The Health Care Blog – Page 479 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

Above the Fold

An Outbreak of Outbreaks

Jun 11, 2014• 2

By Melinda Moore, Andrew M. Parker, and Courtney Gidengil

Lately, stories about outbreaks seem to be spreading faster than the diseases themselves. An outbreak of measles in Ohio is just part of an 18-year high of U.S. cases. Meanwhile, polio continues to circulate in Pakistan, Afghanistan, and Nigeria, while spreading to other countries, like Cameroon, Equatorial Guinea, and Syria, leading the World Health Organization to declare a “Public Health Emergency of International Concern” last month.

The Role of Globalization

As recent threats of H5N1, H1N1, and MERS attest, the increasingly global nature of infectious diseases presents serious risks. Foreign tourists, Americans returning home from international travel, immigrants, and refugees can all expose countries to disease.

With modern transportation shuttling people and products to nearly any part of the world in a matter of hours, the volume of these comings and goings is unprecedented. In 2008, approximately 360 million travelers entered the United States, which also takes in about 50,000 refugees annually.

It should be unsurprising, then, that the Ohio measles outbreak started when unvaccinated Amish missionaries visited the Philippines, then returned home. Infected persons spread the disease to others within their largely unvaccinated communities. The last naturally occurring U.S. outbreak of polio occurred in similar fashion: An outbreak in the Netherlands spread to Canada in 1978, then to the United States the following year, all among unvaccinated Amish populations across four states.

Compared to the United States, nations experiencing social unrest and political conflict face even more serious obstacles to preventing infectious disease.

Strife can interrupt routine vaccination campaigns, as is largely happening with polio. For example, the largest numbers of polio cases last year were in Somalia and Pakistan. Refugees and other displaced populations without health care access can create fertile settings for disease spread, especially if they’re not protected by vaccination. Health workers involved in vaccination campaigns can become targets of violence. And in some areas—Nigeria, for example—religious leaders haveconvinced their followers that the polio vaccine is a biological weaponpromulgated by the West.

For the most part, the United States doesn’t face these barriers. In America, vaccination is more of a choice. Unfortunately, some Americans are putting themselves, their families, and their communities at risk by choosing not to get vaccinated. If those who opt out of vaccination travel to areas where diseases are more common or come in contact with individuals arriving from such areas, they’ll be at risk of becoming ill from otherwise preventable diseases.Continue reading…

How Does the VA’s Technology Rate Against Other EMR Vendors?

Jun 10, 2014• 3

By EDMUND BILLINGS, MD

Health care for veterans has been all over the news. At the same time, the DoD is moving to procure a replacement EHR system. So it seems there is no time like the present to review a recent RAND case studies report entitled “Redirecting Innovation in U.S. Health Care: Options to Decrease Spending and Increase Value.”

The case studies include a chapter comparing America’s two most broadly deployed EHRs: The VA’s VistA and Epic. The tale RAND tells is not one of different EHR technologies, as both VistA and Epic both employ the MUMPS programming language and file-based database. Rather, it is about how different origins, business models and practices have dramatically influenced the respective systems. As the report itself says, the contrast offers “useful insights into the development, diffusion, and potential future of EHRs.”

VistA

VistA, “the archetype of an enterprise-wide EHR solution,” supports the Veterans Health Administration, “the largest integrated delivery system in the United States.” Initial VistA development was a collaborative, distributed, grass-roots effort where individual VA medical centers built out new clinical functionality on a common platform.

In the mid 90’s, VistA became the instrument of change at the VA.

The pace and scope of EHR adoption increased dramatically under the leadership of Dr. Kenneth W. Kizer, who served as the VA’s Undersecretary for Health from 1994 through 1999. Dr. Kizer considered installation of a major system upgrade to be a core element in his effort to transform the organization …Continue reading…

Coming To a Decision On Decision-Support Technology

Jun 10, 2014• 21

By JAAN SIDOROV, MD

For more than a decade, a running joke among electronic health (EHR) record skeptics has been that its clunky “decision support” functions, defined as the on-screen provision of clinical knowledge and patient information that helps physicians enhance patient care , is condemned to always remain an innovation of the future. Yet, while published studies like this continue to fuel doubt about the prime-time readiness of this EHR-based technology, a growing body of clinical research suggests that the science is getting better. Jonathan Cohn, writing in The Atlantic, points out that IBM’s Watson has achieved enough of a level of sophistication to warrant clinical trials at prestigious institutions such as the Cleveland Clinic and Memorial Sloan-Kettering.

