Surprise #1. It’s not called the iWatch, as many observers had predicted. Meet the Apple Watch.
Surprise #2. No camera.
Not really-a-surprise: The $350 price tag is now trending on Twitter.
Above the Fold
Should Wearables Data Live In Your Electronic Medical Record?
The great promise of wearables for medicine includes the opportunity for health measurement to participate more naturally in the flow of our lives, and provide a richer and more nuanced assessment of phenotype than that offered by the traditional labs and blood pressure assessments now found in our medical record. Health, as we appreciate, exists outside the four walls of a clinical or hospital, and wearables (as now championed by Apple, Google, and others) would seem to offer an obvious vehicle to mediate our increasingly expansive perspective.
The big data vision here, of course, would be to develop an integrated database that includes genomic data, traditional EMR/clinical data, and wearable data, with the idea that these should provide the basis for more precise understanding of patients and disease, and provide more granular insight into effective interventions. This has been one of the ambitions of the MIT/MGH CATCH program, among others (disclosure: I’m a co-founder).
One of the challenges, however, is trying to understand the quality and value of the wearable data now captured. To this end, it might be useful to consider a evaluation framework that’s been developed for thinking about genomic testing, and which I’ve become increasingly familiar with through my new role at a genetic data management company. (As I’ve previously written, there are many parallels between our efforts to understand the value of genomic data and our efforts to understand the value of digital health data.)
The evaluation framework, called ACCE, seems to have been first published by Brown University researchers James Haddow and Glenn Palomaki in 2004, and focuses on four key components: Analytic validity, Clinical validity, Clinical utility, and Ethical, Legal, and Social Implications (ELSI). The framework continues to inform the way many geneticists think about testing today – for instance, it’s highlighted on the Center for Disease Control’s website (and CDC geneticist Muin Khoury was one of the editors of the book in which the ACCE was first published).
Is Healthcare a Business?
In the United States, the question has been asked time and again but never satisfactorily answered. By virtue of publically financed healthcare systems, the rest of the developed world has decided, to a greater or lesser extent, that medicine and healthcare are not pure businesses—that citizens have a right to care, even when they can’t pay all associated costs.
It’s starting to look like Americans won’t be able to duck the question for much longer.
In the last year, the profitability of U.S. hospitals eroded for the first time since the Great Recession, pushing some closer to and others over the solvency precipice. Revenues are down and costs are up. And these issues appear systemic and entrenched, giving rise to a series of important and relevant questions: How can hospitals adapt? If they do, will they still survive? And, do we as a nation think it’s important to make hospitals accessible, even if they lose money?
As recently reported in the New York Times, analysis by Moody’s Investors Service shows that this year nonprofit hospitals had their worst financial performance since the Great Recession. Among the 383 hospitals studied, revenue growth dipped from a 7 percent average to 3.9 percent on declining admissions. For the last two years, expenses have grown faster than revenues, and fully one quarter of all hospitals are operating at a loss.
In a word, Moody’s describes the situation as “unsustainable” because it is the product of what look like enduring realities:
- Private insurers did not increase payments to hospitals.
- Medicare reduced payments due to federal budget cuts.
- Demand for inpatient services declined as outpatient care options rose.
- Retail outpatient options now compete with hospital clinics.
- Patients with higher copays and deductibles chose not to seek care.
- Hospitals are buying up physician practices.
- The costs of electronic medical record systems are impacting the bottom line.
Behind the CVS Health Decision
Last Tuesday at midnight, CVS officially changed its name to CVS Health and simultaneously cleared its 7,700 retail stores of tobacco products a month earlier than previously reported. Its stores will be called CVS Pharmacy with plans to expand its 900 primary care clinics to 1,500 by 2017, and its $90 billion pharmacy benefits management unit, CVS Caremark, continuing to play a key role in serving its 65 million customers(1).
And the following day, the CMS Office of the Actuary released its forecast of health spending, predicting that health spending will likely return to 6% annual increases for the next decade(2).
No doubt, the timing of the two is coincidental. But taken together, they paint a future state in healthcare that’s distinctly different from its recent past.
What Killed Joan Rivers? Piecing Together a Medical Mystery
There are minor operations and procedures, but there are no minor anesthetics. This could turn out to be the one lesson learned from the ongoing investigation into the death of comedian Joan Rivers.
Ms. Rivers’ funeral was held yesterday, September 7. Like so many of her fans, I appreciated her quick wit as she entertained us for decades, poking fun at herself and skewering the fashion choices of the rich and famous. She earned her success with hard work and keen intelligence–she was, after all, a Phi Beta Kappa graduate of Barnard College. Ms. Rivers was still going strong at 81 when she walked into an outpatient center for what should have been a quick procedure.
