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Deciding What Works

Mar 28, 2011• 4

By STEVEN GOLDBERG

Steven Goldberg is probably best known for the controversial “Billions of Drops in Millions of Buckets: Why Philanthropy Doesn’t Advance Social Progress.” In this post he looks at the ways in which success and failure are measured in his field. Healthcare audiences will note many familiar themes. What should we measure? How should we measure it? How much weight should we give the results? And perhaps most importantly: what other questions should we be asking? — John Irvine

Conventional wisdom holds that randomized control trials (RCT) are the “gold standard” of evaluation. In fact, RCTs only make sense under very strict conditions that can rarely be met in the real world. Most of the time, RCTs produce inconclusive results and simply aren’t worth the time and money. As the social sector assumes greater responsibility for improving the lives of many more people, it should focus less on pseudo-scientific “proof” that programs work and focus more on making good programs better.

Now that the Social Innovation Fund (SIF) appears to have survived the “transparency” commotion, the eleven chosen intermediary grantmakers have less than six months to select their portfolios of nonprofit grantees.

As a commendable exercise in “evidence-based” grantmaking, SIF requires the intermediaries to incorporate evaluation into every step of their awards, from the initial competitive solicitations all the way through final payments and renewals. Applicants will be required to explain how their success should be measured and demonstrate their capacity to do so, and awards will be contingent upon the establishment of meaningful performance metrics, the timely collection and reporting of reliable data, and the faithful implementation of sound evaluation protocols.

How I Learned to Stop Worrying and Love the (EHR) Bomb

Mar 28, 2011• 25

By MARGALIT GUR-ARIE

Remember the fear mongering rhetoric about weapons of mass destruction and all sorts of other bogey men that sometimes led to war death and true destruction and other times to just animosity, hatred and counterproductive waste of time and resources?

This is exactly what we are witnessing today in Health Information Technology (HIT). Granted this is only a sideshow, while the main stage is occupied by the unprecedented Federal push to computerize medicine, but it has a very shrill voice and it seems to be confusing many good people. There are many legitimate questions that need to be asked, many strategies that should be debated, many errors that must be corrected, but the unsubstantiated, dogmatic and repetitive accusations directed towards HIT in general, EHR in particular, and chiefly at technology vendors and their employees, are borderline pathological in nature.

To be clear here, there are many practicing physicians and nurses who are either forced by an employer to use an EHR they dislike, have tried to use an EHR and didn’t enjoy the experience, or are opposed to the EHR concept on principle because the software has no return on investment in their situation, is not “ready for prime time” or is too closely aligned with the goals of the Federal government. These are all valid points of view and should be listened to and considered by policy makers as well as technology builders, and I have to confess that I do agree with much of what these practicing folks write and say, and as I said many times in the past, practicing physicians, i.e. those who see patients every day, are dangerously underrepresented in all HIT policy and technology decisions being made now at a federal level. Unfortunately, the practicing doctors’ message is being obscured and tainted by the “naysayers who predictably and monotonically chant the “HIT is evil” mantra at every opportunity” (quoting the famed HIT blogger, Mr. Histalk). These “self-proclaimed experts” and their incendiary and largely self-serving monologues are making it very easy to dismiss legitimate problems present in HIT policy and technology.Continue reading…

A Patient is Not a Shunt

Mar 28, 2011• 24

By EVAN FALCHUK

Some people may tell you that health care IT will solve many of the quality and cost problems in health care.

I don’t believe them.

I know a 70-year old man named Carlos (not his real name) who was hospitalized following a bout of hydrocephalus. Hydrocephalus is a build-up of fluid in the skull, which affects the brain. Among other things, people with hydrocephalus can be confused, irritable, and nauseous. Carlos had all of these symptoms.

Carlos’ problem was fixable by inserting a special kind of drain in his head called a “shunt.” This kind of shunt is, essentially, a series of catheters that runs from the brain into the abdomen, and which drain the excess fluid. You can’t see it from the outside, so it’s meant to stay inside of you for a very long time.

For a week after Carlos’ shunt was installed, his symptoms completely disappeared. But they soon started to re-emerge. Worried, his family took him to the hospital. Doctors found that his hydrocephalus was back – the shunt wasn’t draining properly. They admitted him to the hospital, and the next day they put in a new shunt. The surgery went well.

Primary Care Workforce Situation: Not Hopeless

Mar 26, 2011• 3

By DAVID E. WILLIAMS

I sometimes observe that the only sector of the economy as messed up as health care is higher education, where the US has some great institutions but where costs are incredibly high and have been rising relentlessly for long periods of time. These two dysfunctional systems intersect in multiple places, one of which is the cost of medical school and its impact on the physician workforce.

One of the reasons the cost of health care is so high in the US is the overemphasis on specialists vs. primary care relative to other advanced countries. That overemphasis is a result of multiple factors, including a reimbursement system that favors procedures and the prestige associated with specialties. But another significant factor is the cost and financing of medical school. Average debt levels for graduating medical students are around $150,000. Combine that with leftover debt from college and it’s easy to get up into the $200,000 range. That’s a big nut to pay off in primary care where typical compensation is $150,000 per year or so.

