Category Archives: healthcare

data saving lives, entrepreneurship, healthcare, healthy habits, nutrition, policy, politics, quantified self, rapid learning health systems, research methodology

HICCUP: Health Initiative Coordinating Council

This manifesto aligns tightly with my own vision of how preventive health funding should be financed – data-driven and in a for-profit context.

HICCup

 

The HICCup experiment: Manifesto

Just imagine:

It’s 2019 and the mayor is having a bad day.  She wants to spearhead a new community program for bike-sharing, but she’s not sure the town can afford it.  Meanwhile, one of the new council members is pushing for an overhaul of the school lunch program.  She sighs as the assistant deputy mayor walks in.  “What now, Henry?” she asks with a slight edge in her voice.  But Henry is cheerful: “Mayor, I think we may have a way to fix this. I was just reading about the HICCup Experiment in a town just like ours…. It seems that if we did both the bike program and the school lunches, and made some other changes..”

“But what about our rising health care costs?” asks the mayor.

“That’s the point,” says Henry.  “HICCup showed that we can actually reduce those costs if we do multiple interventions simultaneously…even though none of them by itself would make a difference. And there’s an investment banker who just called us that’s eager to work with us to finance the project.  They’re asking us to set up a meeting with the big employers and Mercy Saints Health. Using the HICCup data, they think they can finance it all out of the health-care cost savings that would result, as long as we commit to following certain protocols.”

And the vision:

Now it’s 2040.  The mayor’s teen-aged son, also called Henry, is discussing his history project on the HICCup Experiment with other members of his MOOC.  “Of course,” he concludes, “the HICCup Experiment proved that multiple interventions can dramatically include the overall health of a community.  But the Experiment itself wouldn’t work anymore, as a funding vehicle.”

“Why not?” asks Susan, who clearly hasn’t done her homework.

Henry responds patiently with the obvious answer: “Because there are very few places with inflated, unnecessary health care costs anymore.”

The background

It is hard to find anyone in health care who does not believe that spending an extra $100 now on healthy behavior – exercise and proper nutrition, counseling for pre-diabetics, risk monitoring, and so on – could yield more than $120 in lowered costs and improved outcomes later. The numbers are fuzzy, of course, and there are plenty of methodological caveats, but there is little dispute about the plausibility and desirability of such an approach.

Yet neither individuals nor communities seem to act on the basis of this knowledge. Moreover, it’s likely that spending $110 now has no impact, as other factors dissipate any gain, but spending $110 million now (vs. a health-care budget of $100 million) should indeed return savings of $20 million annually over time.  Individuals often lack willpower or access to healthy food or convenient exercise facilities, and are surrounded by poor examples that encourage instant gratification rather than effort and restraint. And, on a broader, institutional scale, the money spent and the money to be gained do not belong to the same pocket.

Enter HICCup!

The goal of HICCup, the Health Initiative* Coordinating Council, is to facilitate the launch of five to eight community-wide experiments dedicated to proving that this can work, and to learning from both successful and unsuccessful efforts.  HICCup is a self-appointed counseling service and will persuade and guide local institutions to embrace a long-term perspective and launch a full-scale intervention experiment in their communities. For practical reasons, there are a few guidelines – but anyone who wants to do this without following our rules is welcome to do so.   (*Yes, it used to be “health intervention…” but initiative is more friendly and positive, and still let us keep the logo!)

For starters, HICCup will focus on communities of 100,000 people or fewer. The majority of each community and its institutions must be enthusiastic for the initiative to gain traction. If the community members mostly work for just a few employers and obtain health care from just a few providers, that makes the effort of corralling the players easier. And, of course, you need community leaders – mayor, city council, and others – who will work together rather than undermine one another.

So, how will this be funded? Not by HICCup, which is only a coordinating body.  The trick is for an investor in each community to capture some of what is being spent already on health care. As a rough calculation, assume $10,000 in annual per capita health-care costs, or $1 billion per year in a community of 100,000. (There are also all the separate costs of bad health, which are much harder to count or capture.)  That money ultimately comes from individuals and employers who pay it in taxes, insurance premiums or direct payments; the place to intercept it is somewhere between the payers and the health-care delivery system.

Instead of spending $1 billion a year, imagine spending $1.1 billion the first two years, but, say, only $900 million in the fifth year (possibly a $300 million savings off projected costs of $1.2 billion by then). That sounds like an attractive proposition – but only if someone else will make that initial investment in return for a claim to those presumed later savings.  These numbers are just for illustration; figuring out actual and predicted numbers for each community will be a key task.

The first challenge is for each HICCup community to get the involvement of a benevolent but ultimately profit-driven billionaire or hedge fund, or a philanthropic fund that sees a way to do good while earning money for future goodness. There are a lot of billionaires out there, some with vision. There are health-care companies that might bite, hedge funds looking for large-scale projects, and so-called social-impact bonds. There also are large employers that might decide to work with other employers in certain communities.

The funder makes a deal with whoever is responsible for the health-care costs (buyers): The funder makes upfront investment in health interventions and pays the health-care costs, against continued payment from the health-care buyers of the $1-billion yearly baseline, with the funder to keep (most of) the savings against originally predicted rising costs in later years. The money may be paid by employers, private insurers (which collect it from individuals, who, in the United States, are now required to buy insurance) or from government health-care funds, which will be the trickiest source.

One way or another, the investor/experiment manager will need to figure out how to realign some of the sick-care facilities and workers to some other role, including prevention, serving outsiders or some other use entirely.  That’s the second challenge HICCup experimenters need to address – one that is being addressed in part by the creation of Accountable Care Organizations, but without community involvement in preventive health.

All together now!


All these entities will be taking a substantial leap of faith. But we believe they can succeed – especially if they work together through HICCup to figure out the numbers, study the effects of small-scale healthy-living/preventive health-care efforts, and encourage one another to move forward. Regardless, each investor must work with existing institutions – if only to get at the revenue stream initially and benefit from the lowered costs in later years.

Although grants are a nice source of funding for demonstration projects and research, the best way for HICCup’s vision to catch on and be widely copied is by adopting a for-profit approach that attracts broader investment once it is shown to work.  Indeed, if a benefactor makes a donation, they feel good when they send off the money. An investor feels good only after the investment actually pays off.

Community officials and voluntary organizations also need to sign on…or  they can drive the process and find the benefactor/investor. They will also contribute by implementing complementary changes in school meals and gym classes; enacting zoning and other changes to encourage cycling, walking, and the like; hiring health counselors and care workers; and perhaps working with local restaurants and food stores to subsidize healthy choices and discourage unhealthy ones.   Local media can report on the experiment’s progress, and each community will likely engage in healthy rivalry with other HICCup experimenters.

Though it won’t get to keep the direct health-care cost savings, each community will get all the ancillary benefits of a healthy population, including an enhanced reputation.  Indicators of population health include not just rates of obesity, diabetes, high blood pressure, and diseases and related costs, but also whether the elderly can live (and be cared for) at home, absenteeism, school grades and graduation rates, employment statistics, accidents, and the like. Although the funder keeps the reduction in health-care costs, the community gets the benefit in the many payoffs from a healthier population over time.

Open enrollment

HICCup will not choose which communities participate. They will be choosing them selves. HICCup’s role will be to advise them and help them to communicate and learn from other communities going through the same process. We also want to be a clearinghouse for vendors of health-oriented tools, services, and programs. There are many bargains to be struck between communities and vendors offering discounts in exchange for wholesale adoption of their tools or programs.

However, there is one unbreakable rule: To work with HICCup, communities must collect and publish a lot of independently vetted data (without personal information, of course). For starters, they will need benchmarks of current conditions and projected costs, and then detailed statistics on the adoption of the measures, their impact and costs, and what happens over time.  HICCup will welcome input from lawyers and actuaries!

