Credit Suisse Says Wearable Tech "The Next Big Thing":
via Tumblr http://drnic1.tumblr.com/post/50916719025
You bet - this market and area is going to explode
via Tumblr http://drnic1.tumblr.com/post/50916719025
Monday, May 20, 2013
Tuesday, April 23, 2013
Social Network Sways Vaccine Compliance
via medpagetoday.com
Excellent article that demonstrates the challenges facing scientists and data. Despite the data clearly showing the benefits far outweighing the risks parents opinion and decision is swayed by "social norms"
As a society, we respect the privacy of healthcare decisions; however, if we are to sustain adherence to the recommended immunization schedule as a social norm, we need to learn how to empower immunizing parents to become vocal and talk with other parents, including prospective parents, about why they chose to immunize their children
Quite!
Wednesday, April 17, 2013
Four Reasons Doctors Worry About Social Media - #GetOverIt
I’m fortunate enough to spend a lot of time interacting with physicians, entrepreneurs, and investors on the bleeding edge of digital health – and it’s a consistently thrilling experience.
At the same time, the continuous exposure to the imaginative and the extraordinary can also be a bit deceptive. Self-associating groups, as Sunstein has discussed, tend to adopt relatively extreme views, and it’s easy to envision this happening in Silicon Valley in general, and to digital health innovators in particular.
Consequently, it was probably healthy, and certainly arresting, to attend a breakout session on social media at recent a medical conference; the audience members were mostly practicing physicians, seemed passionate about patient care, and were explicitly interested in learning about social media. Yet, most of the clinicians were not prepared to embrace it, and many were poignantly struggling to come to terms with a phenomenon they recognized as important, yet which viscerally troubled them.
Their concerns seem to fall into four categories, two involving patients, and two involving physicians.
1. Patients Receiving “Bad” Information
Many physicians described the challenges of dealing with patients who had retrieved wrong or incomplete information from the internet. This turns out to be a remarkably common problem; doctors reported spending a lot of time undoing bad information.
The challenge was highlighted by the observation that 25% of Google searches for headache reportedly discuss brain tumors, even though such a diagnosis would be exceptionally uncommon. The thought was that while physicians have learned during their training to appropriately weigh pre-test probabilities, patients have not, and are likely to fixate on extreme diagnoses rather than those that are most likely.
It seemed to me that “Dr. Google” upset many doctors not only because it complicated office visits, but also because it fundamentally altered the traditional doctor/patient relationship; as one physician said – verbatim – “I’ve lost my authority.” It’s hard not to see this as a profound shift in perspective many experienced physicians understandably struggle to manage.
2. Patients Transmitting “Bad” Information
Many doctors in the audience were also visibly troubled by the ease with which patients could share “misleading” information, whether about medicine or the doctors themselves.
Despite the clear repudiation of a link between vaccines and autism, for instance, many patients continue to worry, a concern reportedly spurred on by an active internet anti-vaccine community.
Doctors were also fretting about the ease with which disgruntled patients could use the internet to besmirch reputations — one physician complained that when he Googled himself, the first links that came up were bad reviews he said represented a small number of extremely vocal patients.
3. Physicians Receiving Information Badly
While some senior physicians worried that young doctors might start to rely on tweets rather than peer-reviewed articles, it seemed that the most significant concern raised was the impact that the “internet culture” was having on the practice of medicine. “We need to teach students that traditional values are still important,” one audience member said (again, verbatim), suggesting that students have become progressively less reflective.
The use of mobile devices – what consultants call “phone hygiene” – emerged as a particular source of physician aggravation. Rounding residents would routinely look at the cell phones rather than pay attention to either the patients or the senior doctors, leading at least one doctor to prohibit the use of mobile devices on rounds – except for a 5’ phone break he built into the schedule, to accommodate what he described as the young doctors’ obvious addiction.
Another senior doctor, in a complaint evocative of this recent, much-discussed NYT article, noted that residents would routinely update her by text, rather than by phone. She suggested this reflected a more general trend of young physician disengagement, evidently preferring to interact with devices rather than with other people.
4. Physicians Transmitting Information Badly
The ability afforded by social media to share information rapidly and broadly was another source of concern. Many senior physicians worried young doctors might use social media in unprofessional ways – sharing things they shouldn’t, saying things they shouldn’t – potentially placing themselves and their institutions at risk.
In some cases, even seemingly innocent activities might be deemed inappropriate. One young physician offered as an example a (medically-related) internet survey research project he wanted to do. He said that while he could do this very easily, nearly instantly, and essentially for nothing using Google, he learned from his department this would violate institutional policy, and to conduct the research with the required protections in place would cost at least $25,000; naturally, the research has not progressed.
Moving Forward
via forbes.com
Great post by David on why clinicians should jump with both feet into the world of Social Media
Monday, April 15, 2013
Vaccine and autism: UK measles outbreaks and the Disgraced Mr Andrew Wakefield
Right now, in the UK, the outbreak of measles has reached epidemic proportions. Nearly 700 people have come down with the highly contagious disease in south Wales, and that number may double. Measles can cause a nasty rash and high fever, and in children can cause ear infections, encephalitis, and death.
Yes, death. Measles can kill.
So right now would be the worst of all possible times to give Andrew Wakefield precious front-page space on a newspaper to promote his incredibly dangerous antivax nonsense. Yet that’s exactly what the UK newspaper The Independent did.
Andrew Wakefield is the one who published a paper in The Lancet that started the modern fear of vaccines; the paper contained shoddy and subsequently disproven work in 1998 that contributed so much to the antivaccination movement of today. His work has been called fraudulent by the British Medical Journal, and the paper was so awful The Lancet retracted it. Time and again, MMR vaccines have been shown to have no link to autism, which is what Wakefield claimed. His serious professional misconduct led to his being struck off the official listing of doctors in the UK.
He is widely blamed for the recent outbreaks of preventable diseases. In recent years, vaccination rates have dropped, and we’ve seen outbreaks of pertussis (including in my home town of Boulder, with an infant nearly killed by it) and measles all over the world.
So why did The Independent give him a front page link on their site to air a diatribe blaming the government for the epidemic? That’s right, Wakefield had a press release saying the government’s interest was more in protecting the vaccine than protecting children, which is particularly rich coming from someone who was found to have used children unethically and with “callous disregard” in his own study. And The Independent ran his screed in its entirety.
The good news is, after getting blasted by skeptics like Ben Goldacre, the press release was taken down. If you want you can still read it the drippingly antivax site Age of Autism (read that site at your own risk). I do want to point out that in an irony so thick it’s palpable, Wakefield refers to vaccine researcher Paul Offit as a millionaire, using the old “follow the money” tactic. Really, Mr. Wakefield? Do you really want us to do that?
Back to The Independent, they also ran an article about Wakefield and vaccines along with the press release. To be fair, the article does condemn Wakefield, and if read carefully it does do a somewhat decent job overall of discrediting him. But it does have to be read all the way through, which is not something most people do these days (I expect the comments below to this very post will prove my point pretty well). And the headline with the article was, “MMR scare doctor: this outbreak proves I was right”.
Technically correct, but c’mon. That’s not a good synopsis of the article, to say the least. Martin Robbins at New Statesman dismantles the article thoroughly, and I strongly urge you to read that.
This kind of thing is not to be toyed with; people’s lives are at stake. Babies die due to these illnesses, easily preventable diseases if more people would get actual facts about vaccines.
