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Above the Fold

Where Doctors Locate

Feb 8, 2011• 24

By JOHN GOODMAN, PhD

Pop quiz. How many doctors are at the top of Mt. Everest? None, actually. Yet, think about how many people get sick up there. Think about how many die? Do you think extra bonus payments could coax a few doctors to relocate up there? What if we waived their student loan debt? If you find these questions interesting, there’s clearly something wrong with you. But cheer up. As the map below shows, there is a lot of variation in the number of people per doctors across Texas counties. [Thanks to Jason Roberson and his colleagues at The Dallas Morning News for making the data available.] At one extreme, Bandera County in the Texas Hill Country has 21,266 people and only one doctor. At the other extreme, Baylor County, near the Oklahoma border, has 666 patients per doctor.

Should we care about any of this? If so, why?

Before getting into specifics, let me address a cultural issue that I believe greatly prejudices all discussions of doctor location.

Bandera County bills itself as “The Cowboy Capital of the World.” It clearly promotes tourism. But the online reviews of its eight area restaurants don’t make me want to visit any time soon. Ditto for the online reviews of its 10 hotels, motels and dude ranches. Still, a lot of people visit there and it has a growing population.

Ethical Blinders?

Feb 8, 2011• 7

By PAUL LEVY

Is this a case of ethical blinders?

Today's New York Times has an important story about the ineffectiveness of removal of lymph nodes for certain women with breast cancer. That is a significant result of clinical research. But read this:

Experts say that the new findings, combined with similar ones from earlier studies, should change medical practice for many patients. Some centers have already acted on the new information. Memorial Sloan-Kettering Cancer Center in Manhattan changed its practice in September, because doctors knew the study results before they were published.

And they felt no need to spread the word quickly to other hospitals and to breast cancer patient advocacy groups and help women across the world avoid the surgery and its after-effects? (As noted in the article, "It can cause complications like infection and lymphedema, a chronic swelling in the arm that ranges from mild to disabling.")

Paul Levy is the former President and CEO of Beth Israel Deconess Medical Center in Boston. For the past five years he blogged about his experiences in an online journal, Running a Hospital. He now writes as an advocate for patient-centered care, eliminating preventable harm, transparency of clinical outcomes, and front-line driven process improvement at Not Running a Hospital.

Transmogrifying California Healthcare

Feb 8, 2011• 3

By LISA SUENNEN

I’m really looking forward to this coming Friday, February 4th, as I get to moderate a panel on “The Impact of Health Reform on California.” The panel, which was organized by UC Berkeley’s Institute for Governmental Studies is being held in Sacramento and will take place before a sold-out crowd of nearly 200, in large part because it has a meaty topic and some really top-notch participants, including:

Diana Dooley
Secretary, Health and Human Services Agency
Cindy Ehnes
Director, California Department of Managed Healthcare
Paul Markovich
Chief Operating Officer, Blue Shield of California
Saumya Sutaria
Director, McKinsey & Co.

Sacramento Mayor Kevin Johnson (who I went to college with) and Congresswoman Doris Matsui will also make some remarks.

This should be a great event because each of the panelists has a pretty significant role to play in how the State of CA adopts and adapts to health reform, and there is a remarkable amount at stake.

Saul Bellow once said, “California is like an artificial limb the rest of the country doesn’t really need.” That may be true, but in our healthcare economy we can’t afford to amputate.

A Multi-Layered Defense for Web Applications

Feb 8, 2011• 1

By JOHN HALAMKA, MD

The internet can be a swamp of hackers, crackers, and hucksters attacking your systems for fun, profit and fraud. Defending your data and applications against this onslaught is a cold war, requiring constant escalation of new techniques against an ever increasing offense.

Clinicians are mobile people. They work in ambulatory offices, hospitals, skilled nursing facilities, on the road, and at home. They have desktops, laptops, tablets, iPhones and iPads. Ideally their applications should run everywhere on everything. That's the reason we've embraced the web for all our built and bought applications. Protecting these web applications from the evils of the internet is a challenge.

Five years ago all of our externally facing web sites were housed within the data center and made available via network address translation (NAT) through an opening in the firewall. We performed periodic penetration testing of our sites. Two years ago, we installed a Web Application Firewall (WAF) and proxy system. We are now in the process of migrating all of our web applications from NAT/firewall accessibility to WAF/Proxy accessibility.