That large debt level certainly encourages graduating medical students from going into primary care. My guess is it also deters some would-be primary care physicians from going to medical school in the first place.Continue reading…

The Neverending Story

Mar 26, 2011• 38

By STEVE SANDERS

We’re hearing a lot about the use of electronic medical records (EMR) in medicine. The government is all for it—providing financial incentives for those with EMRs and disincentives for those still relying on paper charts to make their way through the world. Most health professionals, especially new physicians in training, simply can’t imagine a world without an EMR at their fingertips.

The ability to electronically capture discrete bits of data on each patient allows us to categorize, tally, and build unbelievably beautiful charts and graphs.

These systems also uncover deficiencies in patient care; with the push of a button, we know whose blood pressure or blood sugar is out of control, or how many patients weigh too much for their height. Clinicians click-through as many templates as possible in order for the system to capture these professional nuggets of information. Nuggets worth their weight in gold to researchers and pharmaceutical companies, eager to market their next blockbuster drug to physicians whose patients just happen to fit their marketing profile.

The trouble is when you’ve seen one template–built patient medical record, you’ve seen them all. These systems do such a great job of capturing discrete bits of data that patients become just that—only discrete bits of data.The essence of who they are, their story, becomes lost in attempts at efficiency.

What interests me about each patient is their story: what’s happening in their life that brings them stress or joy. Are they wanting medication for their cough, or really just needing assurance they don’t have lung cancer. Each visit brings a new chapter, a peeling of the onion allowing me to see the various layers of their personality over time. This is more important than almost any other discrete piece of data we could fit into a template. It takes time and effort to build an electronic medical record that speaks for the patient; time that is often in short supply for busy clinicians.Continue reading…

Life Saving Errors

Mar 26, 2011• 15

By DENNIS GRACE

On March 28, 1979 the Three-Mile Island Unit-2 nuclear power plant experienced a feed system failure which prevented the steam generators from removing heat from the plant. The reactor automatically shutdown but, without the feed system to cool the primary, the pressure in the primary system (the nuclear portion of the plant) began to increase. In order to prevent that pressure from becoming excessive, a relief valve opened. The valve should have re-closed once the pressure dropped by a small amount, but it didn’t. The only indication available in the control room showed the valve in the closed position, but that indication was erroneous, representing only that the signal to close the valve (pressure below a set value) had been sent to the valve. Nothing in the system verified the actual valve position. This stuck-open valve caused the pressure to continue to decrease in the system (and ultimately provided a path for spewing thousands of curies of radioactive material into the atmosphere), but the false shut indication prevented the operators from taking actions to mitigate their severe loss of coolant accident.

The primary relief valve design had a history of sticking. That same valve had been involved in at least nine other minor incidents prior to the TMI incident. Most notably, eighteen months before TMI, a similar incident had occurred in another nuclear plant involving a loss of feed and rising temperatures shutting down the plant. In that incident, the plant was just starting up after a maintenance shutdown, so the power level and temperature of the system were not as dangerously high as at Three-Mile Island.

Are Patients and Interoperability Finally Coming to the Fore of Health IT?

Mar 25, 2011• 4

By ADRIAN GROPPER, MD

In recent weeks, I’ve witnessed a huge change among my practicing colleagues. For the first time, the true cost of vendor-proprietary records is seen as an existential issue for practices that may need to join an Accountable Care Organization to survive.

To a doctor in the good old days, IT meant practice management as a tool to get paid. As the days of fee-for-service give way to ACOs and global payments, doctors are starting to realize the direct link between payment, health records and patient engagement.

In a recent essay titled “Show Me the Money” in Patient Safety and Quality Healthcare, Barry Chaiken, MD summarizes:

“Regular assessment of quality performance will identify those providers who might be withholding care or over-utilizing care, helping to balance the equation between clinical and financial objectives. Entities such as ACOs and patient-centered medical homes will either take on the financial risk and therefore share in the savings generated by their transformed care delivery processes or receive added payments, along the lines of current pay-for-performance schemes, for delivering predetermined clinical and financial outcomes.”Continue reading…

The Incredible and Wasteful Complexity of the US Healthcare System

Mar 24, 2011• 152

By HUMPHREY TAYLOR and IAN MORRISON

During the health care reform debate, we wrote that most people’s attitudes to it were “confused, conflicted, clueless and cranky.” A major reason was that the American health care “system” is fiendishly complicated and few people really understand it. As a result hardly anyone knows much about what is actually in the reform bill (but that does not prevent them from having strong opinions about it). Sadly, the reforms, whatever their merits, will make the system even more complicated, the administration more Byzantine and the regulatory burden more onerous.

System complexity.

