The Health Care Blog – Page 692 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

Above the Fold

Steve Jobs, Health Care Apps & Me

Oct 10, 2011• 5

By Michelle Snyder

When I heard the news about Steve Jobs on Wednesday, I was surprised at how profoundly sad I felt. Although I had never met him, my company had the thrill of sharing the stage with Steve when Apple announced they would open their platform to third party developers. At the time, I was head of marketing and subscriptions for Epocrates, then best know for our Palm Pilot application for physicians.

At the time, we thought we had done a pretty good job of disproving the old notion that physicians are slow to adopt new technologies. Steve was about to show us our full potential.

It was a surprise for us to be up on that stage, to say the least. Our fellow presenters were industry giants: EA, AOL, SalesForce, Sega and…us. The Sesame Street song ran through my head – “one of these things is not like the other.” Naturally, we were thrilled, but we had no idea how profoundly our company and industry were about to change.

Before the iPhone, Epocrates had built a great business creating drug, disease and formulary content for mobile devices. We launched our first product in 1999 with the premise that physicians were mobile and wanted to access information anywhere, anytime. Health care professionals loved their Palm Pilots – and I still have a bag of Palm IIIs, VX, Tungsten, Handspring, and Treo devices to prove it! Business was going well and we had grown to 25% of U.S. physicians. But we faced a challenge – we had already saturated the market of physicians with a device – and growth of the mobile device market had stagnated.

To this day, I don’t really know how we ended up that stage. But I like to believe the story we were told. Apparently, Steve asked one of his personal physicians why she wouldn’t switch to an iPhone and she replied “because I can’t use Epocrates on it.” True or not, we got an invitation from Apple to be one of their very first third party developers.Continue reading…

Why Doctors Don’t Like Electronic Health Records

Oct 7, 2011• 82

By RICHARD REECE, MD

Why are doctors so slow in implementing electronic health records (EHRs)?

The government has been trying to get doctors to use these systems for some time, but many physicians remain skeptical. In 2004, the Bush administration issued an executive order calling for a universal “interoperable health information” infrastructure and electronic health records for all Americans within 10 years.

And yet, in 2011, only a fraction of doctors use electronic patient records.

In an effort to change that, the Obama economic stimulus plan promised $27 billion in subsidies for health IT, including payments to doctors of $44,000 to $64,000 over five years if only they would use EHRs. The health IT industry has gathered at this multibillion-dollar trough, but it hasn’t had much more luck getting physicians to change their ways.

What is wrong with doctors that they cannot be persuaded to adopt these wondrous information systems? Everybody knows, after all, that the Internet and mobile apps, powered by Microsoft, Google, and Apple and spread by Facebook, Twitter, YouTube, and the iPhone and iPod, will improve care and cut costs by connecting everybody in real time and empowering health-care consumers.

How Patients Think

Oct 6, 2011• 8

By Kenny Lin, MD

Recently, I had a conversation with Shannon Brownlee (the widely respected science journalist and acting director of the Health Policy Program at the New America Foundation) about whether men should continue to have access to the PSA test for prostate cancer screening, despite the overwhelming evidence that it extends few, if any, lives and harms many more men than it benefits. She felt that if patients could be provided with truly unbiased information and appropriate decision aids, they should still be able to choose to have the test (and have it covered by medical insurance). Believing that one of the most important roles of doctors is to prevent patients from making bad decisions, I disagreed.

After reading Your Medical Mind, the new book by Harvard oncologist and New Yorker columnist Jerome Groopman, I think he would probably side with Brownlee’s point of view. Groopman, whose authoring credits include the 2007 bestseller How Doctors Think, and wife Pamela Hartzband, MD have written a kind of sequel to that book that could have easily been titled How Patients Think. Drawing on interviews with dozens of patients about a wide variety of medical decisions – from starting a cholesterol-lowering drug, to having knee surgery, to accepting or refusing heroic end-of-life interventions – the authors explore many of the factors that influence people’s health-related choices. The result is a compelling narrative that seamlessly blends “rational” factors such as interpreting medical statistics and decision analysis with personal factors such as past experience, emotional states, and personality styles.

FDA Should Consider Cost in Some Decisions

Oct 5, 2011• 3

By STEVEN GROSSMAN

FDA decides whether drugs, biologics and medical devices are safe and effective and can be marketed legally in the United States. The agency analyzes risk-benefit, but never cost. In contrast, public and private insurers, along with physicians and pharmacists, have the responsibility for cost-benefit decision making.

I have always felt quite strongly that this was the right way to allocate roles. Safety and efficacy determinations are difficult enough without weighing cost, so keeping a barrier between them makes sense. Two events this past week have left me wondering whether there are certain limited circumstances when FDA should be able to take product cost into consideration.