It is now time to try this on a broad scale. Five years from now, we will wonder what took us so long to get started. So, again, who will those investors be?

cool, data saving lives, healthcare, quantified self

Very cool Eulerian Video Filtering to monitor heart rate

This is so cool and will transform biological monitoring… can’t wait for it to become mainstream.

http://people.csail.mit.edu/mrub/vidmag/

Abstract

Our goal is to reveal temporal variations in videos that are difficult or impossible to see with the naked eye and display them in an indicative manner. Our method, which we call Eulerian Video Magnification, takes a standard video sequence as input, and applies spatial decomposition, followed by temporal filtering to the frames. The resulting signal is then amplified to reveal hidden information. Using our method, we are able to visualize the flow of blood as it fills the face and also to amplify and reveal small motions. Our technique can run in real time to show phenomena occurring at temporal frequencies selected by the user.

An example of using our Eulerian Video Magnification framework for visualizing the human pulse. (a) Four frames from the original video sequence. (b) The same four frames with the subject’s pulse signal amplified. (c) A vertical scan line from the input (top) and output (bottom) videos plotted over time shows how our method amplifies the periodic color variation. In the input sequence the signal is imperceptible, but in the magnified sequence the variation is clear.

 

business, entrepreneurship, healthcare, management and leadership, policy, politics

HBR Blog: Resolving Health Care Conflicts with a walk in the woods

4 step process to resolving conflict:

  1. Have each stakeholder articulate their “self-interests” so that they are heard by the others. What does each need to get from this exchange?
  2. Look at where the overlap among these self-interests reveals agreement, what we call the “enlarged interests.” In our experience, these agreements always outnumber the disagreements.
  3. Collaborate to develop solutions to the remaining disagreements, or “enlightened interests.” This is the time for creative problem solving.
  4. Certify what has now become a larger set of agreements, or “aligned interests.”

Any outstanding disagreements are held to the side for future negotiations.

[…….]

The inclusion of all stakeholders is essential because people only truly embrace solutions that they help create. Anytime that one party tries to impose something on another, the natural inclination of the imposed upon party is to resist. A little time spent upfront engaging in joint problem solving saves many hours — and headaches — that come with a mandate.

http://blogs.hbr.org/2013/10/four-steps-to-resolving-conflicts-in-health-care/

We have been engaged in health care negotiation and conflict resolution for two decades. We have worked on conflicts as mundane as work assignments and as complex as hospital mergers. We use and teach a simple four-step structured process that works in cases ranging from simple one-on-one interactions to extended multi-party discussions.

After assembling representatives of all stakeholders in a conflict, the first step is to have each stakeholder articulate their “self-interests” so that they are heard by the others. What does each need to get from this exchange? The second step is to look at where the overlap among these self-interests reveals agreement, what we call the “enlarged interests.” In our experience, these agreements always outnumber the disagreements.  The third step is to collaborate to develop solutions to the remaining disagreements, or “enlightened interests.” This is the time for creative problem solving. The fourth step is to certify what has now become a larger set of agreements, or “aligned interests.” Any outstanding disagreements are held to the side for future negotiations. We’ve taught people in as little as 30 minutes how to use this approach. (See our book Renegotiating Health Care for more detail on the process.)

We call this process the Walk in the Woods after a play that dramatized a well-known negotiation over nuclear arms reduction. The delegations from the United States and the Soviet Union were at loggerheads. During a break, the two lead negotiators went for a walk during which they unearthed their personal as well as each nation’s deeper, shared interests in peace and security. This understanding enabled them to break the deadlock and move forward.

The same negotiation principles that can reduce nuclear stockpiles can be effectively applied even at the front lines in health care. For example, there is often pressure to change who does what when new technologies are deployed or initiatives are undertaken to lower costs. Consider the situation in a traditional orthopedic practice where a physician sees every patient who comes through the door. Is this really best for the patient, the practice, and the larger system?

Most patients who arrive at an orthopedic office suffer from straightforward conditions such as a simple, non-displaced fracture or a sprain. These can be adequately treated by a properly trained physician’s assistant (PA), and patients can typically be seen much more quickly by a PA than by a specialist. If outcome quality and patient satisfaction can be maintained and costs lowered, this should be an easy move to make. Such shifts in responsibility, however, are often resisted and the resulting conflict can be acrimonious. Why?

Both physicians and patients have come to expect to interact with each other. Doctors prize their clinical autonomy and their relationships with those they treat, and the fee-for-service model rewards them for taking care of patients themselves. Patients, meanwhile, want to be treated by an “M.D.” and often a board-certified specialist rather than their primary care physician (PCP). The PCPs value their relationships with the specialists in the network and focus on their gatekeeper role rather than stretching the scope of care they provide. Insurers want to control costs, of course, and they and others exert pressure to divert simple cases from high-cost specialists to less expensive physician’s assistants or other non-specialist care-givers. No one is happy with the resulting conflict: Orthopods fear losing their patients; patients are anxious about getting lesser care; PCPs worry that their relationships with specialists will erode; and insurers and administrators find the resistance by all parties frustrating, time-consuming, and expensive.

Now, imagine that the physicians in our orthopedic practice host an open house Walk in the Woods discussion that includes referring PCPs, patients, and representatives from insurers. Engaging in the four-step process, the parties would find that high outcome quality, patient satisfaction, and keeping care affordable are on everyone’s list of self-interests. Through the process, the orthopedists could educate both the PCPs and patients on when a specialist’s expertise is truly needed. Patients could articulate how they weigh the trade-off between waiting time and the provider they would see. The insurers could explain some of the cost implications of different options. One can envision the idea of physician’s assistants treating routine injuries emerging from the process as each party identifies the benefits that meet their combined and self-interests:  The orthopods may be freed up to see a greater number of more complex and interesting cases; the PAs are able to work to the level of their ability; the PCPs expand their relationships with more members of the orthopedic practice; the insurer reimburses less for uncomplicated treatments; and patients would get appropriate care, save time, and help keep premiums down.

The two aspects of this approach that can be extrapolated to myriad other conflicts are the use of a structured process and inclusion of all key decision-making stakeholders. The structured process minimizes the ego battles and tangential scuffles by keeping all parties focused on productively resolving the central issues. Depending on the number of parties and complexity of the negotiation a Walk can take from 10 minutes to 10 days or more.

The inclusion of all stakeholders is essential because people only truly embrace solutions that they help create. Anytime that one party tries to impose something on another, the natural inclination of the imposed upon party is to resist. A little time spent upfront engaging in joint problem solving saves many hours — and headaches — that come with a mandate.

facts & data points, healthcare, management and leadership, rapid learning health systems

Health management self-delusion stats…

 

  • Humans are not wired to seek contradictory perspectives.  Instead, we seek to reinforce what we already believe to be true.  No surprise, therefore, that 80.6% of healthcare leaders believe the quality of care at their hospital is better than at the “typical” hospital.  And only 1.2% believe their hospitals are below average in performance.  As a result, most leaders in health care are slow to react to their changing environment because they are convinced that they already outperform their peers.

[NOTE THIS RELATED OBSERVATION: 
We are also notoriously bad at evaluating the merit of our own ideas. Most people fall trap of anillusory superiority that causes them to overestimate their creative talent, just as in other domains of competence (e.g., 90% of drivers claim to be above average — a mathematical improbability). It is therefore clear that we cannot rely on people’s self-evaluation to determine whether their ideas are creative or not.
FROM: http://blogs.hbr.org/2013/10/the-five-characteristics-of-successful-innovators/]

From: http://blogs.hbr.org/2013/10/bringing-outside-innovations-into-health-care/

Bringing Outside Innovations into Health Care

by Mike Wagner  |   9:00 AM October 28, 2013

Spurred by government reforms and market expectations, healthcare leaders are being forced to reinvent their organizations. The model for healthcare is being flipped upside down — from decades of focusing on acute care episodes and encouraging utilization to a future where successful organizations are able to reduce utilization, manage population health, and activate patients in the consumption (and delivery) of their own care.

But, most organizations are likely to fail in this pursuit. History shows that 65% of transformation efforts yield no improvement while 20% of efforts result in worsened outcomes.  Even when there is improvement, performance usually returns to previous levels within a few years.

This failure is not for lack of effort — health systems are making massive investments in new infrastructure, technology, processes and managerial approaches designed to manage change, such as electronic health records, Six Sigma and Lean Management.  But, all of these efforts are dependent on people for both initial implementation and long term execution. The only organizations that will prosper in this environment of disruptive and massive change are those that build a resilient and adaptive culture in which staff members:

  • Welcome and seek change, rather than resist it;
  • Experiment and innovate, rather than maintain the status quo; and
  • Make hard decisions without relying on approval from senior leaders.