The American healthcare system is already by far the most complex and bureaucratic in the world. We were once asked to spend ninety minutes explaining American health care to a group of foreign health care executives. Ninety minutes? We probably needed a few weeks. Most other countries have relatively simple systems, whether insurance coverage is provided by a government plan or by private insurance or some combination of these. But in the United States insurance coverage, for those who have it, may be provided by Medicare Parts A, B, C, and D, 50 different state Medicaid programs (or MediCal in California), Medicare Advantage, Medigap plans, the Children’s Health Insurance Plan, the Women, Infants and Children Program, the Veterans Administration, the Federal Employees Health Benefits Program, the military, the hundreds of thousands of employer-provided plans and their insurance companies, or by the individual insurance market. This insurance may be paid for by the federal or state governments, by employers, labor unions or individuals. Some employers’ plans cover retirees, others do not. The result is that the system is pluralistic, mysterious, capricious and impossible for most patients and providers to understand.

Administrative complexity

The administrative complexity is amplified by the multiplicity of insurance plans. About half of all Americans with private health insurance are covered by self-insured plans, each with its own plan design. Employers customize their plan documents, led by consultants who make a good living designing their plans and tailoring their contracts. As one prominent consultant told us recently, if all the self-insured plan documents were piled on a table they would not just exceed the 2,700 pages of Obamacare, they would probably reach the moon. For the rest of the commercially insured population, health plans may be traditional indemnity plans, Preferred Provider Organizations or Health Maintenance Organizations.

The coverage provided by different plans varies dramatically. They may or may not include large or small deductibles, co-pays or co-insurance. Beneficiaries may pay a large, small or no part of their health insurance premiums. Some plans cover dependent family members and children, others do not. The Medicare Part D pharmaceutical benefit plan involves a “doughnut hole,” which will disappear as health reforms are implemented. Surveys have found that few people fully understand their own insurance plans let alone the bigger picture. While health reform takes some steps toward standardization of insurance offerings and improving transparency, overall it is likely to increase complexity.Continue reading…

Is That Thorazine in the Baby’s Bottle?

Mar 24, 2011• 5

By PSYCH GRIPE

One of the most disturbing trends in mental health today is the increasing use of powerful antipsychotic medication to treat behavioral problems in children, even very young children. According to a 2009 report by the Food and Drug Administration, there are 500,000 children in the United States being administered regular doses of antipsychotics. Medicaid data shows public health monies spent on antipsychotic drugs for children exceeding $30 million in New Jersey and topping $90 million in Texas. It is a trend that has built relentlessly for the past ten years and continues unabated.

I find the use of these drugs on children to be appalling almost beyond words. Having worked as a mental health professional for many years, I am well acquainted with these medications. This class of drugs, sometimes referred to as neuroleptics, are major tranquilizers and are primarily used and intended for controlling hallucinations and delusions in cases of psychosis and schizophrenia. For an adult with severe schizophrenia, these medications may be a glimmer of hope, but it is always a difficult risk-benefit analysis because there are potentially severe side effects and reactions. Permanent neurological damage can occur in the form of tardive dyskenisia, and sudden death can occur from a reaction called neuroleptic malignancy syndrome. With newer forms of antipsychotics, these type of side effects are less frequent and less severe, but continue to be a risk depending on the reaction of the individual’s body. However, newer, “atypical,” antipsychotics present new dangers to the patient, metabolic changes that result in a dramatic increase in the instances and severity of diabetes and heart disease. The result is that adults on antipsychotic medications have a life span that is 20 years shorter then the average person.Continue reading…

No One Cares About Your Health (or No One is Willing to Pay For It)!

Mar 23, 2011• 9

By JOSEPH KVEDAR, MD

Of course that is not true, but it seems like that sometimes, doesn’t it? If you are working to promulgate a solution that promotes health in the context of our current healthcare system, there is no end to the challenges you will face. Lets think a bit about the various actors, why they should care and why they do not.

I’ll start off with you. No one should care more about your health than you. But as the behavioral economists remind us, we are not rational beings. We are more likely to focus on tangible things in the moment rather than long-term uncertain benefits. So we persist in participating in unhealthy behaviors that provide short-term pleasure and lead to downstream sickness. In addition, we’ve been addled into believing that once we are diagnosed, we are victims and that we can abdicate all responsibility for our care. (see 5-17-2010, Are Individual’s with Chronic Illness More Passive?). This insidious combination makes it hard to hold ourselves accountable for our own health. Most times, we’d rather blame the environment, or bad luck, and ask if we can take a convenient pill to make it better.

Next, how about your loved ones? They are the best targets. In most cases our loved ones (the more current phrase is ‘social network’) can and do affect our health (See Nicholas Christakis’ book Connected and related articles). It has, however, been challenging to get loved ones to open their wallet to pay for service offerings that improve your health. In my experience, this is most often because of the same mentality that makes you a passive victim once you get sick. We feel that society owes a victim. We all feel like we’ve paid into various insurance programs – public and private – and that they should be the ones to pay for health-related services, particularly in the setting of chronic illness. So your loved ones do care, but they have been trained not to open their wallet to support your care. I can think of a dozen or so business plans I’ve seen over the years where the service to support a chronically ill individual was to be paid for by the “sandwich generation.” There is an appeal to this on the surface, but I haven’t seen one of those businesses scale yet.Continue reading…