My vaccinations are up-to-date. So are my wife’s. So are my daughter’s, including Gardasil. We understand the very small risks as well as the very large advantages of vaccinations. We also know the need for herd immunity.
You should understand them too. Don’t believe Wakefield. Don’t believe Jenny McCarthy. Don’t believe Age of Autism, or the Australian Vaccine Network, or any of those so-called “vaccine injury” groups. Talk to a real, board-certified doctor, and get their recommendation about vaccination.
What's happening in Wales can happen anywhere where vaccination rates are low. It's happening in my hometown. I sincerely hope it won't happen in yours.
Tip o’ the syringe to Rachael Dunlop and Ben Goldacre.
SIGN UP FOR MYSLATE×
via slate.com
Great expose slating the press given to the disgraced Mr Andrew Wakefield - he was struck of by the General Medical Council for perpetrating a fraud yet the Independent gave him ink on the front page over the weekend
Thursday, April 4, 2013
Clinical Documentation Lifeblood of Healthcare
Awesome video put together showcasing the various aspects of clinical documentation and why it is so important to capture the complete patient story in narrative form
Putting all the details means capturing the diabetes and loss of consciousness
Everything from Assure and the ability to capture anywhere and the exploding area of mobile integration of voice and all the follow up in the back end for HIM
Putting all the details means capturing the diabetes and loss of consciousness
Everything from Assure and the ability to capture anywhere and the exploding area of mobile integration of voice and all the follow up in the back end for HIM
Tuesday, April 2, 2013
Science at Work - Number Of Early Childhood Vaccines Not Linked To Autism
Jeff J. Mitchell/Getty ImagesA new study from the Centers for Disease Control and Prevention finds no link between the number of vaccinations a young child receives and the risk of developing autism spectrum disorders.
A large new government study should reassure parents who are afraid that kids are getting autism because they receive too many vaccines too early in life.
The study, by researchers at the Center for Disease Control and Prevention, found no connection between the number of vaccines a child received and his or her risk of autism spectrum disorder. It also found that even though kids are getting more vaccines these days, those vaccines contain many fewer of the substances that provoke an immune response.
The study offers a response to vaccine skeptics who have suggested that getting too many vaccines on one day or in the first two years of life may lead to autism, says Frank DeStefano, director of the Immunization Safety Office of the CDC.
To find out if that was happening, DeStefano led a team that compared the vaccine histories of about 250 children who had autism spectrum disorder with those of 750 typical kids. Specifically, the researchers looked at what scientists call antigens. An antigen is a substance in a vaccine that causes the body to produce antibodies, proteins that help fight off infections.
The team looked at medical records to see how many antigens each child received and whether that affected the risk of autism. The results, published in The Journal of Pediatrics, were unequivocal.
"The amount of antigens from vaccines received on one day of vaccination or in total during the first two years of life is not related to the development of autism spectrum disorder in children," DeStefano says.
The finding came as no surprise to researchers who study the immune system, DeStefano says. After all, he says, kids are exposed to antigens all the time in the form of bacteria and viruses. "It's not really clear why a few more antigens from vaccines would be something that the immune system could not handle," he says.
The study also found that even though the number of vaccines has gone up, the number of antigens in vaccines has gone down markedly. In the late-1990s, the vaccination schedule exposed children to several thousand antigens, the study says. But by 2012, that number had fallen to 315.
That dramatic reduction occurred because vaccines have become much more precise in the way they stimulate the immune system, DeStefano says.
“ The sad part is, by focusing on the question of whether vaccines cause autism spectrum disorders, [researchers are] missing the opportunity to look at what the real causes are. It's not vaccines.
- Ellen Wright Clayton, professor of pediatrics, Vanderbilt University
Hardcore vaccine skeptics are unlikely to be swayed by the new research. But many worried parents should be, says Ellen Wright Clayton, a professor at Vanderbilt University who helped write a report on vaccine safety for the Institute of Medicine.
"I certainly hope that a carefully conducted study like this will get a lot of play, and that some people will find this convincing," Clayton says. That would let researchers pursue more important questions, she says.
"The sad part is, by focusing on the question of whether vaccines cause autism spectrum disorders, they're missing the opportunity to look at what the real causes are," she says. "It's not vaccines."
Autism Speaks, a major advocacy and research group, seems ready to move beyond the vaccine issue. Geraldine Dawson, the group's top scientist, praised the new study and says the result should clear the way for research on other potential causes of autism.
These include factors like nutrition, which can affect a baby's brain development in the womb, Dawson says. Other factors could include medications and infections during pregnancy, she says, or an infant's exposure to pesticides or pollution.
"As we home in on what is causing autism, I think we are going to have fewer and fewer questions about some of these things that don't appear to be causing autism," Dawson says.
via npr.org
More coverage and science referring to a recent study showing no link between vaccines and autism. This was covered in the SBM Site
The Final Nail in the Coffin - sorry if some of yo have trouble getting to the site as it appears to be having problems
As one commentator articulated
"The sad part is, by focusing on the question of whether vaccines cause autism spectrum disorders, they're missing the opportunity to look at what the real causes are, It's not vaccines."
If you are interested in a detailed analysis of the science and statistical analysis the SBM article is excellent. The analysis
They sliced and diced the data in a variety of ways looking for correlations and didn’t find any
And does an in depth debunking of the lack of science in the broadside from antivaccinationists who's fear mongering seems to date back to the widely and roundly debunked falsification of data by Andrew Wakefield that was described as the most damaging medical hoax of the last 100 years. He was struck of the GMC register and barred from ever practicing medicine in the UK.
As David Gorski in his title the study had not intended to disprove the relationship between the "toxins" used as part of vaccine make up. This study came as close as one can to disproving that relationship:
Which brings us to “too many too soon.” It appeared to be a “hypothesis” that was impossible to falsify, but DeStefano et al came about as close as it’s ethically possible to do to falsifying the hypothesis. No wonder that all that antivaccinationists are left with are calls for “vaxed versus unvaxed” studies and pharma shill ranting.
Science at work!
Thursday, March 21, 2013
Great Guidance on Presenting
Awesome presentation on presenting.....
<iframe src="http://www.slideshare.net/slideshow/embed_code/17313548?rel=0" width="427" height="356" frameborder="0" marginwidth="0" marginheight="0" scrolling="no" style="border:1px solid #CCC;border-width:1px 1px 0;margin-bottom:5px" allowfullscreen webkitallowfullscreen mozallowfullscreen> </iframe> <div style="margin-bottom:5px"> <strong> <a href="http://www.slideshare.net/HubSpot/what-would-steve-do-10-lessons-from-the-worlds-most-captivating-presenters" title="What Would Steve Do? 10 Lessons from the World's Most Captivating Presenters" target="_blank">What Would Steve Do? 10 Lessons from the World's Most Captivating Presenters</a> </strong> from <strong><a href="http://www.slideshare.net/HubSpot" target="_blank">HubSpot All-in-one Marketing Software</a></strong></div>
Along with some key guidelines to help you put together really compelling presentations that will stick and people will remember. My favorite quote:
It's not a presentation, it's a performance
You can read the full article: 7 Lessons From the World's Most Captivating Presenters
- That includes specifics such as
- Start with paper not powerpoint
- Don't use bullet points
- Practice, practice, practice....and then practice again
Great stuff!
