Category Archives: healthcare

health market quality, healthcare, policy, politics, rapid learning health systems

End of medicare?

Excellent summary of the early 2014 state of play in health policy replete with solid historical perspective from Anne-marie and Jim Gillespie.

 

http://www.smh.com.au/federal-politics/political-news/is-this-the-end-of-medicare-20140609-39t2b.html

Is this the end of Medicare?

Date

A national institution, Medicare turns 40 this year. But are budgetary changes such as the doctor co-payment the beginning of the end for universal healthcare? Michael Green reports.

Victorian Aboriginal Health Service chief executive Jason King, clinical program manager Andrew Baker and medical director Mary Belfrage.

Victorian Aboriginal Health Service chief executive Jason King, clinical program manager Andrew Baker and medical director Mary Belfrage. Photo: Eddie Jim

Medicare was always a dogfight. It became law in the most extraordinary circumstances: one of a handful of bills passed during the only joint sitting of Federal Parliament in the nation’s history, after the double dissolution election in 1974.

As the Whitlam government prepared to introduce the system – then known as Medibank – its opponents rallied. The Australian Medical Association marshalled a million-dollar ”Freedom Fund”, donated by members. Determined to stop bureaucrats interfering with patients, it hired a former Miss Australia to front its publicity campaign. The General Practitioners’ Society of Australia circulated a poster depicting social security minister Bill Hayden dressed in Nazi uniform.

Dr Anne-marie Boxall, co-author of Making Medicare, says Whitlam had little support, even from within the Labor Party. The party platform advocated a fully nationalised model, along the lines of the British National Health System. By contrast, Whitlam’s plan was for a public insurance scheme. Health services would be delivered by a mix of public and private providers, paid for by taxpayers and guaranteed for everyone.

”The crucial members of his caucus didn’t agree with him, but he was adamant,” she says. ”He’d done a lot of thinking about it. So he waged the war of public opinion and he won. It’s an amazing political story.”

Medibank began full operation on October 1, 1975, just six weeks before the dismissal of the Whitlam government. The Fraser government tinkered with the system several times before abolishing it – only for it to be revived by the Hawke government in 1984 in almost exactly the same form.

Thirty years later, Medicare enjoys overwhelming public support. Politicians will swear to defend its honour, no matter their stripes or the system’s shortcomings. And yet, in the wake of the federal budget, many people believe Medicare is under threat. The target of most ire is the proposed co-payment for doctor visits, under which even the poorest will have to pay for up to ten appointments each year.

Are these changes the beginning of the end of universal coverage? Or another nail in its coffin? Or are they actually a distraction from the deeper afflictions at the heart of Australia’s healthcare system?

Health Minister Peter Dutton describes the Coalition as ”the greatest friend Medicare ever had”. The Coalition has demonstrated its amity with a host of announcements, including the co-payment, which also affects diagnostic tests and prescription drugs. (These charges will be capped for children, low-income earners and the chronically ill.)

More people will pay the Medicare levy surcharge, and fewer will qualify for the private health insurance rebate. Billions of dollars have been cut from public hospitals, and the preventive health agency and other health promotion programs have been shut down. The savings will be directed to a medical research fund.

Dutton says that without these reforms, spiralling costs will jeopardise Medicare’s viability. ”The government is very keen to keep Medicare and strengthen it. To keep it universal, we have to make sure it’s affordable. In my view, Medicare is only sustainable if those people who have a capacity to pay contribute to the system.”

However, Professor John Deeble, one of the original scheme’s architects, says while costs have been rising, they’re manageable. Health spending by our governments is low compared with other wealthy countries. The Coalition’s planned changes, he says, are not really about the sustainability of Medicare. ”They just want to spend the money on something else, simple as that.”

The Medicare levy (currently 1.5 per cent of an average income) was introduced to help fund a universal healthcare scheme. If our health costs rise, the government can raise the levy, Deeble says. In that way, people’s contributions are determined by their capacity to pay – their income – not by how often they need treatment. By introducing co-payments instead, the government is embracing something fundamentally different: a ”user-pays” notion of fairness in health funding.

In Medicare’s first incarnation, when social security minister Bill Hayden introduced the bill to Parliament, he declared that its three motivating principles were ”social equity, universal coverage and cost efficiency”.

Although the full details of the Coalition’s reforms haven’t been released, public health experts have been unanimous: as a package, it’s simply bad policy.

”We’ve actually tried all these solutions before, which is why we know they don’t work,” says Boxall, who is the director of the Deeble Institute for Health Policy Research. ”We need to step back and look at the structural problems with our health system.”

Two key problems were unforeseen at the time of Medicare’s design: the rise of private healthcare, and the growing burden of chronic illnesses. ”Things have changed,” Boxall says. ”So what are we doing to improve universality, equity and efficiency?”