So when she suffered cardiac arrest on August 28, and died a week later, we all wondered what happened. I have no access to any inside information, and the only people who know are those who were present at the time.
But the facts as they’ve been reported in the press don’t fully make sense, and they raise a number of questions.
What procedure was done?
Early reports stated that Ms. Rivers underwent a procedure involving her vocal cords. A close friend, Jay Redack, told reporters at the NY Post, “Her throat was bothering her for a long time. Her voice was getting more raspy, if that was possible.” In a televised interview, Redack told CNN that Ms. Rivers was scheduled to undergo a procedure “on either her vocal cords or her throat.”
However, the Manhattan clinic where Ms. Rivers was treated, Yorkville Endoscopy, offers only procedures to diagnose problems of the digestive tract. All the physicians listed on the staff are specialists in gastroenterology. Any procedure on the vocal cords typically would be done by an otolaryngologist, who specializes in disorders of the ear, nose, and throat.
So it may be that acid reflux was considered as a possible cause of Ms. Rivers’ increasingly raspy voice, and she may have been scheduled for endoscopy at the Yorkville clinic to examine the lining of her esophagus and stomach. Endoscopy could reveal signs of inflammation and support a diagnosis of acid reflux.
Upper gastrointestinal (GI) endoscopy involves insertion of a large scope through the patient’s mouth into the esophagus, and passage of the scope into the stomach and the beginning of the small intestine. It’s a simple procedure, but uncomfortable enough that most patients are given sedation or, less commonly, general anesthesia.
Was sedation given?
Three types of medication are commonly used for sedation during endoscopy:
1. Midazolam, diazepam (Valium), or other medications in the benzodiazepine family are often used to help patients relax before the start of the procedure and to produce amnesia.
2. Narcotics such as Demerol and morphine are often used to provide pain relief and make the procedure less uncomfortable.
3. Propofol, a potent sedative and hypnotic medication, may be used to induce sleep and prevent awareness. Many people first heard of propofol as the medication associated with the death of singer Michael Jackson in 2009.
Why Nobody Is Using Your Health App (And How to Fix It)
People are becoming more conscious about their health. It’s why fitness apps are booming and both Apple and Google are looking to get into the health game. But apps that try to go beyond simple calorie counting and movement tracking often struggle to gain traction with users.
Although people are open to sharing how many steps they’ve taken or how much they weigh, they’re more hesitant to share their personal medical details.
Here are some data-related fears consumers often have with healthcare apps:
- Personal medical information could get leaked. Revealing users’ medical information could be embarrassing and life shattering.
- Companies could use the data for marketing purposes. Imagine your spam getting smarter about your personal health details. Companies are already pinpointing viewers’ interests, and revealing this information could expose you to targeted email spam and calls tailored to your health issues. Members of Congress have already discussed legislation that would forbid medical apps from selling personal data without the user’s consent.
- Unqualified employees could access their information. Patients feel comfortable divulging medical information to a doctor, but they probably wouldn’t want the IT guy who supports the app to see and read their information.
There are many reasons people might hesitate to use your app. But by identifying potential concerns and considering them as you develop and market your app, you can quell their fears and ensure the long-term success of your medical app.Continue reading…
Yes, Doctors Are Sick of Their Profession. And You’re Making Things Worse!
By KAREN SIBERT
Dr. Sandeep Jauhar, a cardiologist, believes with good reason that many physicians have become “like everybody else: insecure, discontented and anxious about the future.” In a recent, widely-circulated column in the Wall Street Journal, “Why Doctors Are Sick of Their Profession,” he explains how medicine has become simply a job, not a calling, for many physicians; how their pay has declined, how the majority now say they wouldn’t advise their children to enter the medical profession, and how this malaise can’t be good for patients.
Dr. Jauhar gets it right in many ways, but the solutions he recommends miss their mark completely.
I was 100% in accord with Dr. Jauhar when he argued that “there are many measures of success in medicine: income, of course, but also creating attachments with patients, making a difference in their lives and providing good care while responsibly managing limited resources.”
The next paragraph, though, I read with astonishment. Does Dr. Jauhar really believe that publicizing surgeons’ mortality rates or physicians’ readmission rates can be “incentive schemes” that will reduce physician burnout? Does he seriously think that “giving rewards for patient satisfaction” will put the joy back into practicing medicine?
If so, I’m afraid he doesn’t understand the problem that he set out to solve.
Sometimes the Best Choice is the Simplest One
CMS recently announced another change to health IT policy in order to offer healthcare providers greater flexibility. But what will the unintended consequences of this latest change be?