The bias of #bigdata - move towards Data With Depth #dwd #hcsm
This is a great presentation by Kate Crawford
Algorithmic Illusions: Hidden Biases of Big Data
interspersed with some nice visuals (a silhouette illusion - a Kinetic bistable optical illusion that lacks visual clues for depth - the spinning cat!) to make the point that big data. The point being there are ways we see data and potentially the wrong picture.
So the belief that with Big Data we get closer to truth does not necessarily hold true in all cases.
"With enough data, the numbers speak for themselves" Chris Anderson, 2008
Beep....beep....beep....back the truck up
Numbers don't speak for themselves. We (the people) and int he case of clinicians are the ones that interpret the data. Big data is not the complete answer - it is a form of
Epistemological blindness
So we ned to think about how we bring big data alongside small data.....hmmm perhaps taking the history and talking to the patient concurrent with big data analysis might provide a better, clearer picture
Move from #BigData to Data with Depth #dwd
You can watch it here or if the embedded version below:
<iframe width="1280" height="720" src="http://www.youtube.com/embed/irP5RCdpilc" frameborder="0" allowfullscreen></iframe>
Tuesday, March 19, 2013
Why EHRs Really Haven’t Made Us Healthier: A Response To Glen Tullman
Brian Klepper
Recently-fired Allscripts CEO Glen Tullman waxed progressive in a self-promotional Forbes article last week, describing the ways past and forward for electronic health records (EHRs) and health information technology (HIT). It may have been a way of trying to recover from a damning New York Times article that clearly illustrated the relationships between campaign contributions, influence over health information technology policy, and business success.
Tullman recalls building EHRs that moved many physicians away from paper and the errors it fosters. He calls out David C. Kibbe, MD as an example of the forces wanting to preserve paper and opposing EHRs, with quotes from a 2008 blog post suggesting that the current crop are “notoriously expensive,” “difficult to implement” and unable to demonstrate care quality improvements. He predicts that, in the future, the industry will leverage open platforms and interoperability, yielding new monitoring and management utilities that can facilitate better care at lower cost.
Tullman’s forecasts are hardly news, and there are two problems with his portrayals. The first is the dissonance between what he says now and actually did. Tullman became a multi-millionaire crafting products and policy that delivered intentionally costly, unfriendly and incompatible systems. Under his leadership, Allscripts products never embraced a national standard for health information exchange, even though those standards were available, or developed the capacity to seamlessly trade information with other systems.
As a Trustee of the Certification Commission for Health Information Technology (CCHIT), a quasi-governmental credentialing agency and offshoot of the Health Information Management Systems Society (HIMSS), he oversaw policies that favored large, established HIMSS members and set up roadblocks to innovation by technology startups. I testified on this topic to a Health and Human Services (HHS) panel in July, 2009. HHS subsequently rescinded CCHIT’s monopoly on EHR certification, and CCHIT’s Executive Director, Mark Leavitt, resigned shortly afterward.
Tullman’s strong support of and relationship with President Obama facilitated his role as one of the architects of the Meaningful Use (MU) subsidies. Those actions brought billions of dollars to EHR vendors between 2010 and now, but these EHR systems still can’t talk with one another. As I’ve described elsewhere, even while the health IT industry extolled the benefits that would come from easy sharing of health data, they nearly unilaterally resisted interoperability. (If you can’t easily move your data to another vendor’s platform, you’re less likely to make them your vendor.) The result is that our inability to seamlessly exchange health information continues to undermine our ability to coordinate care, costing America thousands of lives and hundreds of billions of dollars a year.
Tullman also paints Kibbe and the American Academy of Family Physicians (AAFP) as obstacles to HIT progress, when in fact it was Tullman and his EHR vendor colleagues who engineered the barriers to interoperability. The quotes by Dr. Kibbe are taken out of context and misrepresent him as an opponent of EHRs. In fact – and Mr. Tullman knows this – Dr. Kibbe has been in the vanguard of EHR use. He was the lead architect of the Continuity of Care Record (CCR) standard, the forerunner of the Consolidated Clinical Document Architecture (CCDA) which has become the standard of choice for MU data structure during health information exchange. When he was Executive Director of the American Academy of Family Physicians’ Center for Health Information Technology (AAFP CHIT), his campaigns resulted in a five-fold increase in the percentage of family physicians with EHRs, from 10 percent to 50 percent between 2003 and 2007. Today, he spearheads DirectTrust, an approach to securely and privately transfer health information by email, independent of platform. If anyone has moved health information generally and EHR technology specifically forward in this country to the common benefit, it is Dr. Kibbe. By contrast, Mr. Tullman has represented the special interest, blocking advances to make as much money as possible.
Physicians, purchasers and patients should take umbrage at Tullman’s article. Along with EPIC, Cerner, NextGen and other old guard EHR vendors, Tullman and Allscripts are directly responsible for most current EHRs’ outrageous costliness, lack of usability and interoperability, and their limited clinical decision support. Through their scale and influence over policy, they have effectively manipulated the EHR market, gouging purchasers and delivering marginally capable products. Health care costs more, and outcomes have suffered as a result.
Most Forbes readers won’t have enough health industry background to place Tullman’s comments into context. They are opportunism masquerading as good policy. Past performance is indicative of what we can expect in the future. Caveat emptor.
Tagged as: Allscripts, CCHIT, CDA, Continuity of Care Record Standard, Electronic Health Record Technology, Glen Tullman, health information technology, HIMSS
Nice piece responding the the disingenuous quotes and references taken out of context suggesting David Kibbe is against implementation of EHR's. HE like many of us is in favor but has long been an advocate of and vanguard of EHR use
Dr. Kibbe has been in the vanguard of EHR use. He was the lead architect of the Continuity of Care Record (CCR) standard, the forerunner of the Consolidated Clinical Document Architecture (CCDA) which has become the standard of choice for MU data structure during health information exchange. When he was Executive Director of the American Academy of Family Physicians’ Center for Health Information Technology (AAFP CHIT), his campaigns resulted in a five-fold increase in the percentage of family physicians with EHRs, from 10 percent to 50 percent between 2003 and 2007. Today, he spearheads DirectTrust, an approach to securely and privately transfer health information by email, independent of platform. If anyone has moved health information generally and EHR technology specifically forward in this country to the common benefit, it is Dr. Kibbe
Quite! Long standing advocate and unlike many of the commercial interests who spend much time, energy and resources blocking open access.
There remain challenges and the competing interests embedded in commercial incentives but to call out an icon in #HealthIT and unnecessary
Tuesday, March 12, 2013
Accounting for Calories - Eat + Run
One of the more titillating medical stories to make news recently is a study in the American Journal of Clinical Nutrition indicating that calorie intake in the United States has come down, and obesity rates have not. What makes this titillating, of course, is that it seems to suggest some great new mystery of energy balance. But I think we can account for this finding without revisiting laws of thermodynamics. We can, and we should—because there is real potential danger in abdication. If we don't account for these calories, others will.
For example, as I was indulging recently in one of my all-too-infrequent guilty pleasures, namely cuddling with my wife and watching American Idol, I was fascinated by Coca-Cola's latest commercial. This ad, brilliantly produced and polished as ever with Coca-Cola, invites us, essentially, not to worry and just be happy with the calories Coca-Cola serves.