For most of the 20th century, Australia had a two-tier medical system: a very basic insurance system for the working class and a fee-paying model for those who could afford it. ”Doctors offered quite different services, and in many cases different waiting rooms for each group,” says Associate Professor James Gillespie, from the University of Sydney’s school of public health, co-author of Making Medicare.

The World Health Organisation says ”universal coverage” means ”all people have access to services and do not suffer financial hardship paying for them”.

But under Medicare, we’re already failing the equity test. More than one-in-six Australians say they don’t see a doctor or fill prescriptions because of the cost, according to an international study published by the journal Health Affairs. Other research has shown that people who live in poorer neighbourhoods are more likely to delay medical care.

Even without co-payments, Australian patients fork out a lot for treatment from their own pockets, compared with other developed countries. The two-tier system has re-emerged. One reason, says Gillespie, is that ”both sides of politics have refused to think seriously about the role of the private system”. Major reviews commissioned by both the Howard and Rudd governments specifically avoided examining its role.

When Medicare began, private hospitals were a small industry, run by churches and charities. But in the past two decades they’ve become a big business, where doctors earn much more.

Until the 1990s, private health insurance was in terminal decline. But spurred on by the Howard government’s incentives – the Medicare levy surcharge and lifetime cover discount – just under half the population now has private cover. ”We’ve ended up with a private system that shifts services away from the public and creates more privileged ways of doing things,” says Gillespie.

He says private funding can contribute to universal care, so long as core services are delivered the same way to everyone. Canada has a similar system to ours, but private insurance isn’t allowed to cover the services offered by its public system. ”If there’s a different system for those who can afford better, you end up with a residual service, which gets squeezed and becomes second best,” he says.

The Coalition argues the co-payment is a ”price signal” to alert people to the real cost of treatment. But there’s something unusual about healthcare – even economists say so. In simple terms: you can judge how you’ll feel if you forgo buying a hamburger, but not if you forgo visiting the doctor.

”In the case of healthcare, part of the product itself is giving you that information,” explains Professor Jeff Richardson, from Monash University’s centre for health economics. ”You’re not in a position to judge what life would be like with and without it.” All of which means that promoting efficiency is more complex than imposing a price signal.

Australia’s health costs have been rising, but compared with other OECD countries our total health spending – both private and public – is just below average. It’s half that of the United States, as a percentage of GDP.

”When the government says Medicare is unsustainable, it’s lying,” Richardson says. ”The Australian government could spend much more on health if it wished. It’s simply a political and social judgment that it doesn’t want to.”

Curiously, despite Dutton’s warnings about unsustainable health spending, his reforms – which aim to push more people into the private system – will end up costing more overall. When the government acts as our single-insurer under Medicare, it has the power and incentive to bargain hard: as a result of bulk billing, GPs incomes are low by international standards. But with many different payers – like in the US system – it’s easier for private insurers to increase fees than control costs.

And for now, GPs and pharmaceuticals are the most cost-effective parts of the health system. Increasing their price will push more patients into hospitals, which are much more costly.

The measures are not a question of efficiency, Richardson says, but rather an ideological choice that health is an individual responsibility, not a shared one, like defence or policing. ”If we swing over to the private sector and push it back on individuals, the health of poorer people will suffer and overall costs will almost certainly rise.”

Dutton, however, maintains the measures aren’t about ideology, citing the Hawke government’s plans to introduce a $2.50 co-payment for GP visits in 1991. (Paul Keating scrapped the idea as prime minister.) ”I strongly believe that the changes we’ve put forward will improve access and the standard of care provided by GPs,” Dutton says.

But the biggest challenge to the standard of care now comes from an entirely different source, one his reforms do nothing to address. Our greatest healthcare inefficiency is found in a disconnect between the system – the fragmented network of hospitals, specialists and GPs, and their mishmash of state, federal and private funding – and the kinds of illnesses we have.

Where once we suffered acute ailments, we now need ongoing support with chronic conditions, says Dr Steve Hambleton, outgoing president of the Australian Medical Association. The number of deaths from heart attacks, for example, peaked in the 1970s. But living with heart disease requires continual treatment and adjustment, especially as you develop other conditions.

Patients with chronic diseases need to see a variety of health professionals and have frequent tests – but they are often seeing them in a piecemeal way with little continuity or communication between experts. Many of these, such as physiotherapists, psychologists or dieticians, are excluded or receive only limited funding under Medicare.

Both parties have attempted limited reforms to address the rise of chronic illnesses. But Hambleton says: ”We need a proactive, long-term approach … supporting primary healthcare to keep patients out of hospitals, and make sure people don’t fall through the cracks when they move between community and hospital care.”

The wide hallway of the Victorian Aboriginal Health Service in Fitzroy is humming: people young and old are waiting and chatting. Some are on the go, others hovering around a wood heater. Today, a specialist is visiting to conduct an ear, nose and throat clinic.

