First, let’s get the plug out of the way, shall we? Here’s the deal: The Robert Wood Johnson Foundation has a new initiative, Flip the Clinic—and we want you to join us.
We’re launching the new Flip the Clinic site this week. Here’s the trailer. Please take a look, and then let me know what you think:
[vimeo=89722532]
So, what’s with all this flipping business? What’s all this talk about health conversations?
The year is 2020, or sometime in the future when the healthcare system is better, much better. Patients have access to their medical notes, are encouraged to read the notes regularly and ask physicians relevant questions. This is to facilitate patient-centered participatory medicine (PCPM), previously known as shared decision making. In fact, note reading by patients is now a quality metric for CMS.
The CEO of the Cheesecake Hospital Conglomeration, one of the hospital oligopolies, has set up a Bureau for Transparency and Protection of Patients from Complex Medical Terminology. The goal is to risk manage troublesome medical writing that could result in poor satisfaction scores, complaint or a lawsuit.
Mr. Upright (MU) is the Inquisitor General for the bureau. He has called the author (SJ), a repeat offender, to his office to discuss elements of his medical record keeping.
Disclaimer: Any resemblance to future events is purely coincidental. The narration is merely a reflection of the author’s paranoid affect and a tendency to believe in conspiracy theories.
MU: Dr. Jha, you’ve been summoned because your open medical notes do not meet the standards for empathy and compassionate care and seem devoid of a reflection on the complex interplay between social determinants of health.
SJ: Has a patient complained?
MU: No. But that’s what the bureau is trying to prevent. We protect patients from physicians. Actually, we protect physicians from their most dangerous enemy: themselves.
PCORI is pleased to announce the PCORI Matchmaking App Challenge. This initiative seeks to create research partnerships that allow innovators and patients to work together. Developers are invited to make a full functioning, ready-to-publish app that has the capability to connect patients with researchers.
The Initiative
We are inviting developers to create an app that brings together patients, stakeholders, or researchers, and move toward collaborative research. These apps must integrate with already established research networks, and preferably integrates social media and robust user profiles. The developer is also encouraged to include an advanced search option and customizable displays.
Reviewers will include technology experts, PCORI staff members, and members of PCORI’s multi-stakeholder Advisory Panels. Reviewers will consider how well each developer facilitates connections that allow equal access to people from different backgrounds and with varying health interests and research experience, as well as considering creativity and the past experience of the developers.
The rewards are substantial, with PCORI awarding first place with $100,000, second place with $35,000, and third place will take home $15,000.
How to Apply
To enter your team for the Challenge, please go to the pre-registration form.
PCORI and Health 2.0 will host an hour-long informational webinar on Wednesday, April 30, at 1 p.m. (ET) to present the challenge goals and guidelines. We will describe the motivation behind and purpose of the Matchmaking App Challenge; explain the submission guidelines, judging criteria, and other conditions of the challenge; and answer questions from potential applicants. Registration for the webinar is now open. Questions and answers will be posted after the event.
I recently spoke to a quality measures development organization and it got me thinking — what makes a good doctor, and how do we measure it?
In thinking about this, I reflected on how far we have come on quality measurement. A decade or so ago, many physicians didn’t think the quality of their care could be measured and any attempt to do so was “bean counting” folly at best or destructive and dangerous at worse. Yet, in the last decade, we have seen a sea change.
We have developed hundreds of quality measures and physicians are grumblingly accepting that quality measurement is here to stay. But the unease with quality measurement has not gone away and here’s why. If you ask “quality experts” what good care looks like for a patient with diabetes, they might apply the following criteria: good hemoglobin A1C control, regular checking of cholesterol, effective LDL control, smoking cessation counseling, and use of an ACE Inhibitor or ARB in subsets of patients with diabetes.
Yet, when I think about great clinicians that I know – do I ask myself who achieves the best hemoglobin A1C control? No. Those measures – all evidence-based, all closely tied to better patient outcomes –don’t really feel like they measure the quality of the physician.