On September 26, 2011, The Oncology Commission of the British medical journal, Lancet, released a report entitled: “Delivering Affordable Cancer Care in High-Income Countries.” The 40-page report is wide-ranging, but its conclusion straightforward: as cancer care grows more expensive (and it is doing so at a rapid pace), affordability, accessibility and value are issues that need to be confronted aggressively.

Why Do You Care Whether I’m Insured?

Oct 5, 2011• 102

By JOHN GOODMAN

If you care a great deal, I’ll give you an account number you can use to make a deposit.

[Note to Self: Send this Alert to the folks at Commonwealth. Also to Nancy Pelosi and Harry Reid. CC Uwe Reinhardt as well. You never know what they might do. They certainly talk about this topic a lot.]

While you’re thinking about the initial question, here are a few follow-up questions:

Do you care whether I have life insurance?

What about disability insurance?

Homeowner’s insurance?

Auto casualty?

Auto liability?

What about retirement insurance? (A pension or savings plan.)

Do you care whether I keep my money at an FDIC-insured institution?

Or whether I bought an extended warranty on my car?

Or whether I bought travel insurance before taking my scuba diving trip to Palau? (It pays off if you get sick and can’t go.)

I’m sure there are busybodies who would like to run everyone else’s life. But society as a whole has taken a more rational approach. We basically don’t care whether people insure to protect their own assets (at least we don’t care enough to make them do so). But we do care about events that could create external costs for other people.

More Information Makes You More Confident, If Not More Accurate

Oct 5, 2011• 4

By Art Markman

Confidence matters. We are much more likely to act in situations when we are confident. We make purchases based on confidence. We are also persuaded by others based on their confidence. A statement made confidently and forcefully is much more likely to sway our opinion than a statement that is hedged.

Presumably, the power of confidence lies in the belief that when people are more confident in an outcome they are more likely to be correct in their predictions.

There have been many studies over the years that demonstrate that people tend to be overconfident in their judgments about how likely they are to be correct about a prediction or an answer to a question. But what causes this overconfidence?

A 2008 paper by Claire Tsai, Joshua Klayman, and Reid Hastie in Organizational Behavior and Human Decision Processes suggests one factor that makes people overconfident. They find that as people get more information about a judgment they are making, it increases their confidence, even if it does not increase the accuracy of their judgment.

In one study in this paper, they found experts in college football and asked them to predict the outcomes of a number of games. The names of the schools playing the games were not given. Instead, people were given information about how the teams had performed to that point in the season on a variety of aspects of performance that are useful for predicting the outcome of a game (like the average number of yards that the teams had gained in their games so far that season).

Who Should Pay for EHRs?

Oct 4, 2011• 33

By MARGALIT GUR-ARIE

During the 2008 Presidential campaign, Candidate Obama promised an EHR for every American by 2014. The goal was to improve quality of care, reduce disparities and contain costs of health care. When the HITECH act became law in 2009, physicians found themselves under increased pressure to purchase an EHR. Many took action, went out and bought an EHR for their practice, and these are now well positioned to collect the financial incentives put forward by the HITECH act. Many more did not. EHRs are by and large a complex and expensive proposition and the HITECH incentives are not covering the average cost of purchasing and maintaining an EHR. In survey after survey, physicians consistently rank cost associated with EHRs as their top concern when considering transition from paper charts to electronic medical records. This is a bit disconcerting, since physicians have no problem buying other expensive tools and paying for human resources in their practices. How are EHRs any different?

There are three primary stakeholders in health care: those who receive care, those who provide care and those who manage the financial aspects of health care, and no, we are not getting into the quintessential argument of whether there should be only two primary stakeholders. There are several secondary stakeholders as well: those who manufacture medical goods, those who provide ancillary services and those engaged in medical research.

Should Hospital Boards Embed Generative Thinking into Their Agenda?

Oct 4, 2011

By Kent Bottles, MD

Hospital systems and physician groups are faced with unprecedented change demanding decreased per-capita cost and increased quality in American health care. Boards of directors are underutilized resources that must be tapped more effectively in order for such organizations to survive in a time of industry consolidation. Generative thinking is a tool that can help organizations innovate in order to improve patient care and the financial bottom line.

Generative thinking is when a board becomes involved early on with management in trying to make sense of the current environment. For example, any US hospital must figure out strategies and tactics to deal with Medicare cuts, demands for higher quality, and migration away from fee for service to global payments in both the PPACA and the federal budget ceiling compromise that will result in at least $1.5 trillion or $1.2 trillion federal budget cuts staring in January 2012. Local events in each market will be different in each region. Western Pennsylvania hospitals, for example, must effectively respond to the Highmark purchase of West Penn Allegheny and the continuing tensions between Highmark and UPMC.