There is no simple or single approach to building such a culture. But in our experience helping hundreds of hospitals and health systems manage this transformation, we have found three disciplines that are essential to the effort:  Importing new knowledge, strategically deploying existing skills, and disseminating leadership across the ranks.  This and posts to follow will explore each of these disciplines.

Importing New Knowledge

While businesses in other sectors have become adept at bringing in ideas from outside their walls, health care has lagged behind. A key reason is that healthcare leaders are often blind when it comes to creatively responding to the industry’s challenges.  The source of this blindness is twofold.

  • Humans are not wired to seek contradictory perspectives.  Instead, we seek to reinforce what we already believe to be true.  No surprise, therefore, that 80.6% of healthcare leaders believe the quality of care at their hospital is better than at the “typical” hospital.  And only 1.2% believe their hospitals are below average in performance.  As a result, most leaders in health care are slow to react to their changing environment because they are convinced that they already outperform their peers.
  • The second blinder is more common in health care than in other sectors — leaders often actively isolate themselves from the outside world, believing that their industry’s challenges are entirely unique.  These leaders resist the idea of learning from exemplars outside of health care.  As a result, they are often ignorant of the managerial advances being made in other industries.

To respond to disruptive change, health care leaders need to first acknowledge their blindness and then actively overcome it by learning how other industries are addressing similar challenges. This requires developing creative approaches to finding new ideas from outside of healthcare. While this concept has been around for some time (pioneers like Virginia Mason started importing lean six-sigma practices into health care at least a decade ago) it is still not widely accepted and is rarely done as a matter of routine.

One hospital that has done this well is Memorial Hospital of South Bend, Indiana. They introduced the concept of the “Innovisit” — a routine and structured outreach that sends staff members to visit businesses in other industries.  Support from the top is critical to the success of such initiatives, as it has been at Memorial where president and CEO Phil Newbold has championed the program.

At Memorial, each Innovisit involves a cross-functional team of “Innovisitors” who have been specially recruited and prepared for these events.  Visits are carefully planned with the host organization and key questions are crafted in advance.  Upon their return, innovisitors share their observations during special conferences and educational sessions offered at Memorial’s own “Innovation Café” — a dedicated space that was remodeled to support creative thinking and sharing.  The “Innovation Café” itself is the result of an innovisit to a Whirlpool Corporation facility that included an Innovation Training Center.   

The development of Memorial’s Heart and Vascular building is another example of ideas inspired by innovisits. While on one such visit, the innovistor team learned of a design consultancy whose architectural approach seemed like a much better fit with Memorial’s needs than the approach in development. The fact that the planning process was well underway did not deter Memorial from tapping the design consultancy to experiment with new design principles that resulted in a more patient-friendly center, replete with a meditation garden.  Memorial further supports the organization’s innovation effort through its “Wizard School” that trains the entire staff — from parking lot attendants to C-suite executives — to think creatively.

Kaiser Permanente has sponsored similar excursions.  For example, during a tour of a flight school, Kaiser staff took note of the “sterile cockpit” concept — specific times during a flight when no conversations are allowed between pilots unless they are necessary for safely flying the plane.  This concept was adapted to create safer medication administration protocols that reduced interruptions and errors.

At Kaiser, spreading new ideas is a massive undertaking due to the size of the organization — more than 175,000 employees. To meet this challenge, Kaiser’s Innovation Consultancy — an internal consulting group — will routinely run pilot projects in order to test and prove a concept.  The Consultancy will then use the results of those pilot projects to encourage other departments to adopt new ideas and improvements as well: its input in developing the Nurse Knowledge Exchange is an example of that. Working with nurses and patients, and tapping new tracking software for data input, the Consultancy team helped develop a quick, reliable and efficient process for transferring patient information between nurses at a patient’s bedside during shift changes. The impact of the Nurse Knowledge Exchange in boosting the quality of the information exchange and enhancing patient care soon led to its deployment at all Kaiser hospitals. In effect, the Consultancy accelerates the adoption of new ideas by doing much of the legwork required to implement new practices across multiple locations: Line managers are not burdened with the effort and work required to share and spread ideas with others.  (Here’s more on the Consultancy’s approach.)

A leadership team that has been constantly bombarded with mind-stretching ideas from other organizations and disparate industries will possess a treasure trove of proven and practical ideas ready to be adapted and implemented.  Many of the challenges that healthcare leaders will soon face — collapsing prices (consider Blu-Ray players now selling for $49); disruptive technologies (digital photography supplanting film); fierce competition (iPhones stealing the market made by Blackberry); and entirely new business models (Netflix doing what Blockbuster could not) — have already been seen in other industries, and have given rise to adaptive new strategies. Health care leaders would be unwise to repeat the mistakes of others; they would be foolish to overlook strategies and solutions that have already been developed and proven effective elsewhere.

cool, healthcare, musings

Facebook as the template for a shared EMR

As naive as it sounds, this actually makes a lot of sense and couldn’t be any worse than current arrangements. The doctors would hate it on account of it being too easy, but then again, it might not be up to them in the end…

Source: http://qz.com/161727/wed-all-be-better-off-with-our-health-records-on-facebook/

THE DOCTOR IS ON

We’d all be better off with our health records on Facebook

By Melissa McCormack December 27, 2013

Melissa McCormack publishes reviews and writes buyers’ guides on electronic health records for Software Advice, a medical software company.

For doctors, Facebook could be a revolutionary tool. AP Photo/Kingman Daily Miner/JC Amberlyn

A Facebook user’s timeline provides both a snapshot of who that user is and a historical record of the user’s activity on Facebook. My Facebook timeline is about me, and fittingly, I control it. It’s also one, single profile. Anyone I allow to view my timeline views my timeline—they don’t each create their own copies of it.

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Intuitive, right? So why don’t medical records work that way? There is no unified, single patient record—every doctor I’ve ever visited has his or her own separate copy of my records. And in an age where we can conduct banking transactions on my smartphone, many patients still can’t access or contribute to the medical records their doctors keep for them.

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My proposal? Medical records should follow Facebook’s lead.

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Cross-industry innovation isn’t new. BMW borrowed from the tech world to create its iDrive; Fischer Sports reduced the oscillation of its skis by using a technologycreated for stringed instruments. So I asked myself: Who has mastered the user-centric storing and sharing platform? The more I thought about it, the more I decided a Facebook timeline approach could be just what medical records need.

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To see what I mean, let’s explore some of Facebook timeline’s key features to see how each could map to features of the ideal medical record.

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“About” for Complete, Patient-Informed Medical History

On Facebook: The “about” section is the one that most closely resembles the concept of a user profile. It includes a picture selected by the user and lists information such as gender; relationship status; age, political and religious views; interests and hobbies; favorite quotes, books and movies; and free-form biographical information added by the user.

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In medical records: The “about” section would be a snapshot of the patient’s health and background. It should include the patient’s age, gender, smoking status, height, weight, address, phone number, and emergency contact information; the patient’s primary care provider; and insurance information. This section would include a summary list of the patient’s current diagnoses and medications, as well as family history. And importantly, both the doctor and the patient would be able to add details.

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FACEBK about-patient

“Privacy Settings” and “Permissions” for Controlled Sharing

On Facebook: Privacy settings allow users to control who can see the information they post or that is posted about them. For example, in my general privacy settings I can choose to make my photos visible only to the people I’ve accepted as “friends.” However, if I post a photo I want the entire world to see, I can change the default setting for that photo to be visible publicly instead.

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Facebook also allows users to grant “permissions” for outside applications to access their profiles. For example, let’s say I use TripAdvisor to read travel reviews. TripAdvisor lets me sign in to its site using my Facebook account, rather than creating a separate TripAdvisor account. But, to do this I must grant TripAdvisor “permission” to access my Facebook account.

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In medical records: Patients could use “privacy settings” to control whether all or part of their information can be seen by a family member or caregiver. For example, if my aging mother wanted to give me access to her “events” (upcoming doctor’s appointments), she could do so. If my college-aged son who is still on my health plan wanted to give me access to his knee X-rays, he could.