So where’s the disconnect? What does make a good doctor? Unsure, I asked Twitter:
Over 200 answers came rolling in.
Continue reading…
Why should I be in the same room with these people?
That’s one of the many smart questions participants posed at a Stanford Medical School meeting I attended last weekend. If I had been daydreaming (I’d never do that), I might have thought the question was for me. You see, the participants were a handpicked set of national medical education experts, folks nominally from the status quo medical-education-industrial complex—the very thing we’re trying to change.
You might think that they embodied that dreaded status quo. I’m happy to report they did not—not even close. I’m also relieved to tell you that the question (in spite of my paranoia) wasn’t for me. Instead, it was one of many challenges these thoughtful, passionate teachers tossed at each other.
“Why are we in the room?” was a challenge to each other. Why and when should teachers be in the same room with the learners?
When you think about it, that’s actually a central question if you’re attempting to use online education to flip the medical education experience. It’s also a brave one if you’re a teacher: justify the time you spend with your students.
We’ve seen shorter abstracts, and we’ve seen abstracts with more curious findings, but we’ve never seen a shorter abstract with more curious findings than this one, done by Dignity Health and Dr. Rajan Merchant, and financed by the California Healthcare Foundation, evaluating a gadget made by Propeller Health.
The study group’s use of inpatient care for asthma declined by a whopping 62% vs. the control group. You might think this result violates Dr. John Ioannidis’ well-known conclusion that large treatment effects are usually wrong, but you’d be mistaken. You see, there was no treatment here.
There was only an effect. Dr. Ioannidis’ result applies only to actual comparisons of effects due to different treatments, not to random changes in effects using the same treatment. In this study, the actual treatment protocol was the same and the inhalers were the same.
The only thing different was frequency of drug use. Whereas the conventional wisdom for disease management states that hospitalizations can be avoided by more adherence and hence more drug use, in this case the study group used less medication than the control group, reaching for their rescue inhalers 25% less– once every 6.3 days vs. every 4.7 days for the control group.
Robert McNutt and Nortin Hadler respond to med student Karan Chhabra’s original post, “Actually, High Tech Imaging Can Be High Value Medicine” and the resulting discussion thread.
Thank you for your comments. First, we are happy you are so interested in medical practice and how to do it better. Please do not think for one second that our comments are critical of you.
However, since you persist in thinking that money matters, that you have the right to think that way during your care of a patient, and that economic principles help patients, let’s look again at this issue you have raised.
Nearly 20 years ago, Hadler published his first “Four Laws of Therapeutic Dynamics” (JOEM 1997; 39:295-8):
1) . The Death Rate is One per Person
2) . Never Poke a Skunk
3) . There has Never been a Quack without a Theory
4) . Institutions Die; People Live
Now we present, for the first time ever, the econometric corollaries, the McNutt-Hadler Credo for Value-laden Medical Decision Making:
1) Don’t think of money; think of what the money buys. No patient should be offered a pig-in-a-poke.
2) Don’t think for one moment that medical pricing is rational, let alone market driven. Medical pricing is designed to serve the greed of stakeholders, greed that seems to know no ethical boundaries. Caveat emptor is no match for “common practice” The only way the “consumer” stands a chance is if there are physicians committed to explaining the basis for clinical decisions in an unbiased, transparent, and ethical fashion.
3) If it doesn’t benefit the patient, we don’t care if they give it away – don’t prescribe or order it. (For example, no stable in-patient should have any of the following tests: amylase or lipase; any test for iron deficiency other than the ferritin; CRP, BNP, MRI after a CT of the head, or any chronic care medicine like a statin, iron tablet, heart healthy diet in a cancer patient, vitamin, a blood pressure medicine that costs more than the cheapest alternative, a non-generic medicine that is available in generic form, enteric coated aspirin, or bone scans in women looking for osteoporosis)
A THCB reader in San Diego writes:
I am SERIOUSLY annoyed. I just got off the phone with my insurer. I’d called a day ago and spoken to a representative (who was very helpful) about a claim. I called back today to follow up and check on a detail.