Over the Labor Day weekend, CMS announced that the Meaningful Use Stage 2 deadline will be extended through 2016 in order to offer more options and greater flexibility to providers for the certified use of EHRs. In the interest of full disclosure, I found the timing to be strange— a rule published over a holiday weekend seems an odd choice, particularly when it is being touted as a benefit to the industry and the impact on healthcare provider organizations and clinicians, alike, is monumental.
Unfortunately, I think the additional flexibility allotted by this rule is the latest example of the unintended consequences of health IT regulations. In an effort to make things easier and give healthcare providers more leeway, they have, in fact, made the situation unnecessarily more complex.
Agility is not healthcare’s strong suit
It seems at this point, too many options, or waffling between them (for instance the new ICD-10 transition deadline), can be more crippling than stringent regulations, particularly when there is so much on the line. Healthcare organizations don’t have the wherewithal to vacillate with implementations; they are wrestling with string-tight budgets and constantly shifting rules require large cultural and behavioral changes. As a result, as Dr. John Halamka noted, health IT agendas are being constantly hijacked by regulatory changes, such as Meaningful Use and ICD-10.
It now seems that hospital administrative teams and physicians again must endure constantly shifting rules that they’ve been coping with for years under Meaningful Use. As Dr. Ben Kanter, former CMIO of Palomar Health, so astutely noted “A computer system is a tool, just as a scalpel is a tool. What if a surgeon’s scalpel changed every few weeks? How is it possible to deliver good care if the primary tool you are using keeps changing on an irregular basis?”Continue reading…
It is Time for Clinicians to Engage: Let’s Criticize Less and Dare Greatly More
When I write or speak about healthcare transformation, I am often asked why I do not criticize more. Criticize health system leadership. Criticize governmental policies. Criticize burdensome regulations. It’s a long list. Why avoid criticism? The answer is simple. Discerning emerging solutions is much more productive and fun.
We are living during a very interesting period in the history of health care. No doubt, it is a time of great transition. We are passing from one time to another. Transition periods are important, yet they are hard to define because it’s difficult to determine exactly when they start and when they end. To understand the transition healthcare is now experiencing, we must do our best to understand what is on either side of it.
The traditional approach to delivering care has served us well and accomplished great things over the past century. Yet, it is also being overwhelmed by complexity and producing inconsistent quality, unacceptable levels of harm, too much waste and spiraling costs.
The traditional method of delivering care is struggling and another is emerging to take its place. Because the traditional approach has served us well and accomplished great things, we want to believe that the present state will continue forever. Because conditions have changed, this will not happen. We are in need of a new approach. An approach that carries the best of the past forward, yet also addresses present day challenges. It just might be that on the other side of this current transition is potentially a time unmatched by any other in the history of healthcare. Thanks to visionary clinical leaders at institutions across the country, there is growing evidence this is not only possible; it is likely.
Who does the future belong to? If we look closely at other transition periods in history, two groups of people are apparent. The first are what we recognize as critics. They are people whose response to the need for change is criticism. Critics always exist, but in a time of transition they tend to multiply. What do they criticize? They criticize the new, they criticize the change, they criticize the change for being unnecessary or too fast, or they criticize the change for being too slow. They criticize anything and everything. Critics are abundant. The question we should consider is, “Will criticism solve problems?” Typically, it does not. While constructive criticism has its place, it alone is not likely to accomplish much especially when the world is yearning for innovative solutions.
Medicaid 2.0
While fierce debate continues to envelop much of the Affordable Care Act, financial data for many of the nation’s health systems reveal one clear fact: the optional Medicaid expansion has resulted in hospital haves and have nots.
An analysis by PwC’s Health Research Institute (HRI) of newly released earnings and patient volume data shows a clear financial split between healthcare providers operating in states that expanded Medicaid and those that have not. The law as written would have provided Medicaid coverage to every American earning less than 138% of the federal poverty level ($16,105 for an individual). But a June 2012 Supreme Court ruling made the expansion optional for states, creating a patchwork of coverage.
Health systems and physician groups delivering care in the 26 states and the District of Columbia that have embraced the federally-funded expansion have reported a significant rise in patient volumes and paying consumers and a measureable reduction in uncompensated care levels.
This year alone LifePoint Hospitals has seen a 30.3% reduction in its uninsured and charity care patients, according to filings with the Securities and Exchange Commission. Tenet Healthcare, which operates in five Medicaid expansion states, saw uninsured and charity care admissions decline by 46% in the expansion states, coupled with a 20.5% increase in Medicaid inpatient admissions in those same states, according to an HRI analysis which will be released next week.
In all, HRI analyzed financial data from the nation’s five largest for-profit health systems—HCA Holdings, LifePoint, Tenet, Community Health Systems and Universal Health Services, representing 538 hospitals in 35 states. Our team also reviewed data from several mid-sized hospitals, government reportsand industry surveys.