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facebook privacy

Additionally, a patient could grant “permission” for other doctors to access their records. When I visit a new doctor, rather than signing a form granting my previous doctor permission to fax over copies of my records, I could simply grant permission electronically within the record–and presto! The new doctor would have instant online access.

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And doctors could use “permissions” in lieu of the paper forms patients typically have to sign during office visits today–to get patient signoff on the sharing of their information with insurance providers or other doctors, in compliance with thelatest HIPAA regulations for patient privacy.

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“Status Updates” to Document Diagnoses and Treatments

On Facebook: “Status updates” let Facebook users broadcast what’s going on with them at a given moment. (For example, my status update might say: “I just had a great idea for improving medical records.”) A user’s latest status update appears toward the top of the timeline; older statuses can be viewed by scrolling through the timeline.

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In medical records: Doctors could post “status updates” to log new diagnoses, medications or treatments. For example, if a doctor prescribes a patient Lipitor, a status update would be posted automatically to note the new prescription. These types of new prescription updates would also generate drug interaction alerts. Think of those drug commercials that warn, “Before using our drug, tell your doctor if you have any of the following conditions.” Similarly, the timeline medical record would prompt a doctor prescribing that drug to ask the patient about those conditions before prescribing.

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facebook status

“Photos” for the Online Delivery of Test Results

On Facebook: Users can upload pictures they’ve taken. Photos are organized into albums that are visible on the user’s timeline. There’s also a special “photos” section where viewers of the timeline can go to see all of a user’s photo albums.

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In medical records: Doctors could upload scans, X-rays, and other test results to a patient’s medical record timeline. When uploading the images, the doctor would be prompted to select the type of image being uploaded, the applicable body part and the date, which would create an album titled with those details–for example, “X-ray-Left foot-11/17/2013.” The timeline record would serve as a single repository for all such “photos,” rather than each doctor or facility having their own copies. The patient or any doctor granted permission to access the record would be able to view past test results.

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facebook photos

“Tagging” to Involve Other Parties and Track Common Themes

On Facebook: Users can “tag” other users to indicate their involvement with the content being posted. For example, when I post a picture of myself with a friend, I can “tag” the friend in that photo. This ties the photo to both our timelines instead of just mine. It also triggers a “notification” to the friend that she’s been tagged. She can remove the tag if she doesn’t wish for the photo to be tied to her timeline.

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In medical records: Providers can use tagging to alert other providers involved in a patient’s care of pertinent updates. For example, let’s say my primary care physician refers me to a specialist for some tests. When the specialists posts the tests results as “photos,” she could “tag” my primary care physician to ensure he’s notified of the test results as well.

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facebook tagging

“Notifications” for Test Result Alerts, Medication Alerts, or Preventive Care Reminders

On Facebook: Users are alerted by red “notification” messages when another user writes them a message, posts a picture of them or otherwise interacts with their profile. These notifications are a way to make the user aware of interactions or information involving them.

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In medical records: Patients would be notified when a provider uploads “photos” of them–i.e., lab results or scans. Notifications should also be triggered when patient vitals are out of normal range at an appointment–for example, when blood pressure is low or temperature high. The medical record timeline should also notify both patients and providers when a patient is due for a preventive care visit or screening.

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facebook notification

“Check-Ins” to Denote Office Visits

On Facebook: Users can “check in” to places they’re currently visiting. For example, I could “check in” to the concert I’m at on a Saturday night. This would serve as both a status update and a record of my attendance of the concert. Photos can also be marked with places to record where they were taken.

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In medical records: Patients literally check in when arriving for doctor appointments. When medical staff check the patient in, this would automatically generate a note on the patient’s timeline recording the date and which provider the patient is visiting. Visits to a specialist would trigger a “notification” to the primary care provider, allowing that physician to better track a patient through the continuum of care.

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facebook check-in

“Friendships” to Track New Provider Relationships

On Facebook: Users can create “friendships” with other users when one party electronically requests a friendship and the other party electronically accepts. These friendships are marked on the user’s timeline (“Jane Doe is now friends with John Smith”) along with the date the online friendship was created.

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In medical records: “Friendships” in medical records would really be relationships with medical professionals and caregivers. For example, when a patient checks in to an appointment with a doctor he’s never visited before, the timeline would automatically note the new relationship with that doctor. All providers could be accessed via a list of providers, similar to Facebook timeline’s “friends” list. This would serve as a record of all touch-points for care.

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facebook providers

“Events” to Track and Remind for Upcoming Appointments

On Facebook: Users can create online “events” to manage attendance and other details for in-person events. For example, I might create an event for the New Year’s party I plan to host, and I might invite my Facebook “friends” to that online event, where they could RSVP and receive reminders as the event date approaches.

+

 

In medical records: “Events” in a medical record would represent upcoming doctor appointments or scheduled tests or procedures. Events would be created automatically when a patient schedules an appointment, and as the time of the appointment gets closer, patients would receive online reminders about the upcoming event.

+

 

facebook events

It’s Time(line) for a Patient-Centric Medical Record

Dr. Rob Lamberts–a practicing physician, speaker, blogger, and health IT evangelist–tells me his biggest complaint with today’s digital record: “It’s not a patient-centered [medical record]; it’s payment-centered.” This he credits to the way the US health system has historically paid for healthcare, which is based on the volume of treatments rather than the quality of outcomes, requiring doctors to log complex medical codes into their EHRs.

1

 

Lamberts voices support for a timeline-like record, but he points out that the right incentives must be in place: “An improved record system like this would have to go hand-in-hand with a business model of medicine that benefited from it.” In other words, a business model which is patient-centric.

+

 

facebook whole timeline-medical-record

Luckily, this looks more like the direction the US health system is starting to take. Healthcare reimbursement models are slowly but surely shifting to reward physicians for better care instead of more care, and as that happens, technology providers will be incentivized to create solutions that align with that goal. Mine is to bring the magic of Facebook to medical records. But I’m open to other ideas that solve the patient-centric needs of tomorrow’s health ecosystem.

2

 

You can follow Melissa on Twitter at @ProfitPractice and read her reviews atSoftware Advice. We welcome your comments at ideas@qz.com.

business, data saving lives, healthcare, management and leadership, policy, rapid learning health systems

Toby Cosgrove: Leaning in to healthcare changes….

 

  • frames consumer need for selection apps
  • frames payer need for analytics

http://www.linkedin.com/today/post/article/20140107180116-205372152–leaning-in-to-healthcare-changes

“Leaning in” to Healthcare Changes

January 07, 2014  


Healthcare is in the midst of an unstoppable transformation. The pressure to reduce costs, improve quality, and provide a better patient experience is relentless. How will providers respond? Which organizations are best positioned to succeed?

These changes have been a long time coming. Forces favoring consumerism have completely transformed the airline, manufacturing and retail sectors. Now it’s healthcare’s turn. The primary drivers are information technology and high-deductible healthcare plans. Patients didn’t shop around when it was the insurance company’s dollar they were spending. But when you’re paying for routine healthcare, x-rays, and colonoscopies out of your own pocket, you start looking at the price tag.

Information technology is going to be the comparison driver. Consumers can already compare rates for hotels, airlines and appliances with the swipe of a finger. Soon there will be apps showing you which healthcare providers provide which services at what costs. You’ll be able to sort them from lowest to highest cost, and make your choice: Does it matter to you if your angioplasty (a minimally invasive procedure to open blocked arteries) is performed by a highly regarded academic medical center backed by full cardiac surgery capabilities, or if it is performed less expensively at a private cardiology practice, where you would have to be transported elsewhere for life-saving surgery in case of an emergency? I know what I would choose, but you, as a consumer, will have to make your own risk-benefit calculations.

In addition to consumerism, the Center for Medicare and Medicaid Services (CMS) will be exerting its own pressure, paying doctors and hospitals less for their services and demanding more accountability for quality, safety and patient experience. Private insurers, who usually follow the lead of CMS, will also be paying less and demanding more. Toss in all the unknowns that accompany the federal government’s Patient Protection and Affordable Care Act, and you are looking at Force 5 cost headwinds.

