool we can use to deliver better individual and population care. Technology, like data, is only useful when it enables clinicians and teams to work effectively to provide the highest quality care for patients.

Hospitals and physician groups throughout the country are installing and working with electronic health records at a rapid pace. Some organizations integrate the systems beautifully, others do not.

Privacy and Security and the Internet of Things

Feb 3, 2015• 7

By DAVID HARLOW

In the future, everything will be connected.

That future is almost here.

Over a year ago, the Federal Trade Commission held an Internet of Thingsworkshop and it has finally issued a report summarizing comments and recommendations that came out of that conclave.

As in the case of the HITECH Act’s attempt to increase public confidence in electronic health records by ramping up privacy and security protections for health data, the IoT report — and an accompanying publication with recommendations to industry regarding taking a risk-based approach to development, adhering to industry best practices (encryption, authentication, etc.) — seeks to increase the public’s confidence, but is doing it the FTC way: no actual rules, just guidance that can be used later by the FTC in enforcement cases. The FTC can take action against an entity that engages in unfair or deceptive business practices, but such practices are defined by case law (administrative and judicial), not regulations, thus creating the U.S. Supreme Court and pornography conundrum — I can’t define it, but I know it when I see it (see Justice Stewart’s timeless concurring opinion in Jacobellis v. Ohio).

To anyone actively involved in data privacy and security, the recommendations seem frighteningly basic:

–build security into devices at the outset, rather than as an afterthought in the design process;

– train employees about the importance of security, and ensure that security is managed at an appropriate level in the organization;

– ensure that when outside service providers are hired, that those providers are capable of maintaining reasonable security, and provide reasonable oversight of the providers;

– when a security risk is identified, consider a “defense-in-depth” strategy whereby multiple layers of security may be used to defend against a particular risk;

–consider measures to keep unauthorized users from accessing a consumer’s device, data, or personal information stored on the network;

–monitor connected devices throughout their expected life cycle, and where feasible, provide security patches to cover known risks.

–consider data minimization – that is, limiting the collection of consumer data, and retaining that information only for a set period of time, and not indefinitely;

– notify consumers and give them choices about how their information will be used, particularly when the data collection is beyond consumers’ reasonable expectations.

HIT Newser: A Meaningful Sigh of Relief

Feb 3, 2015• 4

By MICHELLE RONAN NOTEBOOM

ONC Issues Draft HIT Interoperability Road Map

The ONC releases a draft of its 10-year nationwide interoperability road map, which includes a focus on helping the majority of providers across the care continuum and consumers achieve basic interoperability of health data over the next three years. The ONC also released a draft of its Interoperability Standards Advisory, which includes an assessment of the best available standards and implementation specifications for clinical health information interoperability.

Public comment for the draft Roadmap closes April 3, 2015; comment period for the Standards Advisory closes May 1, 2015.

Meaningful Use Reporting Relief

CMS proposes rule changes for the EHR incentive program, including a reduction in the 2015 reporting period from one year to 90 days. An additional change would re-align the reporting period to match the calendar year, giving hospitals more time to incorporate 2014 Edition software into their workflows and better align with other CMS quality objectives. CMS will consider additional program modifications to reduce complexity and lessen providers’ reporting burdens.

CMS noted that the proposed rule changes are separate from the upcoming Stage 3 proposed rule that should be be released in March that is expected to limit the scope of the Stage 3 requirements for MU in 2017 and beyond.

Providers, vendors, and professional organizations are breathing a collective sigh of relief over the CMS announcement. The proposed changes aren’t too surprising, given low Stage 2 attestation numbers and overwhelming provider dissatisfaction with the MU program.

New Valued-based Payment Goals to Drive HIT Adoption

HHS sets a goal for 30 percent of Medicare payments to be link to value-based performance through alternative payment models, such as ACOs, by 2016 and 50 percent by 2018. In addition, HS wants 85 percent of traditional Medicare payments tied to quality by 2016 and 90 percent 2018.

Achieving those objectives will require technology that supports quality-based payments versus the traditional fee-for-service model, so both vendors and providers will need to make aggressive moves to deploy the appropriate tracking and reporting tools. No doubt this will be one of the hotter topics at the HIMSS conference in April.

CPOE For Management

Feb 2, 2015• 9

By PETER ELIAS, MD

At a recent clinical staff meeting, a physician complained that the new requirement that clinicians enter all orders manually into the electronic record (CPOE) is slowing us down and causing errors. The IT and administrative staff were not the least sympathetic. Their message: it’s really not a big deal, it only takes an extra minute or two, and smart people like you should be able to master a simple skill like this. On the way home, I came up with a way to help them better understand: CPOE for management.

I would like to see them forced to use their own version of CPOE: Computer Process for Organizing Errands. Here’s how it would work.Every errand they do requires a computerized planning and documentation process. Whether they were going grocery shopping, out to fill up the tank on their car, buying shoes for their child, or a present for their spouse, here is what they would have to do:

Go to their computer and start the Errand Management Resource (EMR).
Go to the Schedule Errands tab and open it.
Enter each errand (picked from a list of 20,000 possible errands) and link it to a household or family category. Examples might include:
Continue reading…