Unfortunately, there is an under-recognized threat to EHR-based decision support: the dysfunctional U.S. tort system.

The experience of Google’s “driverless car” may be instructive. According to National Public Radio, years of testing is putting this technology within reach of consumers. Thanks to the prospect of fewer accidents, better transportation options for the disabled, reduced traffic congestion and lower hydrocarbon consumption, some states have responded by attempting to support this promising technology with “enabling legislation.”

Unfortunately, the legislation in some state jurisdictions is being hindered by the prospect of complicated lawsuits. As physicians know all too well, when a single mishap lands in court, adroit attorneys can use the legal doctrine of joint and several liability to tap multiple deep pockets to increase the potential size of the award. In the case of driverless cars – in which the owner is more of a passenger than a driver – the accidents that are bound to happen could metastasize upstream from the owner and tie up the driverless automobile manufacturers and all of their business partners in time-consuming and expensive litigation.

Ditto the EHR’s decision support technology. Even with Watson’s intelligence, medicine will remain imperfect and allegations of medical mistakes will be inevitable. When lawsuits arise, the defendant medical providers will likely argue that their judgment was clouded by the very technology that otherwise helped them better serve their other patients. Personal injury lawyers are unlikely to let that theory of liability go unused. Tapping the same kind of lucrative joint-and-several legal theories that have served them so well in decades of standard malpractice litigation, they’ll undoubtedly be happy to name the EHR manufacturer and all of its decision-support business partners in these lawsuits.

10 Things You Can Do With CMS Data

Jun 9, 2014• 17

By Farzad Mostashari,MD

Five years ago, my mother needed an orthopedic surgeon for a knee replacement. Unable to find any data, we went with an academic doctor that was recommended to us (she suffered surgical complications). Last month, we were again looking for an orthopedic surgeon- this time hoping that a steroid injection in her spine might allay the need for invasive back surgery.

This time, thanks to a recent data dump from CMS, I was able to analyze some information about Medicare providers in her area and determine the most experienced doctor for the job. Of 453 orthopedic surgeons in Maryland, only a handful had been paid by Medicare for the procedure more than 10 times. The leading surgeon had done 263- as many as the next 10 combined. We figured he might be the best person to go to, and we were right- the procedure went like clockwork.

Had it been a month prior to the CMS data release, I wouldn’t have had the data at my fingertips. And I certainly wouldn’t have found the most experienced hand in less than 10 minutes.

It’s been a couple of months since the release of Medicare data by the Centers for Medicare and Medicaid (CMS) on the volume and cost of services billed by healthcare providers, and despite the whiff of scandal surrounding the highest paid providers (including the now-famous Florida ophthalmologist that received $21 million) the analyses so far have been somewhat unsurprising. This week, coinciding with the fifth Health DataPalooza, is a good time to take stock of the utility of this data, its limitations, and what the future may hold.

The Future of the Physician

Jun 7, 2014• 52

By DAVID DRANOVE and CRAIG GARTHWAITE

On Wednesday June 4, the Kellogg School of Management hosted its annual MacEachern Symposium. A packed auditorium listened to an impassioned discussion about The Future of the Physician. Presidential adviser Ezekiel Emanuel and AMA President Ardis Hoven were among the speakers. While Emanuel was optimistic about the impact of the Affordable Care Act on hospital-physician integration and the resulting potential for cost savings and quality improvements, Hoven was concerned about the impact of the business of healthcare on the medical profession. In this blog, we offer our perspective on the evolving role of the physician.

The hit television series Marcus Welby, MD last aired in 1976. Dr. Welby was the physician of every baby boomer’s dreams, whose patients always felt cared for and always got better. By the end of the century, Dr. Welby had been replaced by Dr. House, an MD cum Sherlock Holmes with Narcissistic Personality Disorder and an opiate addiction. While his bedside manner is decidedly not Welbyesque, Dr. House still embodied the basic premise of the all-knowing and dedicated provider that solves problems with little concerns for costs or standard practice.

But in the real world, physicians are evolving along a different—and we argue—better path. The 20th century physician was self-employed, championed the interests of patients, and had complete control over the medical system. But this system had at least two primary problems: (1) ever escalating costs and (2) dramatic variations in physician practice patterns with little connection to outcomes. We shudder to think how much Dr. House spent on his patients. This system is no longer sustainable.