There is no escaping the conditions that are forcing this transformation. The providers who succeed will be those who “lean in” to the changes – hospitals and medical centers who embrace cost awareness not as an onerous duty, but as a patient care issue. Because along with lowering costs, we are improving efficiency, reducing variability of outcomes, and accelerating medical innovation. All of this adds up to better patient care, and that’s what we’re here for.

cool, healthcare, technology

Bloodless detection of malaria

AMAZING: Able to spot single malaria infected cell among a million healthy ones without any false positives whatsoever…

http://www.medgadget.com/2014/01/new-detector-reliably-spots-malaria-in-seconds-all-without-blood-draws.html

New Detector Reliably Spots Malaria in Seconds, All Without Blood Draws

by EDITORS on Jan 6, 2014 • 6:08 pm

malaria blood free detector New Detector Reliably Spots Malaria in Seconds, All Without Blood Draws

A laser pulse creates a vapor nanobubble in a malaria-infected cell and is used to noninvasively diagnose malaria rapidly and with high sensitivity. Credit: E. Lukianova-Hleb/Rice University

Malaria continues to be a persistent problem in large parts of the world and a great deal of effort has been spent fighting the disease. Yet, diagnosing malaria still requires a blood draw, reagents, and a trained medical professional to perform the test. Moreover, these tests are both labor and time intensive, making them difficult to offer in resource-poor environments. Now a team from Rice University has developed a completely new test that doesn’t require a blood sample nor a reagent to test whether it’s infected by the parasite. Additionally, once developed into a product, the device shouldn’t require a medical professional to do the testing.

The system relies on a laser that creates “vapor nanobubbles” within infected cells. These bubbles eventually pop and create a signature sound that is acoustically detected by the device. In pre-clinical testing, the team showed that the device was able to spot single malaria infected cell among a million healthy ones without any false positives whatsoever.

From the study abstract in Proceedings of the National Academy of Sciences:

Here we show that the high optical absorbance and nanosize of endogenous heme nanoparticles called “hemozoin,” a unique component of all blood-stage malaria parasites, generates a transient vapor nanobubble around hemozoin in response to a short and safe near-infrared picosecond laser pulse. The acoustic signals of these malaria-specific nanobubbles provided transdermal noninvasive and rapid detection of a malaria infection as low as 0.00034% in animals without using any reagents or drawing blood. These on-demand transient events have no analogs among current malaria markers and probes, can detect and screen malaria in seconds, and can be realized as a compact, easy-to-use, inexpensive, and safe field technology.

Study abstract in Proceedings of the National Academy of Sciences: Hemozoin-generated vapor nanobubbles for transdermal reagent- and needle-free detection of malaria…

Rice: Vapor nanobubbles rapidly detect malaria through the skin…

business, healthcare, startup

Steve Blank – Lean LaunchPad class in Life Science

Steve Blank’s Lean LaunchPad start up class covering life sciences, digital health, diagnostics and medical devices.

Ties in to lean start up approach.

http://steveblank.com/category/life-sciences/

Discovered via this MedGadget interview:  http://www.medgadget.com/2013/12/leaning-out-the-life-sciences-interview-with-steve-blank.html

Blank’s HBR article: HBR_LeanStartUp

Business Model Canvas care of Business Model Generation: business_model_canvas_poster

BizModelCanvas

data saving lives, facts & data points, healthcare, policy

Justin Coleman: The ethical imperative to tackle overdiagnosis and overtreatment

  • Beautifully written, wise piece by a friend and colleague of Gavin Mooney
  • Archie Cochrane humorous anecdote
  • Donald Berwick’s 30% waste JAMA link
  • Futility of spinal fusions
  • Futility of knee arthroscopies
  • Testosterone over-prescribing
  • EBM is a necessary but not sufficient condition for practising good medicine.When my friend Prof Gavin Mooney gave me his book, he explained why he’d called it EBM ‘in its place’.

    He did not want to promote a system of slavish adherence to a deontology. As a leftie health economist—a rare breed indeed—his primary concern was always one of health equity. Not health equality, which is clearly unattainable, but equity, where we strive for equal access to equal care for equal need.

    An equitable health system does not mean trying to give everyone the very best, if by that you mean the most; the most tests, the most expense, the most treatments. Not only will that aspiration require others to miss out on even the second-best treatment, but it too often also actively harms the recipient.

    Gavin was killed in tragic circumstances last Christmas, and I dedicate this article to his memory.

    His philosophy was that, sometimes, less is more. We must pare things back, strip away excesses and judiciously apply what we know works, rather than enthusiastically embrace what we wish would work.

    As a GP, I am a gatekeeper to a most powerful, expensive, superb and dangerous health system and I must never forget that sometimes my job is to shut the gate.

Source: http://blogs.crikey.com.au/croakey/2013/06/23/the-naked-doctor-an-indepth-look-at-the-pitfalls-of-cutting-edge-medicine/

The Naked Doctor: an indepth look at the pitfalls of “cutting edge” medicine

MELISSA SWEET | JUN 23, 2013 5:15PM | EMAIL | PRINT

The Naked Doctor is an ongoing project at Croakey that aims to encourage discussion and awareness of the opportunities to do more for health by doing less.

In this latest edition, Dr Justin Coleman suggests that an equitable health system does not mean trying to give everyone the very best, if that means “the most tests, the most expense, the most treatments”.

“Not only will that aspiration require others to miss out on even the second-best treatment, but it too often also actively harms the recipient,” he says.

Perhaps one area where more intervention is needed is in tackling overdiagnosis and overtreatment – Dr Coleman suggests that if the ‘medical market’ is left unchecked, the balance naturally tips towards overtreatment.

He concludes with a powerful call to action:

“As a GP, I am a gatekeeper to a most powerful, expensive, superb and dangerous health system and I must never forget that sometimes my job is to shut the gate.”

The article below is based upon his plenary address to the Qld RACGP Annual Clinical Update in Brisbane last month.

It is dedicated to the late Professor Gavin Mooney, whose philosophy was that we must “judiciously apply what we know works, rather than enthusiastically embrace what we wish would work”.

***

The ethical imperative to tackle overdiagnosis and overtreatment

Justin Coleman writes:

Two years ago my good friend Gavin Mooney gave me a signed copy of his latest—and, as it turned out—last book, Evidence-Based Medicine in its Place. 

Professor of Health Economics at Curtin University, Gavin was an irascible Scot, and his book detailed his work with another great Scotsman, Archie Cochrane, who of course pioneered the science of Evidence-Based Medicine.

According to Mooney, after their first meeting, Cochrane informed him that he had revised his opinion of economists.

On the basis of the evidence of an afternoon with Mooney, he now placed them second bottom, with sociologists at the bottom. This merely confirmed for Mooney that there was much on which they agreed.

Mooney told me the story, repeated in his book, of how Archie Cochrane first gained notoriety as a very junior staff member at the massive Department of Health in London.

The young Archie presented slides from an RCT on outcomes after heart attacks following rehabilitation, either while remaining a hospital inpatient or after early discharge home.

London’s ‘Who’s Who’ of learned physicians nodded sagely as Archie showed the crucial slides where the hospital outcomes—represented in red—outdid the blue columns of home-based outcomes across nearly every parameter. A couple of supportive comments, no questions.

Then the young epidemiologist pretended to look flustered. ‘I’m terribly sorry. I seem to have mixed up the red and the blue!’

He had deliberately switched the labels. All the better outcomes were in fact in the home-based, early discharge group.

Needless to say, chaos ensued as suddenly a hundred disgruntled audience members grilled him on every possible dubious aspect of the study design!

Best practice or common practice?

Until that time, there had been no reason for a London physician to doubt that an intensive, expensive, high-tech hospital stay would improve health outcomes.

It made perfect sense, and a whole bunch of highly intelligent, caring physicians had spent their careers ensuring that such a system existed. Where it wasn’t affordable, public and charity funds were sought to ensure more people could get longer hospital stays.

This was best-practice care, in the same way that bed rest for back pain, monthly breast self-examinations, and antibiotics for sore throats have been understood by clever and well-meaning people to be fairly obvious best care. More about Archie—and Gavin—later.