We have a few hundred externally facing web sites. From a security view there are only two types, those that provide access to protected health information content and those that do not. Fortunately more are in the latter than the former.

Patient Privacy and PCAST

Feb 8, 2011

By JEAN STANFORD, PETER MORK, PhD, and ARNON ROSENTHAL, PhD

The President’s Council of Scientific Advisors (PCAST) report on health care IT points out that “A patient cannot make meaningful privacy choices unless he or she understands the flows and uses of information and can therefore make informed choices. That is not the reality today… While facetoface counseling on privacy choices should be available whenever choice is either required by law, policy or practice, most patients will probably educate themselves on the issues and make privacy choices through a web interface, where they will also be able to change their choices at any time… An important point is that, when patients have a meaningful opportunity to choose, a patient’s choices will be persistent, that is, continuing until changed. Most patients ideally will have elected privacy choices at a time when they are healthy and competent. This is truer to the principal of informed consent than is a rushed signature at thetime of a medical emergency, or when the patient’s physical or mental competency is compromised.”[i]

We have developed a proof of concept prototype (http://sourceforge.net/projects/kaironconsents/) for such a patient privacy preference management system that could be implemented nationwide.

Why This Primary Care Doctor Loves His EHR

Feb 7, 2011• 6

By DAVIS LIU, MD

A recent post in the Wall Street Journal Health Blog noted that a study found electronic medical records don’t improve outpatient quality. The authors of the Archives of Internal Medicine article, Electronic Health Records and Clinical Decision Support Systems, correctly points out that we should be skeptical and “doubt [the] argument that the use of EHRs is a “magic bullet” for health care quality improvement, as some advocates imply.”

This should surprise no one. Were we that naive to think that simply installing health information technology (HIT) in the medical field would generate significant improvement in outcomes? Does simply installing computers in our classrooms improve educational test scores?

Of course not.

The excellent commentary after the article makes some plausible reasons why the clinical decision support (CDS) didn’t seem to improve outcomes on 20 quality indicators. First, it isn’t clear that the CDS implemented across the various doctors’ offices and emergency rooms actually addressed the indicators studied. Second, the data studied is already dated (from the 2005 to 2007 National Ambulatory Medical Care Survey), a long time in technology terms (iPhone first debuted in 2007). The authors of the original article also point out that there is some evidence that institution specific use of CDS actually improves quality. Whether this can be scaled to the national level is the question.

The Greater Fool

Feb 7, 2011• 10

By PAUL LEVY

In the last four decades, we have witnessed a series of investment "bubbles" that have all collapsed. It seems that there is no end to the number of people with cash who will be intoxicated by a good story line, even when there is little substance to back it up. All of these stories depend on the capital markets to bolster the price of investments, counting on the "greater fool" theory: There is always someone who will take on a bad investment at just the wrong time, providing a good return to those who are lucky enough to escape before the crash.

In the early 1990s, ENRON was entering the market with a new electricity trading division. A business partner of mine was asked by one of the largest government pension funds to evaluate a proposal to invest $250 million in the start-up. He came to me a few weeks later, saying that he was having trouble evaluating the deal. They could not give a substantive answer to the basic questions: How will each transaction make money? What will be your competitive advantage in this business? What do you expect your market share to be? When he would ask the ENRON guys for a business plan, their answer was, "We did it in natural gas. We can do it in electricity. Trust us."

My friend advised the pension fund not to invest. It did so anyway, apparently because of personal relationships between the fund managers and people at ENRON. As we now know, the fiction behind ENRON's financial plan eventually led to its collapse.

Health Care Reform in the U.K. and U.S

Feb 5, 2011• 21

By HERBERT MATHEWSON, MD

“England and America are two great nations separated by a common language.”
-attributed to both Winston Churchill and George Bernard Shaw

In 1965 I spent the summer of my third year in medical school at the General Practice Teaching Unit of the Royal Infirmary in Edinburgh, Scotland because I wanted to learn more about the National Health Service (NHS). My impression then was that both the U.K. and U.S. medical care systems were evolving toward the same end result from very different directions. (1) That viewpoint has been reaffirmed by recent events. Both countries have embarked this past year on significant health care reform. Both countries are seeking to reduce costs, improve quality, become more patient-centered, and invest in health information technology (HIT). In both countries the majority of patients are highly satisfied with the NHS or Medicare and are vigilant about not giving up any of its benefits.