One way to encourage generative thinking in this setting is to make sure the board is present when a problem is defined because such a definition will affect strategies, policies, decisions, and actions to respond to the above described environment. Boards should help management decide what problems to pay attention to and not just respond to management’s understanding of the environment. Generative thinking has been described as getting to the question before the question and is about values, beliefs, assumptions, and organizational culture that will affect what problems we pay attention to and what strategies and tactics we choose.

The importance of framing the problem correctly was demonstrated by Clayton Christensen in The Innovator’s Prescription when he described the unsuccessful attempts by a company to increase milkshake sales. As Peter Drucker once wisely wrote: “The customer rarely buys what the company thinks it is selling him.” It turns out that 40% of milkshakes are purchased in the morning by long distance commuters who like the fact that it takes a long time to drink and that you can still drive with one hand on the wheel. By defining the job that the milkshake was being asked to accomplish, the fast food company was able to increase sales by making the shakes thicker so it would take more time to drink them on the long commute.

Generative thinking is not the only function of a board of directors. The three different modes of governance are fiduciary, strategic, and generative. The first two are self-explanatory, but the last mode is the least understood and the most neglected by non-profit boards.

Generative thinking requires a greater comfort with conflict and disagreement than is usually present on nonprofit boards. Because generative thinking is about deciding what the real problem the hospital faces in a confusing, unpredictable, and rapidly changing external environment, there needs to be conflicting viewpoints.

Alfred Sloan, GM chairman from 1923 to 1956, once stated: “Gentlemen, I take it that we are in complete agreement on the decision here. Then I propose we postpone further discussion to give ourselves time to develop disagreement and perhaps gain some understanding of what the decision is all about.” John Wooden, the most successful basket coach in history advised, “Whatever you do in life surround yourself with smart people who’ll argue with you.” He won his first NCAA championship in his 16th year of coaching at UCLA when he stopped hiring yes men and instead chose Jerry Norman as an assistant coach who installed the zone press Wooden detested.

A hospital board needs to understand generative thinking and decide if it wants to be involved upstream in discussions about how the hospital should respond to the environment. If there is agreement about the need to improve this mode of governance, then different methods can be tried to embed the concept into the work of the Board.

References:

Richard P. Chait, William P. Ryan, Barbara E. Taylor, Governance as Leadership: Reframing the Work of Nonprofit Boards. Hoboken, New Jersey: John Wiley & Sons, Inc., 2005.

Manda Salls, Why Nonprofits Have a Board Problem, Harvard Business School Working Knowledge for Business Leaders, 4/4/2005.

Michael A. Roberto, Why Great Leaders Don’t Take Yes for an Answer: Managing for Conflict & Consensus. Upper Saddle River, NJ: Prentice Hall, 2005.

Clayton M. Christensen, Jerome H. Grossman, MD, and Jason Hwang, MD, The Innovator’s Prescription: A Disruptive Solution for Health Care. New York: McGraw Hill, 2009.

Peter Drucker, Managing for Results, London: Heinemann, 1964.

Kent Bottles, MD, is past-Vice President and Chief Medical Officer of Iowa Health System (a $2 billion health care organization with 23 hospitals). He was responsible for the day-to-day operations of a large education and research organization in Michigan prior to his work with in Iowa with IHS. Kent posts frequently at his new blog, Kent Bottles Private Views.

Testing, Testing – Do We Test Interventions Sufficiently?

Oct 3, 2011• 5

By TIMOTHY WILSON

Are Americans becoming more skeptical of scientific inquiry? Some are, according to the pundits. See, for example, Chystia Freeland’s article in the New York Times, “A Deep Faith in What’s Been Proved,” and Paul Krugman’s article in the same paper, “Republicans Against Science.”

Although there does appear to be a growing skepticism about the value of science to address problems such as global warming, there has long been a neglect of social science when it comes to evaluating programs designed to change people’s behavior in beneficial ways, such as those that try to get kids to avoid drugs and alcohol, teach parenting skills, and prevent adolescent behavior problems. Myriad programs that receive federal and state funding have never been adequately tested to see if they work. When they are tested, they are often found to be ineffective or even to do harm.

Consider the D.A.R.E. drug abuse resistance program, which is used in 75% of school districts in the United States and in more than 40 countries. D.A.R.E. lists among its sponsors the U. S. Drug Enforcement Administration, the U. S. Food and Drug Administration, the U. S. Department of State, all five branches of the U. S. military, and the White House Office of National Drug Control Policy. President Obama, like his predecessors, designated a day in April as National D.A.R.E. Day to commemorate the program.

There is only one problem: D.A.R.E. doesn’t work. Studies have repeatedly shown that kids who take part in the program are no less likely to smoke, drink, or abuse drugs than kids who do not. To their credit, D.A.R.E. officials revamped the program in 2009, and maybe this new version will do some good (it is currently being tested). But doesn’t it seem like putting the cart before the horse to sink millions of dollars into a program and implement it in 75% of our schools before we know whether it works?