In the brilliant Mitchell and Webb parody of a Homeopathic Emergency Department, Webb attempts to save a trauma victim’s life by drawing on his palm in pen to extend his life line. He justifies it by asking ‘Have you got a better idea?’

Luckily, the answer is ‘yes’.

There are some things that do work better than a pen mark, or a homeopathic vial of water, even a vial where the water molecules somehow retain the memory of a herb they once knew, while conveniently forgetting they were once flushed down a toilet.

And there are some things that do work better than our mainstream medical interventions, even when tens of thousands of medical practitioners believe they are doing the right thing.

This has always been true, and will ever be so. Our mistakes from the past remind us that we are making mistakes right now. Full credit to all those anonymous doctors and researchers who unwrapped these anomalies.

The art of discovering nothing

History rightly lauds those who discovered ‘something’; Alexander Fleming and penicillin.

But I also dips me lid to those who discovered ‘nothing’. Bloodletting doesn’t work. Arsenic doesn’t work. Keeping kids with polio in hospital back straighteners for six months of their lives doesn’t work.

In many cases, our patients would be better off if we chose not to act.

There’s a minimum standard in the medical profession—not the gold standard, but let’s call it the bronze.

The bronze standard is that the patient is no worse off as a result of seeing us. The bronze standard is probably achieved by enthusiasts who light ear candles and discover people’s chakras. Let’s at least stop doing things which fall below the bronze standard.

We must balance the important and exciting work of discovering new stuff with the un-sexy hard-slog science of analysing those times where we have over-reached and over-enthused.

The best of our medical predecessors started this process and we must continue it; this is why we are a science and not merely a tradition.

Two hundred years ago, the French physician Phillipe Pinel cared enough about the damage his colleagues were doing to his psychiatric patients to observe:

“It is an art of no little importance to administer medicines properly: but, it is an art of much greater and more difficult acquisition to know when to suspend or altogether to omit them.”

It took a young epidemiologist Archie Cochrane to highlight the flaws in obstetric practice that should ideally have already been obvious to the world’s leading obstetricians and their institutions.

And these were not minor flaws. Obstetrics units in one part of the world were teaching methods which had already been shown in another part of the world to kill women and babies, and vice versa.

Cochrane didn’t do the research himself; his genius was to inspire others—in this case, Iain Chalmers— to collect, collate and analyse all the available evidence and, importantly, reject the shoddy stuff: the anecdote and the meaningless trial, so that obstetricians and their departments could make informed decisions as to how to get the best outcomes.

Archie never delivered a baby nor managed a single maternal complication, but his legacy would probably have saved more lives than any doctor watching his slide presentation in London.

Somewhere on the spectrum

Let’s look at chronic diseases, and use diabetes as an example.

Insulin’s invention in 1922 was a miracle, which converted the inevitable rapid death sentence of Type 1 diabetes into a chronic disease. Chronic in the best sense of the word, because insulin bought you time; years, decades.

That simple chemical justifiably sits at the high table in the pantheon of superb medical interventions.

But diabetes, like most chronic diseases, has nominal cut-off points which define its existence and degree. Diseases stretch themselves out along a spectrum, blissfully unaware of how we choose to dissect them.

Medical tests and interventions that work brilliantly at the sharp end of the spectrum do not work nearly so well when we slide towards the middle and enter the grey zone.

Any gains to be had here in the land of the long grey cloud are far foggier than anything out at the extreme edge.

Benefits diminish; every diagnostic test becomes less accurate; false positives increase exponentially; patient numbers increase—and with them, costs, pain and inconvenience; health gains are smaller in this less-sick population; and suddenly being diagnosed with a chronic disease such as diabetes or pre-diabetes doesn’t look so good any more.

Instead of being grateful to Chronos, the Greek god of time who grants you each extra year of life, suddenly the old bugger expects you to jab your finger three times a day, jab your stomach three times a day, and to roll a boulder up Sisyphus’s mountain just to have your liver pecked out by Prometheus’s eagle.

There comes a point where ignoring your diabetes educator becomes…to continue the theme…tantalising!

If the ‘medical market’ is left unchecked, the balance naturally tips towards overtreatment.

The paradigm promoted by industry, the media and some doctors, particularly the sub-sub-specialists, is that the only important news is a new invention, new drug, robotic surgery, more MRIs.

Is the best doctor always the one at the cutting edge? Is the best endocrinologist for my grandmother the one who has just spent a year in America learning the finer points of subcutaneous insulin infusion pumps?

There exists a cut-off point on every disease spectrum, inevitably ignored by drug companies and often enough by doctors, where medications simply don’t help. At that point, they do nothing. Beyond that point, they actively harm. This is true almost by definition for every medical or surgical intervention.

There is pressure from multiple sources—patient, doctor, pharma, specialist, psychologist, media, disease-awareness campaigns, patient advocacy groups—to nudge this point towards the midline of the spectrum.

This is true for diabetes, but also for depression, ADHD, lipid levels, cardiac stents, and deficiencies of a host of replaceable substances including testosterone, oestrogen, and various vitamins, the trendiest of which is Vitamin D.

If we don’t test early and often for all these problems, we are ignoring our duty of care and if we don’t treat when the test result comes back in red, we are downright obstructive and possibly liable.

Andropause: the new epidemic

Take testosterone. In the past five years we have witnessed a concerted wave of discussion around the andropause. Feature articles have called it the hidden epidemic, hinting at reverse sexism whereby women get their daily oestrogen but our men’s hormones have rights too!

Disease-awareness campaigns, subtle in Australia compared to countries that allow direct-to-patient advertising, ask males if they ever experience tiredness, weakness or low libido. The suggested remedy is to get your levels checked by your friendly local GP. It’s not advertising: it’s just caring.

This tumescent rise in publicity tied in beautifully with the advent of ‘men’s clinics’, whose doctors were the only clinicians with enough spare time to keep up with all the clever new ways of getting the testosterone into your body; oral, patches, gels, suppositories, inhalants; no orifice was left unsullied in the competition to supply Vitamin T.

The result?

PBS expenditure on testosterone has increased 450 % since 2006. Patients at the pointy end of the spectrum—men with testicular cancer and orchidectomies—have been swamped by the enormous market of men who are…wait for it…ageing. A bit like what’s happening to the percentage of cancer-sufferers in the opioid market.

Last year, the departing boss of the US Medicare system, Dr Donald Berwick,estimated that 20-30 per cent of US health spending is ‘waste’—as in; it yields no benefit to patients. That one quarter of the US health budget wasted could power the entire GDP of most countries on the planet.

Berwick listed five reasons for this catastrophic waste, and the first of them was ‘overtreament’. We are not talking a minor problem here.

Why do we overtest and overtreat?

Let’s look at some causes of overtesting and overtreating. Why do we do it?

Some of it is simply because the evidence doesn’t exist yet.

There was no shame in a medical graduate treating headaches with bloodletting a century ago; no-one knew any better. According to the prevailing understanding of the human body, it made sense and it no doubt appeared to work in some people.

But lack of evidence is not the only reason for our actions.

I like the list prepared by Australian surgeon Dr Skeptic (clearly his parents were prescient when naming him) of the reasons why we act even when evidence tells us ‘Don’t just do something, stand there!’

Defensive medicine: If you miss one rarity and thereby harm one person, this is more likely to end you up in court than causing far more harm by routinely overtreating everyone.

It takes an epidemiologist to tell you about the latter, whereas a lawyer will be quite happy to keep you posted about the former.

The language of inaction vs. action: Overinvestigation and overtreatment are very difficult concepts to convey to patients.

If we tell the patient ‘I really don’t know precisely why you have low back pain; would you like me to run a few tests?’ then the answer will be ‘yes’.

Our choice of language suggests that after doing the tests, we will know why they have low back pain. But whether doctor, physiotherapist or chiropractor, ye may ask the gods of radiology but shall not receive an answer.

If we give a glucometer to a person with pre-diabetes, or with diabetes that doesn’t require insulin, we will indeed get an answer as to precisely what their blood sugar is at any given moment, but this knowledge will not actually improve health outcomes.

The answer does not help the patient, therefore we are asking the wrong question.