[See Soda, Calories, and a Full Accounting]
The ad gives us a can of Coke, presumably 12 ounces, providing 140 calories. We are then shown the activities we can "enjoy" to burn up those calories. I trust everyone recognizes the activities are additive—you have to do them all to burn those 140 calories. And I trust those watching reliably do the math and reach the conclusion that it's roughly 37 minutes of physical activity all together.
Coca-Cola doesn't address how long it takes to drink those 140 calories, but we all know it's a matter of seconds. Nor does it look at the energy balance situation in reverse: You could replace the calories burned in 37 minutes of moderate activity by drinking just one 12-ounce Coke! And, of course, Coca-Cola doesn't even hint at a reality where most people who drink Coke drink more than 12 ounces and more than one, and where we can't get most people up to even 20 minutes of daily physical activity. Coke's own, happy ad indicates that if you drink two of these babies a day, you need well over an hour and a quarter of moderate physical activity to burn just those calories—to say nothing of any others you happen to consume.
[See Exercise: The Case for Counting What Really Counts]
No, in Coke's accounting for calories, it leaves those logical considerations to us. Because, of course, the company want this to be less about Coke, and more about our couches. If only we would get off the couch more, we could (presumably) drink Coke to our heart's content!
For now, we can leave aside other considerations—such as the quality of calories and the fact that Coca-Cola provides no nutritional value—aside. Let's get back to the new study. I'm sure folks at Coca-Cola love it, because it readily invites a "we're-doing-fine-with-calories-and-not-exercising-enough" interpretation. That's tailor-made to support Big Food's preferred answer to the problem of epidemic obesity.
So we need to account for those calories, or we invite Madison Avenue to do it for us. And we can.
[See How to Take a Stand Against Junk Food]
First, some of the answer may well be a decline in physical activity. We have recent evidence that physical activity is being jettisoned ever more routinely from schools; that we sit more hours a day than ever before, and shorten our life spans as a result; and that sedentariness may now represent the leading cause, and certainly a leading cause, of years lost from life and life lost from years around the globe. This all suggests we should, indeed, increase our activity level. It does not suggest room for adding ever more Coca-Cola calories as we do so.
Second, I'm a bit surprised to hear that obesity rates have only kept rising. Haven't we been told from just the same kinds of studies that obesity rates had plateaued? Haven't we heard that obesity rates have actually declined in locations around the country? I am perennially frustrated by our tendency to forget about every prior medical study that made news every time a medical study makes news. OK, our calorie intake may have come down a bit. But so, I thought we had been told, had obesity rates. These two things fit together rather handily.
Third, there's the fairly obvious possibility of erroneous reporting. Getting accurate dietary intake information is notoriously difficult. We all tend to underreport our caloric intake and overreport our physical activity. We also tend to underreport our weight and overreport our height. None of this is willful deceit; it's just human nature. We tend to spin everything to the positive, ourselves included, apparently.
[See There's No Cure for Obesity]
We also know that in all survey research, participants have some tendency to tell the researchers what they want to hear. As our society has become ever more focused on epidemic obesity, it would be no great surprise if we were ever more inclined to tell, inadvertently, little white lies about our calorie intake.
Fourth, there's the fact that before the recent decline in reported calorie intake, there was a much bigger rise. The researchers tell us average food intake went up by some 314 calories per day between the early 1970s, and 2004. It has apparently gone down by some 74 calories per day since. But that means we've cut back less than a quarter of our new-age gluttony. If we're still eating more calories than we need, we won't be getting thinner any time soon—we'll just start getting heavier less fast.
Fifth, it takes time either to gain weight or lose it. If we really did only recently dial back our average calorie intake, then maybe obesity rates will follow. But we need day after day, month after month of consistently lower calorie intake before it shows up as more than a blip on the nation's scale.
[See Diet Resolutions Worth Making]
And then sixth, and finally, what I think best accounts for a decline in calories, and no corresponding change in obesity rates: the bell curve. I'll explain.
We define "obesity," for better or worse, using the BMI (body mass index) and specific cut-points. A BMI from roughly 18 to 25 is "normal" weight. A BMI from 25 to 30 is "overweight." And a BMI greater than 30 is "obese."
Now imagine that the entire population does indeed reduce average daily calorie intake—and that average weights do come down a bit as a result. Won't all of this weight loss show up as a change in obesity prevalence?
Of course not! If normal-weight people become slightly leaner, there will be no change in obesity rates. If overweight people become less overweight, but stay in the overweight range, there will be no change in obesity rates. And if obese people become less obese but stay in the obese range, there will be no change in obesity rates. The only groups in the population likely to affect obesity rates are those right at the cut-points: those with BMI of just under, or just over 30. The former can gain a little weight and make obesity rates go up; the latter can lose a little weight and make obesity rates go down. Everybody else would have to gain or lose a lot of weight to affect obesity rates at all.
[See 5 Ways to Practice Portion Control]
The data to tell us what percentage of the population has a BMI just north of 30 are available, but I couldn't get my hands on them while writing this. So, invoking the common bell curve distribution as a default, we may reasonably infer that weight is distributed across the spectrum from low to high, clustering around the mean. That suggests that only a very small percent of the population—well below 10 percent, certainly, can lose a bit of weight and affect obesity rates. The study in question, though nationally representative, is still based on samples of just thousands, and could readily be blind to such a relatively rare occurrence.
That will do for now. I acknowledge that the quality of calories matters, but so does the quantity. We cannot allow a seemingly small divergence in calorie and obesity trends to invite wild imaginings. Yes, we should be more physically active—but since it's far easier to out-eat exercise than to out-exercise all those tasty calories, we ignore the "calories in" side of the energy-balance equation at our peril.
We can account for the recent study with no great difficulty. We can certainly do so without rewriting any laws of physics. We can account for those calories, and need to do so—because the likes of Coca-Cola have already indicated how happy they would be to do it for us.
[See Nutrition Tips for College Students]
Hungry for more? Write to eatandrun@usnews.com with your questions, concerns, and feedback.
David L. Katz, MD, MPH, FACPM, FACP, is a specialist in internal medicine and preventive medicine, with particular expertise in nutrition, weight management, and chronic-disease prevention. He is the founding director of Yale University's Prevention Research Center, and principal inventor of the NuVal nutrition guidance system. Katz was named editor-in-chief of Childhood Obesity in 2011, and is president-elect of the American College of Lifestyle Medicine.
Excellent piece reviewing the terrible state of obesity in our country and the impact that the food industry is having - focusing on the Coca Cola advert that tries to persuade people that enjoying a coke is worthwhile because you can do all these activities - all 37 minutes of them!
Its a simple equation - input and output. If you consume more calories than you output in the form of exercise and activites of daily living thenyou will gain weight
As David points out
We cannot allow a seemingly small divergence in calorie and obesity trends to invite wild imaginings. Yes, we should be more physically active—but since it's far easier to out-eat exercise than to out-exercise all those tasty calories, we ignore the "calories in" side of the energy-balance equation at our peril
By any other measure obesity is an epidemic and as I saw recently described the fast food industry as our generations version of nicotine and the smoking.
Thursday, February 28, 2013
Why Even Radiologists Can Miss A Gorilla Hiding In Plain Sight
Trafton Drew and Jeremy WolfeNotice anything unusual about this lung scan? Harvard researchers found that 83 percent of radiologists didn't notice the gorilla in the top right portion of this image.