Enter the 21st century physician, who is increasingly an employee of a large provider organization that scrutinizes every medical decision based on both cost and quality. We may all be better off for this transformation – the question is will we accept it? If past is prologue, we fear that American public is still not ready.

Head Games

Jun 6, 2014• 8

By ART CAPLAN

Concussions are the talk of sports these days. Ex-NFLers are filing suits against the league saying it is clear that the league knew about the dangers of head trauma, knew them a long time ago but, did nothing. Parents in the U.S. and Canada are starting to pull their elementary and junior high kids out of tackle football and hockey leagues that permit body-checking. Even the President has talked about his own experience with concussions (mild he was quick to note!) and convened a high level summit at the White House of all the movers and shakers in the field to discuss the problem.

The NFL is so freaked out about the threat concussions pose to the long-term profitability of the sport that they are trying to calm worried moms with ad campaigns that tout the certification of coaches who teach the ‘safe’ way to play (good luck with that). And arguments are breaking out about whether there is too much emphasis on football and men’s hockey when wrestling, lacrosse, soccer, martial arts, and women’s basketball have their own problems with keeping player’s heads intact (kind of an odd form of anti-discrimination). Some sports experts are even bemoaning the fact that the emerging obsession with preventing, diagnosing and treating concussions is diverting too much attention and resources away from other serious health issues that athletes face including bullying, eating disorders, orthopedic injuries and the abuse of legal and illegal drugs.

Is the Wearable Market About to Explode?

Jun 6, 2014• 2

By Rick Valencia

With Samsung & Apple both making big announcements (if not actually putting out products) and more and more venture money going into trackables of all kinds–including $120m for “chip in pill” maker Proteus–in the last 10 days, there’s tons of hype about consumer tracking in lots of modalities. Qualcomm is the guts behind lots of the chips and technologies that these all use, and have seeded the market with their 2Net data utility layer. (FD I am on the Qualcomm Life advisory board but own no stock). But is the hype justified? Qualcomm Life’s President Rick Valencia is an optimist, and you’ll hear from him at Health 2.0 this Fall—Matthew Holt

Look around. Chances are, someone around you is wearing one right now. I’m not talking about a baseball cap or a pair of minimalist running shoes. I’m talking about a connected device—a “wearable”—a fitness band, a smart watch, a pair of smart glasses…of maybe even connected clothing.

Ready or not, the wearable market is about to explode.

Right now, fitness-related wearables dominate the market—about 90 percent according to a February CNET report quoting Accenture. But by 2018, the market will expand, to where three categories—fitness/activity trackers, smart watches and infotainment, health care and medical categories—will take over 70% of the wearable space says ABI Research. In that same year, you also probably won’t have to look too hard for someone with a wearable, research firm IDC says the number of devices out there will be 118 million.

I too think we’re only touching the tip of the iceberg with wearables. There’s a lot of opportunity out there, not just in form factors but what’s possible with function and value.

Consider fitness bands. They give users real-time feedback on performance and, if you can upload the data to the cloud, onto a platform where you can compare your latest event with previous events, they are a great way to gauge progress. In addition, these cloud-based platforms give wearable device makers a place to begin engaging with customers.

These fitness applications are great, but can we go further?

Pharos Innovations Meets Isaac Asimov

Jun 5, 2014• 16

By AL LEWIS and VIK KHANNA

Isaac Asimov once remarked that a sufficiently advanced technology was indistinguishable from magic.

Were he alive today, Mr. Asimov might also remark that both advanced technology and magic got nothing on Pharos Innovations, whose website reports a world-record 79% reduction in admissions for congestive heart failure (CHF) patient monitoring.

Pharos achieved this Nobel Prize-worthy result in CHF monitoring without actually using CHF monitoring devices, but rather just the telephone and that favorite tool of the frail elderly, the Internet. Most magical was the time this admission reduction took: 31 days.

On the graph below, you can see that the baseline ended December 31, 2007, while the full impact started February 1, 2008.

That means Pharos was magically able to find all these members’ contact information, write to them to announce the program, schedule the phone calls to the members to convince them to join the program, collect their information, conduct those phone calls, explain the system to the members, get them set up on the system, collect the information, get members to visit their doctors, and adjust lifestyles and medications…all during January.

Thanks to that lightning speed, there was literally a 90% decline between the December admissions rate and the February admissions rate, as this chart demonstrates. Overall, this chart is a dramatic rebuttal to the conventional wisdom, which would state that:

it takes a long time to make even the most minor improvements in a population through telephonic and Internet disease management, if indeed improvements are possible at all; and
a trendline that is “unchanged” does not decline 25% like Pharos “unchanged” matched cohort trendline above.