This flawed logic of Test = Answer = Cure is used by iridologists and scientologists. And doctors.

Influence of recent experience: obstetricians who attend a birth with complications are significantly more likely to recommend a Caesarean section in their next 50 cases, before they settle back into a more sensible, case-by-case evidence-based approach.

The lottery mindset: Few people have a good understanding of risk.

My chances of winning the first division prize in tattslotto this Saturday are the same whether or not I buy a tattslotto ticket. The same. Not absolutely, mathematically, precisely the same, but the same in any meaningful, ordinary sense of the word.

People don’t understand tiny chances. I have more chance of being dead next Saturday than being both alive and collecting my winnings.

Studies consistently show that both doctors and patients, just like gamblers and stockbrokers, overestimate gains and underestimate losses.

People will jump at a whole body CT scan to ‘rule out’ a tiny risk of cancer, and ignore the fact that the radiation from each such scan increases their lifetime cancer risk by about 1%.

The prevailing wisdom: Medical students come out of university knowing thousands of new words and knowing about thousands of new interventions. The consultants taught us all the pharmaceutical and surgical interventions in their own specialised area of expertise.

But it’s not really anyone’s job to teach you about how to avoid patient referrals into the system; how to stop the cascade before it starts.

A recent Australian study showed that half of all IV cannulas inserted in ED are never used. Why does every junior ED doctor put the IVs in? Because everyone else has always put them in.

When ‘more’ is harmful

If a junior doctor is trained in breast surgery outpatients and has met women whose cancer was detected by screening mammogram, it takes some active un-training not to assume that therefore all women are better off having a mammogram.

When I was a student, my consultant orthopod took the time to kindly explain the intricacies of spinal fusion and of arthroscopic debridement for osteoarthritic knees, and I think he probably mentioned that ‘some patients don’t seem to gain as much as others’.

However, this is a starkly different prevailing wisdom from the reviews that have shown that neither spinal fusions nor arthroscopies for osteoarthritic knees differ much from placebo. In the US alone, 650 000 such arthroscopies were performed each per year in the late 1990s.

Ironically, sometimes the richer you are, with more access to the private system and doctors who will cut corners for you, the more intervention you get and the more harm is done.

The extreme of this is the Hollywood celebrity with their own physician on call, who would feel like a fool telling his client that for their thousand-dollar callout fee they get absolutely nothing except ‘watch and wait’.

When Michael Jackson went to his umpteenth plastic surgeon, she didn’t say ‘no’. When he complained he was getting anxious and couldn’t sleep and needed something more than light sleeping tablets, I bet Dr Conrad Murray now wishes he had opted for conservative management.

Making the system work

I believe it is our ethical responsibility to avoid overtreatment at an individual level, and also to support system-wide changes in the way we spend money on health.

I am no slave to evidence-based medicine; not one of those sceptical EBM types who eat gruel for breakfast and secretly believe deep down that nothing works. Although, on a bad day this pessimism reaches its ultimate fruition—absolutely nothing I do works!

EBM is a necessary but not sufficient condition for practising good medicine.

When my friend Prof Gavin Mooney gave me his book, he explained why he’d called it EBM ‘in its place’.

He did not want to promote a system of slavish adherence to a deontology. As a leftie health economist—a rare breed indeed—his primary concern was always one of health equity. Not health equality, which is clearly unattainable, but equity, where we strive for equal access to equal care for equal need.

An equitable health system does not mean trying to give everyone the very best, if by that you mean the most; the most tests, the most expense, the most treatments. Not only will that aspiration require others to miss out on even the second-best treatment, but it too often also actively harms the recipient.

Gavin was killed in tragic circumstances last Christmas, and I dedicate this article to his memory.

His philosophy was that, sometimes, less is more. We must pare things back, strip away excesses and judiciously apply what we know works, rather than enthusiastically embrace what we wish would work.

As a GP, I am a gatekeeper to a most powerful, expensive, superb and dangerous health system and I must never forget that sometimes my job is to shut the gate.

• Dr Justin Coleman is a GP at Inala Centre of Excellence in Aboriginal and Torres Strait Islander Health. He is senior lecturer at Griffith University and University of Queensland, and President of the Australasian Medical Writers Association (AMWA). Twitter: @drjustincoleman. Web:http://drjustincoleman.com/

• You can read more about Naked Doctor here and this Croakey page has been established as a memorial to Professor Gavin Mooney.

business, complex adaptive systems, facts & data points, healthcare, policy, politics, quantified self, rapid learning health systems

Dave Chase – How healthcare’s disruption will play out…

 

PDF Report: Volume_to_Value_Revolution

Healthcare’s Trillion-Dollar Disruption

As a healthtech startup, you can’t help but get excited when Bob Kocher (Venrock) or Esther Dyson speak about the opportunities in healthcare given their impressive track records. Both spoke during this past week’s StartUpHealth Summit.

One of Bob’s main points was that the opportunity in healthcare is so big that most startups are thinking too small and his firm is putting their money where his mouth is (e.g. Castlight). Esther has proven time and again to be very prescient — just go back and watch her old interviews on Charlie Rose over the years to see how accurately she predicts the future. She interrupted attending the JP Morgan presentations to visit with the StartUp Health Summit. Paraphrasing, she said companies like those in StartUp Health are the future. Rather than trying to steal share from the companies presenting at JP Morgan, startups should focus on creating the new market space, and the market will move to them…not the other way around.

Transformers vs. Preservatives

While the opportunities are massive, what’s the biggest obstacle to healthcare transformers? It’s the “preservatives” — the incumbent healthcare players. That is, the preservatives are trying to protect the status quo, rather than focusing on how to sincerely address the Triple Aim (improve outcomes, reduce cost, improve patient experience). In every healthcare organization I’ve talked with, whether they are a provider, pharma, or health plan, there are transformers internally who know what to do but are stymied by preservatives.

The same is true politically. There are those who call themselves “progressive” or “conservative.” Unfortunately, it seems that 80 percent of politicos are actually preservatives just doing the bidding of lobbyists trying to protect the status quo. The preservatives are costing thousands of lives and hundreds of billions of unnecessary wasted dollars. The real leaders in healthcare will see through them and get them out of the way of progress.

One of the transformative organizations pushing for change is Oliver Wyman. Oliver Wyman is a leading consultancy that has setup a Health Innovation Center that recently published a paper entitled The Volume-to-Value Revolution (PDF) with the input of an advisory board (PDF) of CEOs ranging from large public companies to emerging companies (disclosure: I’m on the Health Innovation Center Advisory Board). In that paper, authors Tom Main and Adrian Slywotzky make the case that new patient-centered population health models will cause more than $1 trillion of value to rotate from the old models to the new and create more than a dozen new $10 billion high-growth markets (see also Patients Are More Than A Vessel For Billing Codes). Each of these markets creates large opportunities for healthtech startups. Naturally, legacy vendors are optimized for the old models (see Why It’s Good News HealthIT is So Bad) while startups optimize for the new models.

Most industries compete on value. U.S. healthcare does not. But that is about to change.

Healthcare innovators are already redefining healthcare value, putting patients first and inventing with little regard for current constraints. They have ignited a powerful, self-funding upward spiral by focusing first on healthcare’s big opportunities, transforming the value equation, generating large savings, and fueling smart reinvestment in the next wave of innovation. [Introduction, “The Volume-to-Value Revolution”]

In addition, the necessity for change and the accompanying opportunities are causing many healthcare incumbents to establish venture arms. See Strategic Healthcare Investors’ Investment Thesis for more.

Industry Boundaries Rapidly Crumbling

Everyone is getting into each other’s and new businesses. Industry incumbents would be well advised to learn from the mistakes of incumbents in other disrupted sectors. As I observed earlier, providers are making newspaper industry mistakes.

The changes the industry faces will be neither smooth nor linear. A period of intense turbulence will produce more losers and winners than any industry transformation in recent memory. Cross-industry competition (healthcare versus retail versus technology versus others) will erase traditional boundaries and generate exciting new value propositions for patients, payers, and physicians.

For example, just this past week, Walgreen‘s has made it clear they’ll compete with healthcare providers and insurance companies. Competition, as newspapers learned, doesn’t come from obvious places.