Notice anything unusual about this lung scan? Harvard researchers found that 83 percent of radiologists didn't notice the gorilla in the top right portion of this image.
Trafton Drew and Jeremy WolfeThis story begins with a group of people who are expert at looking: the professional searchers known as radiologists.
"If you watch radiologists do what they do, [you're] absolutely convinced that they are like superhuman," says Trafton Drew, an attention researcher at Harvard Medical School.
About three years ago, Drew started visiting the dark, cavelike "reading rooms" where radiologists do their work. For hours he would stand watching them, in awe that they could so easily see in the images before them things that to Drew were simply invisible.
"These tiny little nodules that I can't even see when people point to them — they're just in a different world when it comes to finding this very, very hard-to-find thing," Drew says.
YouTubeIn the Invisible Gorilla study, subjects have to count how many times the people in white shirts pass the basketball. By focusing their attention on the ball, they tend to not notice when a guy in a gorilla suit shows up.
But radiologists still sometimes fail to see important things, and Drew wanted to understand more. Because of his line of work, he was naturally familiar with one of the most famous studies in the field of attention research, the Invisible Gorilla study.
In that groundbreaking study, research subjects are shown a video of two teams of kids — one team wears white; the other wears black — passing two basketballs back and forth between players as they dodge and weave around each other. Before it begins, viewers are told their responsibility is to do one thing and one thing only: count how many times the players wearing white pass the ball to each other.
This task isn't easy. Because the players are constantly moving around, viewers really have to concentrate to count the throws.
Then, about a half-minute into the video, a large man in a gorilla suit walks on screen, directly to the middle of the circle of kids. He stops momentarily in the center of the circle, looks straight ahead, beats his chest, and then casually strolls off the screen.
The kids keep playing, and then the video ends and a series of questions appear, including: "Did you see the gorilla?"
"Sounds ridiculous, right?" says Drew. "There's a gorilla on the screen — of course you're going to see it! But 50 percent of people miss the gorilla."
This is because when you ask someone to perform a challenging task, without realizing it, their attention narrows and blocks out other things. So, often, they literally can't see even a huge, hairy gorilla that appears directly in front of them.
That effect is called "inattentional blindness" — which brings us back to the expert lookers, the radiologists.
Drew wondered if somehow being so well-trained in searching would make them immune to missing large, hairy gorillas. "You might expect that because they're experts, they would notice if something unusual was there," he says.
He took a picture of a man in a gorilla suit shaking his fist, and he superimposed that image on a series of slides that radiologists typically look at when they're searching for cancer. He then asked a bunch of radiologists to review the slides of lungs for cancerous nodules. He wanted to see if they would notice a gorilla the size of a matchbook glaring angrily at them from inside the slide.
But they didn't: 83 percent of the radiologists missed it, Drew says.
This wasn't because the eyes of the radiologists didn't happen to fall on the large, angry gorilla. Instead, the problem was in the way their brains had framed what they were doing. They were looking for cancer nodules, not gorillas. "They look right at it, but because they're not looking for a gorilla, they don't see that it's a gorilla," Drew says.
In other words, what we're thinking about — what we're focused on — filters the world around us so aggressively that it literally shapes what we see. So, Drew says, we need to think carefully about the instructions we give to professional searchers like radiologists or people looking for terrorist activity, because what we tell them to look for will in part determine what they see and don't see.
Drew and his co-author Jeremy Wolfe are doing more studies, looking at how to help radiologists see both visually and cognitively the things that hide, sometimes in plain sight.
via npr.org
In a well documented aspect of the human mind and one we have all probably experienced in one form or another:
If you have seen the gorilla video before (there is a whole web site dedicated to this here) and their video
And the original version of this (I think more compelling) can be seen here
So important in so many areas - in the cockpit of airplanes many of the accidents can be traced to failure to identify what may seem clear indications of the fault or problems. The most recent example in the cockpit of air france Flight 447. My favorite detailed report came in Popular Mechanics: What Really Happened Aboard Air France 447 that highlighted the fact the aircraft was in a user induced stall
during its entire 3 minute 30 second descent from 38,000 feet before it hit the ocean surface
Despite multiple warnings from the onboard systems (visual and audible)
In healthcare the same challenges exist and this was aptly demonstrated in this study by Drew who:
He took a picture of a man in a gorilla suit shaking his fist, and he superimposed that image on a series of slides that radiologists typically look at when they're searching for cancer. He then asked a bunch of radiologists to review the slides of lungs for cancerous nodules. He wanted to see if they would notice a gorilla the size of a matchbook glaring angrily at them from inside the slide.
83% of radiologists missed it.
A problem when we are asking our radiologists (and doctors) to speed through even more images (and patients in less time)
I suspect technology is going to have to help in catching some of these instances and provide additional backup to the human mind. In fact "Assure" is one example of soem of the steps being taken towards this goal
Tuesday, February 26, 2013
Bitter Pill: Why Medical Bills Are Killing Us
THere is something fundamentally wrong and flawed with a system that bills patients at highly variable rates, the highest to those with no "insurance" or poor "insurance".
Insurance in this instance seems like a poor term to describe a system that even with full standard coverage still costs patients thousands if not tens of thousands of dollars of unexpected cost.
It has gotten worse and as the McKinsey study cited in the article highlights
we spend more on health care than the next 10 biggest spenders combined: Japan, Germany, France, China, the U.K., Italy, Canada, Brazil, Spain and Australia. We may be shocked at the $60 billion price tag for cleaning up after Hurricane Sandy. We spent almost that much last week on health care. We spend more every year on artificial knees and hips than what Hollywood collects at the box office. We spend two or three times that much on durable medical devices like canes and wheelchairs, in part because a heavily lobbied Congress forces Medicare to pay 25% to 75% more for this equipment than it would cost at Walmart
There are many drivers but central to them are the disconnect between the payers and the people accessing care. Without any personal accountability it is easy to access the care with no thought of the cost or the possible alternatives and better choices.
Some of the reasons behind this are vested in the history of healthcare and how we got here - but just because that was the way it was done before does not mean it is the way we have to do it now.
There has to be a better way - the same as there has to be a better way of compensating the healthcare providers fairly for the work they do. The system currently is designed to pay for things done not for outcomes and results. And clinicians are locked into a system that forces them to document in great detail, oftentimes repeating information that is already in the medical record - because if they don't they don't get paid
Many wi ll tell you the information is unnecessary and we see some of the effects with reports of duplicate data. So much better to capture decision making, real information and allow the documentation to be the communication tool between clinicians (which was always the original intent) and then determine the care provided and a fair compensation for the hospital, the provider and everyone involved for delivering that care (and importantly linked ot results not to just delivering the care)
I know I am hoping this is on a pathway to getting fixed. At some point I will be facing bills and challenges such as these - and since the education system (thats a whole other blog posting on the meteoric rise of education costs) has essentially stripped me of any savings and value in my one big investment (my house) I like many others are probably tapped out and have little to call upon when we will inevitably face these challenges. That puts me rooting for major change in healthcare, the system with a move to pay for performance much of which is embodied in the ACO initiative.
Thursday, February 21, 2013
NY Times rewrites Health IT History
The approach came in 2009, in a presentation to doctors by Allscripts Healthcare Solutions of Chicago, a well-connected player in the lucrative business of digital medical records. That February, after years of behind-the-scenes lobbying by Allscripts and others, legislation to promote the use of electronic records was signed into law as part of President Obama’s economic stimulus bill. The rewards, Allscripts suggested, were at hand.