It quickly became obvious that something was very wrong. I realized immediately what had happened. She’d made a mistake. And left out a minor but important detail on my claim.
But instead of owning up to it, the woman pretended as though nothing had happened. It was like we’d never met before. After a five minute conversation she accused me of lying. I could not believe what I was hearing. I was outraged. I asked to be transferred to a supervisor.
The super listened to me for a minute and then took the side of her employee. “Why should I believe you? Can you prove it?”
Can I prove it? I’ve been a good customer for years. I shouldn’t have to prove it!!! “ How can I stop this from happening? Can I record my conversation with my insurer? After all, they’re recording me for “quality purposes”!!!
Lost in the health care maze? Having trouble with your health Insurance? Confused about your treatment options? Email your questions to THCB’s editors. We’ll run the good ones as posts.
We are hearing that Republicans are considering proposing high-risk pools as part of an alternative health insurance reform proposal to Obamacare.
A high-risk pool proposal would likely mean the Congress giving states the flexibility, and perhaps funding, to set up these risk pools. Risk pools by definition are a place where people can go when they are not able to buy health insurance in the regular market because they have a health problem.
That means Republicans would be turning the clock back to a time when insurance companies could turn people down for health insurance because of their health status.
Presumably, the Republicans are contemplating a market where insurance companies could once again choose just who they wanted to cover––the healthy but not the sick.
Anyone turned down could then go the high-risk pool to be assured of having health insurance. Presumably, Republicans would assure consumers that they would be able to access the same kind of comprehensive health insurance and at the same market rates as those able to buy from insurance companies would be able to get.
Let me be clear at this point that I don’t know of anyone in the insurance industry asking to go back to the days when a carrier could exclude people as a result of their health status and make money just covering the healthy.
Whether it’s Obamacare or a risk pool concept, policymakers are faced with the same dilemma: How do you insinuate the unhealthy and otherwise uninsurable into a health insurance system in a way that benefits are comprehensive and costs are affordable for everyone?
Lists guide our lives. Some are easy, even fun, like a menu or shopping list. Some are simple tick-offs for work, like my wife’s honey-do list. Others are frightening, like a draft list.
Some are melancholy, such as the inventory in a Will. We are inspired by our bucket-list. Finally, some are exciting, but stir conflict, like awedding invitation list.
I have a list, which makes me slightly anxious, a little depressed, and which takes modest courage to open up. That is my patient’s list of daily X-ray reports.
Our Electronic Medical Record (EMR), as based around a home page or “Inbox.” This is a continuously updated assembly of data and messages from our practice and patients.
There are medical orders to approve, questions from nurses and patients, billing inquiries, documents to sign, lab results and emergency alerts about patients in trouble.
Except for the drudgery of pushing through a pile of CMS documentation, those lists have scant emotional impact on me. Not so the eighth list, just four from the bottom: Radiology Documents.
These are the results delivered electronically of any MRI, CT scan, bone scan, chest X-ray or other imaging study, that I, or other doctors, have ordered on my patients. Every 24 hours, between 15 and 30 new reports pop-up.
Opening this section I see three columns; the patient’s name, the date the test was performed, and the type of test.
One click on each line yields a neat, formatted, typed report. These are more than just data. More than simple facts. These are final, cold, hard answers to the biggest questions of all.
Is Sue’s cancer is responding to therapy? Does Pete’s shortness of breath mean “just” pneumonia or a blood clot, or has his kidney cancer has metastasized to his lungs? Did Sid pull his back shoveling snow or is that sharp pain a vertebra fractured by prostate cancer?
Is Alan’s forgetfulness fatigue, Alzheimer’s or perhaps something more insidious, the bloom of glioma cells deep in his brain?
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