Consumerization Of Healthcare

The consumer empowerment taken for granted from everything from buying cars to planning travel is finally arriving in healthcare nearly 15 years later than most industries.

Consumers, long passive, will have a new role. Employer incentives, retail access, and new technology options will encourage them to engage, demand information, and push for value. Baby boomers reaching the age of peak healthcare need will kindle the fire and Millennials focused on nutrition and fitness will keep it burning. The industry’s metamorphosis from a supply-driven market to a more dynamic one driven by demand will happen more quickly and erratically than we expect. Inevitably, mental models will lag behind market reality, and conventional organizations will fight a rearguard battle, hampered by collapsing margins and eroding market share.  [Introduction, “The Volume-to-Value Revolution”]

Walmart recently validated the domestic medical tourism I wrote about awhile back. Their Centers of Excellence program encourages their insured employees to go to the top facilities in the country for free (including travel expenses). The employees have to pay if they choose to go with organizations that haven’t demonstrated a willingness to have a fixed price while producing some of the best outcomes in the world. Love them or hate them, Walmart has a huge ripple effect. Overnight, every facility in America that does cardiac, spinal, or transplant procedures is now competing with Mayo, Cleveland Clinic and other top providers. Sticking to old models and tools endangers the traditional healthcare player.

By 2014, as many as 85 million consumers with $600 billion in purchasing power may be shopping for their own healthcare on public and private exchanges. Many will be making their own decisions about coverage for the first time. Consumers will shop not just for insurance, but also for their preferred population-health manager and standalone services, such as basic procedures and retail clinics. [pg. 18, “The Volume-to-Value Revolution”]

New Models Jeopardize Hospitals

Many are predicting half of hospitals will close by 2020. In Denmark, nearly 70 percent of hospitals closed as they made the shift from a reactive, sick-care model to proactive care model. More clinicians than ever will be needed. They’ll simply have a mainframe-to-smartphone like shift as outlined inhealthcare’s age of agility. Unfortunately, the average hospital is one of the most dangerous places with over 100,000 hospital-acquired infections causing death every year. Hospitals are almost always the most expensive place to deliver care so smart health systems are developing new models with a fresh start — what I call the Xboxification of Healthcare.

One of the reasons providers are choosing cloud-based systems over on-premise software is the resource-intensive deployments required with legacy systems. We’ve seen a small clinic get their cloud-based system fully setup and ready to use in 30 minutes without any onsite people. In contrast,  in that same amount of time, one might be able to order the server that gets shipped to that clinic. They will then require onsite installers, trainers, etc. and have a dramatically higher cost base to run that system.

For entirely rational reasons, those older systems were optimized for internal workflows and maximizing billing since that is what has been rewarded historically. To think that those traditional systems will then work perfectly well in the ascending “No Outcome, No Income” era borders on delusional. The reality is hitting right away. A recent article in a HIMSS publication quoted a leading thinker in healthIT, Shahid Shah, outlining 9 major gaps in existing EHRs. He listed “sophisticated patient relationship management (PRM)” as the first major gap. It’s my opinion that as integral as EHRs have been to fee-for-service, PRM will be to fee-for-value. The old model relegated patient portal functionality to be little more than a marketing checkbox. In the new model, PRM functionality becomes a linchpin. In other words, patient portals have been like pre-Google web search (low value afterthoughts on web portals). As Google demonstrated, with the right circumstances, there was huge value ignored by the established players. Likewise, if PRM is viewed as an afterthought, that will increase the risk to providers during this transformative period. Being flat-footed in a time of great change is extremely risky.

The New York Times reported this past week that the public hospitals are already changing the way they compensate their doctors. The first performance measure they listed was how well patients say their doctors communicate with them. These doctors are used to easy communication in the rest of their life with email, text, Facebook, etc.  Suddenly, the hospital IT departments are going to start hearing from doctors asking why they can’t have tools that are as easy to communicate with their patients in the other areas of their life. It’s a rare occurrence to hear a doctor say how user-friendly and patient-focused their EHR is. Of course, it’s about more than just technology. The technology simply enables new models. Despite many doctors’ fears, often the changes are for the better as was mentioned by Dr. Bob Margolis, founder and CEO of HealthCare Partners, and one of the physician leaders who has demonstrated extraordinary outcomes:

You get to the tipping point, where the physicians go, ‘Wow, life is a whole lot better.’ You know, I only have to see 20 patients a day and I go home at night and I feel like I really helped them’—as opposed to, ‘I saw 45 patients, worked until 10 o’clock because I had to then do all my paperwork, I’m tired and I can barely pay the bills because Medicare and the commercial insurers are cutting back on my reimbursement.’

Oliver Wyman’s report projects that patient-centered care and the shift to value will eliminate $500 billion in low-value-add activities. One has to be in major denial as a healthcare leader to think that we aren’t entering a deflationary era in healthcare. Just watch Bill Gates’ TED Talk on state budgets if you have any doubts. This is exactly the reason the state of New York has moved aggressively to change care and payment models. While doing that, they recognized new models require new technology and didn’t expect they’d get it from legacy providers. This is why the New York Digital Health Accelerator was established. The good news for proactive health systems is that one can thrive in a deflationary period if they shed old assumptions.

A leader at Virginia Mason in Seattle shared how Starbuck’s pushback on costs caused them to look at their entire care proces:

 “90 percent of what the hospital was doing was of no value.” As it turns out, the best way to treat most back pain is with physical therapy. That insight led to new processes, including same-day visits (as opposed to 31-day waits), reduced use of imaging tests and prescription drugs, and the addition of psychological support. Within three months, 94 percent of Starbucks employees with back-pain complaints were back at work within a day.

Even today, many EMR vendors will justify the price tags that reach into the hundreds of millions of dollars on the basis of increased billings. That game is nearly over and those hospitals will be saddled with systems optimized for the old models. This past week there were articles in the New York Times and Washington Post stating that EHRs have “failed”. I’d dispute that. EHRs have done exactly as they were designed — maximize billings. That’s how they are pitched so it should be no surprise that costs haven’t been lowered.

It has been said that “when the rate of change outside exceeds the rate of change inside, the end is in sight.”

Three Waves Of Disruption

Below, I have excerpted and paraphrased some more of Oliver Wyman’s insights from the Volume-to-Value paper illustrating how each of the three anticipated waves of disruption will shift hundreds of billions of revenue from one set of players to another:

Wave 1: Patient-Centered Care (2010-2016). “If we simply mainstreamed today’s best-in-class models of patient-centered, population-health management, the U.S. health system would eliminate nearly $350 billion of low-value-add activity and shift another $600 billion from provider-centered care models to patient-centered care models.” […] ”Five percent of Americans account for 45 percent of healthcare spending—$1.2 trillion. These 15 million unhealthy Americans at the top of the healthcare pyramid are at the heart of the near-term healthcare affordability crisis and the unfortunate victims of our fragmented, illness- focused healthcare system.” [pages 5 and 7, “The Volume-to-Value Revolution”]

 

Cost & population pyramid

Wave 2: Consumer Engagement (2014-2020). In Wave 2, another $150 billion in low-value-add activities is squeezed out, while $400 billion of additional value will rotate to the new retail value chain.

Oliver Wyman transition


Wave 3: The Science Of Prevention (2018-2025). Wave 2 will help Wave 1’s great population managers become even more effective and will devastate provider-centric players who have lagged the market. Wave 3 will make the most highly evolved and adaptive population health managers more powerful and will significantly constrict the Wave 1 players who don’t continue to accelerate innovation.

Big Opportunities Require Big Brains

I once heard someone say, “There’s a lot of big brains working on small problems.” They were commenting on the brainpower working on the 8,000th social media app versus where they should be applying their brains. That is, there are three areas that demand as many big brains as possible — healthcare, education, and energy. As a skier, I often say that healthtech startups are the double black diamond in whiteout conditions of startups: super challenging and exhilarating but not for the faint of heart.

I believe the trick is to understand the idiosyncrasies of healthcare without being shackled by them. If you want to make a difference, there’s no better place than healthcare. Healthcare needs all the engineering talent possible that is often wasted on low-impact areas of the tech industry.

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