But today, as doctors and hospitals struggle to make new records systems work, the clear winners are big companies like Allscripts that lobbied for that legislation and pushed aside smaller competitors.
While proponents say new record-keeping technologies will one day reduce costs and improve care, profits and sales are soaring now across the records industry. At Allscripts, annual sales have more than doubled from $548 million in 2009 to an estimated $1.44 billion last year, partly reflecting daring acquisitions made on the bet that the legislation would be a boon for the industry. At the Cerner Corporation of Kansas City, Mo., sales rose 60 percent during that period. With money pouring in, top executives are enjoying Wall Street-style paydays.
None of that would have happened without the health records legislation that was included in the 2009 economic stimulus bill — and the lobbying that helped produce it. Along the way, the records industry made hundreds of thousands of dollars of political contributions to both Democrats and Republicans. In some cases, the ties went deeper. Glen E. Tullman, until recently the chief executive of Allscripts, was health technology adviser to the 2008 Obama campaign. As C.E.O. of Allscripts, he visited the White House no fewer than seven times after President Obama took office in 2009, according to White House records.
Mr. Tullman, who left Allscripts late last year after a boardroom power struggle, characterized his activities in Washington as an attempt to educate lawmakers and the administration.
“We really haven’t done any lobbying,” Mr. Tullman said in an interview. “I think it’s very common with every administration that when they want to talk about the automotive industry, they convene automotive executives, and when they want to talk about the Internet, they convene Internet executives.”
Between 2008 and 2012, a time of intense lobbying in the area around the passage of the legislation and how the rules for government incentives would be shaped, Mr. Tullman personally made $225,000 in political contributions. While tens of thousands of those dollars went to the Democratic Senatorial Campaign Committee, money was also being sprinkled toward Senator Max Baucus, the Democratic senator from Montana who is chairman of the Senate Finance Committee, and Jay D. Rockefeller, the Democrat from West Virginia who heads the Commerce Committee. Mr. Tullman said his recent personal contributions to various politicians had largely been driven by his interest in supporting President Obama and in seeing his re-election.
Cerner’s lobbying dollars doubled to nearly $400,000 between 2006 and last year, according to the Center for Responsive Politics. While its political action committee contributed a little to some Democrats in 2008, including Senator Baucus, its contributions last year went almost entirely to Republicans, with a large amount going to the Mitt Romney campaign.
Current and former industry executives say that big digital records companies like Cerner, Allscripts and Epic Systems of Verona, Wis., have reaped enormous rewards because of the legislation they pushed for. “Nothing that these companies did in my eyes was spectacular,” said John Gomez, the former head of technology at Allscripts. “They grew as a result of government incentives.”
Executives at smaller records companies say the legislation cemented the established companies’ leading positions in the field, making it difficult for others to break into the business and innovate. Until the 2009 legislation, growth at the leading records firms was steady; since then, it has been explosive. Annual sales growth at Cerner, for instance, has doubled to 20 percent from 10 percent.
“We called it the Sunny von Bülow bill. These companies that should have been dead were being put on machines and kept alive for another few years,” said Jonathan Bush, co-founder of the cloud-based firm Athenahealth and a first cousin to former President George W. Bush. “The biggest players drew this incredible huddle around the rule-makers and the rules are ridiculously favorable to these companies and ridiculously unfavorable to society.”
This industry, which was pioneered in the late 1970s, first gained widespread attention in 2004 when President Bush in his State of the Union speech called for digitizing national health records.
“After that, every technology C.E.O. wanting a piece of health care would have visited me every day if I had let them,” said David Brailer, whom President Bush appointed as the nation’s first health information czar. Over the next few years, Cerner and many of the other health care data companies increased their presence on Capitol Hill.
The records systems sold by the biggest vendors have their fans, who argue that, among other things, the systems ease prescribing medications electronically. But these systems also have many critics, who contend that they can be difficult to use, cannot share patient information with other systems and are sometimes adding hours to the time physicians spend documenting patient care.
“On a really good day, you might be able to call the system mediocre, but most of the time, it’s lousy,” said Michael Callaham, the chairman of the department of emergency medicine at the University of California, San Francisco Medical Center, which eight months ago turned on its $160 million digital records system from Epic. Michael Blum, the hospital’s chief medical information officer, said a majority of doctors there like the Epic system.
Whatever the case, the legislation has been a windfall to top executives at the leading health records companies. Neal L. Patterson, who grew up on a farm near Manchester, Okla., population 100, co-founded Cerner in 1979. As Cerner’s sales have soared in recent years, so have Mr. Patterson’s fortunes. From 2007 to 2011, he received more than $21 million in total compensation, according to the executive compensation research firm Equilar, and his stake in the company is worth $1 billion.
In recent years, Mr. Patterson and his wife, Jeanne Lillig-Patterson, who ran as a Republican for Congress in 2004, have emerged as social and business leaders in the Kansas City, Mo., area. Mr. Patterson is also co-owner of a real estate development firm whose ventures include a 1,200-acre community near Kansas City called the Village of Loch Lloyd, featuring a Tom Watson-designed golf course.
A spokeswoman for Cerner said Mr. Patterson was unavailable for comment.
The medical records industry did not have much of a presence in Washington before President Bush highlighted it in 2004. Then in November that year, the industry created its first association, the Healthcare Information and Management Systems Society EHR Vendor Association, to make the case for electronic records. Its founding members included Allscripts, Cerner and Epic.
Four years later, in December 2008, H. Stephen Lieber, chief executive of the group, wrote an open letter to President-elect Obama calling for a minimum government investment of $25 billion to help hospitals and physicians adopt electronic records. The industry ultimately got at least $19 billion in federal and state money.
In the months after that windfall arrived, sales climbed for leading vendors as hospitals and physicians scrambled to buy systems to meet tight timetables to collect the incentive dollars. At Allscripts, Mr. Tullman soon announced what looked like a game-changing deal: the acquisition of another records company, Eclipsys, for $1.3 billion.
“We are at the beginning of what we believe will be the fastest transformation of any industry in U.S. history,” Mr. Tullman said when the deal was announced.
Last spring, some of the Eclipsys board members left after a power struggle; Mr. Tullman left in December. He is now at a company he co-founded that focuses on solar energy — another area that, after Obama administration and Congress expanded government incentives in the 2009 stimulus bill, has been swept by a gold-rush mentality, too.
This article has been revised to reflect the following correction:
Correction: February 20, 2013
An earlier version of this article omitted part of the name of the institution that employs Michael Callaham and Michael Blum. It is the University of California, San Francisco Medical Center, not the San Francisco Medical Center.
via nytimes.com
To use Paul Harvey's line....now here's the rest of the story
Yes the stimulus has increased uptake of technology but in so many respects money well spent - would anyone challenge that our old system of single access paper records that were full of redundant, duplicate information, much of it inaccessible and certainly of limited value to the care of complex clinical conditions and management of patient health....this time borrowoign from Monty Python...if we were lucky
No comment about the significant positive job impact - big increase in healthcare jobs and employment
And as one commentator put it in another thread:
There's a good bit of history rewriting in this article
As they pointed out much of the competitive landscape had been formed prior to the Act and they were delivering profits long before the stimulus package
We are seeing the benefits and value of these technologies. Many forget it was not the government that sent us down this track
1999 - To Err is Human
2001 - Crossing the Quality Chasm
2006 - Preventing Medication Errors
Not to mention other countries who have demonstrated the value of Healthcare Technology.