In college Al was assigned a roommate who was like the bad seed from the Richie Rich comics, a kid who, among other things, would have a snifter of cognac before bed. Once Al told this guy he was decadent. “Decadent, Al?” he countered. “Let me tell you about decadent. I spent last summer at a summer camp –everyone was there, Caroline Kennedy, everyone – where we played tennis on the Riviera and then went skiing in the Alps.”

Al agreed he had a point. “Wow, Lance, you’re right. That was decadent.”

“Al,” he replied, “I haven’t even gotten to the decadent part yet.”

The Side Effects of Releasing Public Health Insurance Data to the Public

Jun 5, 2014• 1

By NIAM YARAGHI

Three of the five largest private health insurers in the US – UnitedHealthcare, Aetna, and Humana – have decided to follow the lead of the Centers for Medicare & Medicaid Services (CMS) and release their payment information to the public. According to Bloomberg News, this data will include 5 billion individual medical claims and $1 trillion in spending.

Releasing payment information by governmental and private health insurers is an important step towards transparency. Providing researchers with access to the details of health insurance payments is an unprecedented and long-awaited opportunity to gain insights into the drivers of rising healthcare costs. Although I share the enthusiasm of many other researchers for analyzing this valuable data, I am also concerned with unanticipated consequences that may arise with unrestricted release of sensitive and complicated healthcare insurance data to the public.

Reputation of Physicians

The performance of physicians, as some of the most reputable and highly specialized professionals of our society, cannot be evaluated only based on their insurance billing history. To the untrained eye, the abnormalities in insurance charges may seem unjustifiable. Deep expertise in the medical domain is required to investigate all of the underlying causes of the abnormal prescriptions, medical procedures and equipment utilizations. Accusing physicians of malpractice or misconduct based on hasty analysis of this data and without careful examination of the unique medical context in each case, would be unfair to those who deliver medical care to patients.

Lost in the Health Care System?

Jun 4, 2014• 76

Jack Cochran

By Jack Cochran & Charles Kenney

“As a PCP, I’ve seen the morale in my area, and I see a major crisis coming if the complaints are ignored.”

“I’ve lived in the hell that is American health care…”

A devoted physician wrote these words in reaction to a recent blog post we wrote. And he is clearly not alone.

In our new book The Doctor Crisis, we report on the widespread unhappiness, frustration, dissatisfaction, and anger of so many American physicians.

We believe this crisis is real and growing; that it is an impediment to providing the care the American people need; that dealing with the doctor crisis is fundamentally patient-centered; and that the crisis has not been recognized for the fundamental threat it poses.

Our recent feature on The Health Care Blog elicited some powerful reaction:

Rob: ”In a certain sense, individual doctors ARE victims of a system that rewards over-consumption, ridiculous documentation, attention to codes over people, and bureaucracy over partnership…”

Jeff: “Can validate what Rob has said. I’ve spent the last three years listening to physicians about the possible alternative futures for their profession, and the overwhelming desire was exactly as Rob said- an overwhelming impulse to flee…”

Some commentators wrote that doctors shouldn’t complain because they earn a lot of money, drive fancy cars and own nice homes. But that theme – accurate in many cases but certainly not all — gets us nowhere.

We think the rubber meets the road with this warning from Dr. Rob, ”…As a PCP, I’ve seen the morale in my area, and I see a major crisis coming if the complaints are ignored.”

Is Dr. Rob overstating it? We don’t think so. In fact, we think he has it exactly right. How can our system function properly if the level of job satisfaction among doctors continues to spiral downward?

Harris Interactive research describes the profession as “a minefield’’ where physicians feel burned out and “under assault on all fronts.’’ Has such extreme language ever been used to characterize the medical profession? Have doctors ever faced a time as turbulent as this?

Doctors are certainly not blameless as both Brian and Rob noted in their comments:

Brian: “…I’m concerned that you have framed your argument as though physicians are victims of the system rather than partial drivers of its characteristics …”

Rob: “…physicians as a group have been complicit in building this system, and so should bear a lot of the blame…”

So what needs to be done?

A crucial first step is for health care stakeholders to recognize and acknowledge the existence of the crisis. Doing so will get the doctor crisis on the national health care agenda. Unfortunately, the matter is not currently a priority for many, if not most, provider organizations. That needs to change.