Both health care reform acts are being criticized for being too timid, or too bold, or too incremental, or too radical. The U.K. plan is being attacked by some as a disastrous turn toward privatization while the U.S. plan is “another step toward socialism”, i.e. very little change in the tenor since 1965. Vocal U.K. critics on the left decry the proposed move away from regulation (NHS) toward competition and market-place economics while the vocal U.S. critics on the right warn against more regulation and movement away from reliance on competition and market-place forces.

Increased Primary Care Support
The basic foundation of the NHS has always been General Practice physicians (GPs) who have no hospital privileges and refer all patients needing hospitalization to full-time hospital specialists (Consultants). (2) In 1965, and in 1996, such a separation of outpatient and inpatient medical practice was threatening to community physicians in the U.S. (3) Today it is difficult to recruit primary care physicians (and some specialists) to a community unless the hospital has hospitalists to care for inpatients. The community-based internist in U.S. is now more like the GP in U.K. then ever before, and that is not a bad thing.

Shaw Got It Right

Feb 5, 2011• 23

By PAUL LEVY

George Bernard Shaw wrote The Doctor's Dilemma, Preface on Doctors in 1909. It is fun to read some excerpts:

It is not the fault of our doctors that the medical service of the community, as at present provided for, is a murderous absurdity. That any sane nation, having observed that you could provide for the supply of bread by giving bakers a pecuniary interest in baking for you, should go on to give a surgeon a pecuniary interest in cutting off your leg, is enough to make one despair of political humanity. But that is precisely what we have done. And the more appalling the mutilation, the more the mutilator is paid. He who corrects the ingrowing toe-nail receives a few shillings: he who cuts your inside out receives hundreds of guineas, except when he does it to a poor person for practice.

Scandalized voices murmur that these operations are necessary. They may be. It may also be necessary to hang a man or pull down a house. But we take good care not to make the hangman and the housebreaker the judges of that. If we did, no man's neck would be safe and no man's house stable. But we do make the doctor the judge… I cannot knock my shins severely without forcing on some surgeon the difficult question, "Could I not make a better use of a pocketful of guineas than this man is making of his leg? Could he not write as well—or even better—on one leg than on two?"

Why doctors do not differ

The truth is, there would never be any public agreement among doctors if they did not agree to agree on the main point of the doctor being always in the right. Yet the two guinea man never thinks that the five shilling man is right: if he did, he would be understood as confessing to an overcharge of one pound seventeen shillings; and on the same ground the five shilling man cannot encourage the notion that the owner of the sixpenny surgery round the corner is quite up to his mark. Thus even the layman has to be taught that infallibility is not quite infallible, because there are two qualities of it to be had at two prices.

It Hurts To A Point

Feb 5, 2011• 2

By STEVE SANDERS, DO

She sat straight up, gripping the arms of her chair as if by releasing them she might tumble forward on to the floor. “I’m tired of hurting,” were her first words to me as I entered the room. I barely recognized the person I’d seen occasionally over the last two years. She was only 32–years old but now she carried herself as if she were an octogenarian, missing only the rolling walker. “I hurt all over,” she continued. “I can’t sleep. I can barely get around at work; they even sent me home once. I’m exhausted but sleep doesn’t help. I have to do something or I could lose my job.” With that she began to cry softly, struggling to wipe away tears.

Her history came spilling out. Pain in her back, shoulders arms and upper leg muscles. Rest gave her little relief. Her sleep was fitful; if she was able to sleep more than five hours it seemed miraculous. She awoke with pain that started as she climbed out of bed and lasted all day. She tried taking Tylenol, ibuprofen, Aleve, and aspirin, first in separate small doses then in combination. All these drugs seemed to do was upset her stomach and diminish what little appetite she could muster. Consequently, she lost weight; down ten pounds since her last visit six months ago.

Her disturbed sleep pattern, accompanied by tender points of pain in different regions of the body both above and below the waist fit the diagnosis of fibromyalgia. Medicine is just now coming to terms with this disease that has become the most common cause of muscle pain in women ages 20 to 55. These patients can have numbness, tingling or burning sensations in the arms, legs or both. Not surprisingly they develop mood disorders—difficulty concentrating sometimes even frank, severe depression. Some patients with fibromyalgia also complain of chest pain or develop alternating diarrhea with constipation, what we innocently call ‘irritable‘ bowel syndrome. On close questioning she volunteered she had many of these problems.