Is it perfect - probably not but if this was the tipping point to push everyone towards the same goal then it has had the desired effect, and like many technologies, its good for you on its own, but so much better if everyone participates.
I'm excited to be part of this "Tipping Point" and glad to be working with one of the top 50 disruptive companies in this space.
Wednesday, February 20, 2013
Khan Academy Approach Poised to Solve a "Wicked Problem" in Healthcare
here
Great article on the potential for social media in healthcare and highlighting the phenomenal job the Salaman Khan has done (of the Khan Academy,/a>) with education online.
There are some nice examples of use of video and social media to help in patient engagement and education and as David Chase points out addressing the exploding number of patients who will be accessing the healthcare system will need these kind fo tools and techniques if we are going to be abel to cope and keep up
Nuance joins a who's who in 50 Most Disruptive Companies for 2013
This is really cool - Nuance made the list for top 50 disruptive companies in technology. We join other great and innovative leaders like
SpaceX
Google
IBM
Square
Toyota
Apple
Amazon
Corning
Facebook
....to name a few
But also some neat Healthcare focused companies like
Diagnostics for all
Foundation Medicine
Illumina
UniQure
Congratulations to all the others but should out to Nuance - proud to be a part of this team
Tuesday, February 19, 2013
The law of Unintended Consequences - The "Cobra effect" on Patients
For many decades, newspapers were big; printed on the so-called broadsheet format. However, it was not cheaper to print on such large sheets of paper — that was not the reason for their exorbitant size — in fact, it was more expensive, in comparison to the so-called tabloid size. So why did newspaper companies insist on printing the news on such impractical, large sheets of paper? Why not print it on smaller paper? Newspaper companies, en masse, assumed that "customers would not want it;" "quality newspapers are broadsheet."
When finally, in 2004, the United Kingdom's Independent switched to the denounced tabloid size, it saw its circulation surge. Other newspapers in the UK and other countries followed suit, boosting their circulation too. Customers did want it; the newspaper companies had been wrong in their assumptions.
When I looked into where the practice had come from — to print newspapers on impractically large sheets of paper — it appeared its roots lay in England. In 1712, the English government started taxing newspapers based on the number of pages that they printed. In response, companies made their newspapers big, so that they could print them on fewer pages. Although this tax was abolished in 1855, companies everywhere continued to print on the impractical large sheets of paper. They had grown so accustomed to the size of their product that they thought it could not be done any other way. But they were wrong. In fact, the practice had been holding their business back for many years.
Everybody does it
Most companies follow "best practices." Often, these are practices that most firms in their line of business have been following for many years, leading people in the industry to assume that it is simply the best way of doing things. Or, as one senior executive declared to me when I queried one of his company's practices: "everybody in our business does it this way, and everybody has always been doing it this way. If it wasn't the best way of doing things, I am sure it would have disappeared by now".
But, no matter how intuitively appealing this may sound, the assumption is wrong. Of course, well-intended managers think they are implementing best practices but, in fact, unknowingly, sometimes the practice does more harm than good.One reason why a practice's inefficiency may be difficult to spot is because when it came into existence, it was beneficial — like broadsheet newspapers once made sense. But when circumstances have changed and it has become inefficient, nobody remembers, and because everybody is now doing it, it is difficult to spot that doing it differently would in fact be better.
The short-term trap
Some "best practices" may in fact start out as bad practices, but practices whose harmful effects only materialize years after their implementation. Yet with short-term consequences that are quite positive, firms go ahead and implement them — and never connect the problems of today with the practice launched years ago.
For example, in a project with Mihaela Stan from University College London, we examined the success rate of fertility clinics in the UK. A number of years ago, various clinics began to test, select, and only admit patients for their IVF treatment who were "easy cases"; young patients with a relatively uncomplicated medical background. Indeed, treating only easy patients boosted the clinics' success rates — in terms of the number of pregnancies resulting from treatment — which is why more and more firms started doing it. It improved their rankings over the short term. However, our research on the long-term consequences of this practice clearly showed that selecting only easy patients made them all but unable to learn and improve their treatment and success rate further. Clinics that continued to take on a fair proportion of difficult cases learnt so much from them that after a number of years their success rates became much higher — in spite of treating a lot of difficult patients — than the clinics following the selection practice. Unknown to the clinics' management, the seemingly clever practice put them on the back foot in the long run.
Clearly, the long-term negative consequences of a seemingly "best practice" can greatly outweigh its short-term benefits. But when managers don't see that practice as the root cause of their eroding competitive position, the practice persists — and may even spread further to other organizations in the same line of business.
Self-perpetuating myths
When seeming best practices become self-fulfilling prophecies, they're even more difficult to expose. Take the film industry. Film distributors have preconceived ideas about which films will be successful. For example, it is generally expected that films with a larger number of stars in them, actors with ample prior successes, and an experienced production team will do better at the box office.
Sure enough, usually those films have higher attendance numbers. However, because of their belief that those films will succeed, film distributors assign a much bigger proportion of their marketing budget and other resources to those films, as professors Olav Sorenson from Yale and David Waguespack from the University of Maryland have shown (PDF). Once they factored this spending bias into their statistical models, it became evident that those films, by themselves, did not do any better at all. The distributors' beliefs were a complete myth, which they subsequently made come true through their own actions. The film distributors would have been better off had they assigned their limited resources differently.
Most experienced executives have strong beliefs about what works and what doesn't, and logically they assign more resources and put more effort into the things they are confident about, eager not to waste it on activities with less of a chance of success. As a result, they make their own beliefs come true. The good box office results of the films distributors expected to do well reaffirmed their prior — yet erroneous — beliefs. This reinforced the myth of the best practice, and stimulated it to spread and persist.
Hence, with all the best intentions, executives often implement what is considered a "best practice" in their industry. What they do not know is that some of these practices are bad habits masquerading as efficiency boosters, their real consequences lying hidden. Questioning and uncovering such practices may significantly boost your competitive advantage, to the benefit of your firm and, eventually, us all.
via blogs.hbr.org
Nice piece looking at the challenges of unintended consequences through the ages. The piece is replete with great examples of why introduction of new rules and what appears like a good idea is not always.
This is often described as the Cobra Effect named after a famous incentive introduced by the British rulers in India.
In healthcare we need to be vigilant of the same unintended consequences (as we do in medicine). The new plans with high deductibles and incentives to reduce total spend by individuals is a good case in point. If the incentives are sufficient we could end up stopping patients from seeking therapy. In a recent example related to me a high deductible plan was selected by an individual who discovered to late that his relatively minor medications for a mild skin condition went from a cost of ~$200 per year to a cost of > $4,000 per year.
Casting aside the issue of drug costs that has as yet not been adequately addressed in any of the reforms to date, the unintended consequence is patient stops treatment. This may seem minor but the long term consequences may well be significant and the mental effect alone will have impact on that individual.
It may not be possible to predict all the possible outcomes but it is important to be aware and allow for rapid course corrections as we learn more going through these big changes in our healthcare systems
Tuesday, February 12, 2013
Doc Tornado's Quest for Clinical Documentation
CLINICAL DOCUMENTATION
NOW I'LL TELL YOU WHAT I WANT, WHAT I REALLY REALLY WANTEnough bitching like a Spice Girl, it's time to structure my wish list and share it with you, dear vendors. Let's start with my favorite topic if you don't mind: Clinical Documentation and Data Input.So here's my story from A to Z...if you wanna get with me, you gotta listen carefully.
In his review of what he really really wants Doc Tornado's laid out his requirements that include....choice
No one size fits all and failure to provide clinicians choice is a recipe for problems
Sometimes a form fits, sometimes it doesn't. And of course includes the range of speech tools from mobile dictation to speech recognition that offes flexibility between, as he puts it
On my end, I’ll feel like front-end on Mondays and back-end on Fridays
It should include intelligent understanding and interaction.
The good news is much of this is here today both in terms of the choice for the technology but also the intelligent interaction. This teaser video gives a good sense of what's possible:
So I would say that's "Alohomora":
Come visi our booth at HIMSS to see this in action at Booth 4025 (view a floor plan here
Wednesday, February 6, 2013
Digital Health Needs To Be More Than Just Digital Data
This last week – the widely read Dr. Rob Lamberts lamented the usability of his Electronic Medical Record (EMR) software for his new primary care practice. It’s worth reading (here) as it highlights the larger systemic problem of EMR software generally and then specifically as EMR software is overlaid onto a new payment model.
In Dr. Lamberts case, a software solution – one that was built specifically around billing mechanics (namely ICD-9 and CPT “codes”) – was overlaid onto a new practice model that bills patients a flat monthly fee for “all-they-can-eat” primary health care. Almost all EMR/EHR software has been purpose-built to support billing as the primary function. Clinical data capture is the secondary objective – and the EMR/EHR software vendor landscape is 100% reflective of that priority (as is the entire system). At last count, there were over 600 EHR “vendors” and over 300 that had reported at least one doctor or practice that ”attested” to “meaningful use” with their software (a requirement for HITECH Act payment). To date, we’ve spent over $10B on “digitizing” health records.
I’m struggling to find the right analogy, but I imagine the effect Dr. Lamberts (and others) are feeling is similar to putting a V-8 engine onto a bicycle. Yes, you could (conceivably) engineer that solution – but why would you – and then why would you expect any kind of usable experience? You simply wouldn’t (unless, perhaps, you were Evel Knievel). Even Felix Baumgarten carefully employed a team of 300 (including 70 engineers and doctors) in his lone (and breathtaking) leap from the edge of space.
Forbes colleague David Shaywitz wrote more broadly (and brilliantly) about this in his piece earlier today: Handle With Care: Success of Digital Health Threatened by Power of Its Technology. This too is well worth worth reading as it relates to the “quick-fix” mentality that is pervasive in both our culture and our wheezing health care system. It’s everywhere – and short-sighted. For providers, let’s cram-down EHR solutions so that we can “capture” the downstream data/analytics that we so desperately need to control costs – with little interest, attention or concern to the consequence on the front-end patient dynamics (including both patient AND provider experience). For employers, let’s add “gamification” and “wellness” programs (with “behavioral economics” of course) to the HR/Benefits equation. While we’re at it – let’s automate low-acuity, primary care as much as we possibly can. There – all done. We’ve digitized, gamified and automated the whole mess.
The effect – as evidenced by Dr. Lamberts plight (and flight) – is to eject altogether. The fundamental hope (and risk) of this “direct-to-consumer” model is that personal (and fiscal) sanity will return to the private (often solo) practice of primary care. I’m not sure it’s the right hope (or exit), but I do understand the motivation and it is a worthwhile experiment because, more than ever, we need primary care physicians to stay engaged as we work through our health care transformation. I argue that Medscape’s chart on ”average” physician compensation highlights the broader dilemma – namely that primary care (the very entry point for health care) is the lowest paid.
We pay primary care in much the same way that we pay tellers at the bank. Tellers aren’t dead – nor is their survival at risk – but it’s tilting heavily toward the retail economy. So are primary care physicians. These are all the ”gatekeepers.” In fact, that may well be the exact path we’re on as we attempt to automate (and further minimize) the dynamics of primary care. Several companies (eg: Healthspot – which I wrote about in my CES coverage earlier this month) are building the physical Kiosk’s specifically targeting low-acuity, primary care. As a primary care physician – the assault is relentless – from every direction.
- Current payment rates that are unsustainable to a practice
- Further cuts to payment rates in the forecast
- Increasing demand for “accountability” (both regulatory and ACO’s)
- Complete subjugation by other specialties – where primary care is treated as the “funnel” or “filter” to higher-rate specialties
- Kiosk’s and eVisits as the final automation of primary care altogether (do we know who the doc-in-a-box is? Should we care?)
- Ever increasing volume as more people join the ranks of the “insured”
The technology overlay is simply the gamification and behavioral economics to support an increasingly desperate need for lower cost, but it’s unrelated to any metrics that support either better health outcomes or better care delivery. We don’t know. It’s entirely experimental.
All of which speaks to the huge need for more systemic changes around payment reform. As it stands today, the Affordable Care Act (ACA) does little more than tweak the current payment model. Yes, Accountable Care Organizations (a by-product of the ACA) are scaling broadly, but adding a risk component to the payment of care doesn’t fundamentally change the “fee-for-service” model – or mentality. As Paul Levy highlighted, ACO’s are “Neither Accountable nor Caring nor Organized”. Ouch. Yes, provider compensation will absolutely be tied to outcome (including things like “re-admissions”), but is that really the biggest, the best and only lever?
Don Berwick has suggested three ”triple aims.” We all know the first – better care, better health and lower cost, which is the ultimate goal, but there are two others. The second is:
- We can get to better care, better health and lower cost – but we’re going to have to improve our way there.
- The 1st Law of Improvement is that every system is perfectly designed to achieve the results it gets (ie: the current system is performing as built).
- Improvement science is a system science – not an economic science.
The third is that there are 3 types of product improvements (and we need all 3):
- Defect removal (ie: reducing hospital infections, fraud and waste)
- Reducing costs (while leaving the customer the same or better)
- Creating a new product or service (ie: a new model)
Don’s preferred example of a new model is the (Malcolm Baldridge National Quality Award winning) Nuka system in Alaska– but it’s not the only example. I wrote about the success of “worksite healthcare” last year. Using back-of-the envelope math – SAS (#2 for 2013 – and on the list of Top 100 Companies to Work for – 10 times) estimates that they save about $6M per year on healthcare costs. It’s not just lower cost either. They continuously demonstrate much happier, more productive employees – who also enjoy better health.
When describing either model, Nuka or worksite, there is almost no reference to digitized workflow. There is no reference to “gamification” or ”behavioral economics.” There’s also no reference to ”payment risk” or EMR “woes.” There is just improved healthcare – and the result is threefold. Better care, better health and lower cost. Triple aim. It does exist – and there’s even more than one model. We can get there but it’s through improvement. As Don Berwick suggests – that’s a system science – not an economic one. Unless and until we see that – I question how much healthcare transformation we’re actually getting. I’m just asking.
via forbes.com
Dan's right - it is not just about the data and coding. There are no quick fixes but listening to the clinicians and individuals enduring some of these changes is a good starting point and his point about primary care physicians is important - the key to helping patients manage their care. I would suggest that perhaps that what will happen is individuals will take on more of this role, supported by technology and clinical professionals (and not just doctors)
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