Jason King, the centre’s CEO, says they offer an holistic service. There are GPs, dentists, visiting specialists, social workers and financial counsellors, all supported by Aboriginal health workers. ”It’s not pumping them out every ten minutes. It’s ‘How’s mum and dad going? How’s uncle going who lives with you?’ We’re the central hub, this is where people come and see family.”

Last year, the health service celebrated its 40th anniversary. Each year, about a third of the state’s Aboriginal population pass through its doors. The centre’s model of integrated care, embedded in the values of its community, is exactly what doctors and experts have ordered – along with the WHO, the OECD and several Australian inquires.

But King says the co-payment and cuts to preventive health will either cost the centre patients or take a chunk out of its budget. Either way, that means fewer services.

There are 28 Aboriginal community-controlled health centres around the state. Jill Gallagher, CEO of their peak body, says Aboriginal health remains worse than the rest of the nation. ”The life expectancy in Fitzroy is the same as the life expectancy in Fitzroy Crossing,” she says. ”For every dollar spent on Medicare for a non-Aboriginal person, about 60¢ is spent on Aboriginal people. Access to primary healthcare is still not equitable, in spite of the fact there’s four times the burden of illness in the Aboriginal community.”

Dr Mary Belfrage, the service’s medical director, says any barriers to accessing healthcare cause people to show up later, with advanced conditions, which are more expensive to treat. ”It all translates to worse health outcomes, but it’s also inefficient,” she says. ”This isn’t about party politics or a particular budget. It’s about the principle of equity and how it impacts on health.”

complex adaptive systems, data saving lives, health market quality, healthcare, healthy habits, policy, politics, rapid learning health systems

Duckett: Has health reform failed? Yes

A big issue for the health system in Australia is that no-one’s in charge. Not the Commonwealth, not the states, not the private health insurance funds. Most provision is private: general practitioners are increasingly employed by for-profit chains, and before that, small business people. They respond to incentives designed by the Commonwealth government.

http://theconversation.com/did-the-health-reform-process-fail-now-well-never-know-27921

Did the health reform process fail? Now we’ll never know

Abandoning health reforms will undoubtedly lead to worse performance, including longer waiting times, across the health system. AAP Image/Quentin Jones

Yesterday was a sorry day in the long history of health reform in Australia. The Council of Australian Governments (COAG) Reform Council issued its five year score-keeper’s report on health reform progress. It will be the last such report, since the COAG Reform Council has been sacrificed on the altar of savings in the May budget, and we will no longer know how our governments are performing.

The COAG Reform Council paints some lipstick on the pig but overall reform results are poor in the health system. Compared to last year, Australians are waiting marginally longer for elective surgery, longer for community support in the home, and dramatically longer to get into residential aged care.

On the upside, we’re living slightly longer, having fewer heart attacks and the incidence of some cancers has reduced. The five-year trends for performance paint a similar picture to the year-on-year results.

It’s easy to conclude that the health reform process was a waste of time and money. But this is shortsighted. Many of the structural reforms focused on building the foundations of a health system that was on the verge of being able to deliver real improvements in patient care.

Slow road to reform

Kevin Rudd’s gab-fest of health reform talk in 2009 and early 2010 led to an alphabet soup of new health agencies, some investment in parts of the health system, more data in the public domain than we’ve ever seen but precious little in terms of real on-the-ground improvements.

But there were some important exceptions. The Rudd-appointed National Health and Hospitals Reform Commission identified a gap in availability of rehabilitation beds in the system. Without adequate rehabilitation care people were ending up in nursing homes when they could have been at home. Reform money helped to address that gap, although that funding was abruptly terminated in the 2014 budget.

Funding was also provided for better prevention programs and to reward improvements in waiting times where they occurred. Medicare Locals were created to provide a platform for improvements in primary care such as better after-hours services.

Running a health system is hard, improving it is even harder. But we have to improve every day just to stand still. The new treatments that are introduced every week put pressure on the health dollar. These new treatments, though, mean we’re living longer – so we get something for the extra money.

A big issue for the health system in Australia is that no-one’s in charge. Not the Commonwealth, not the states, not the private health insurance funds. Most provision is private: general practitioners are increasingly employed by for-profit chains, and before that, small business people. They respond to incentives designed by the Commonwealth government.

The pathology and radiology markets are also highly concentrated corporatised businesses. Around one-third of hospital beds are in private hospitals, and most of those are for-profit businesses as well.

Abolishing the foundations

The health reform process mainly concentrated on two aspects of the system: primary care and public hospitals. Primary care reform was mainly effected through the creation of Medicare Locals and GP Super Clinics.

Both were good ideas but flawed in implementation: some Super Clinics are still not open five years after the policy got underway. Medicare Locals were over-hyped by the previous government, wrapped up in red tape by the Commonwealth Health Department and as a result of the budget are being abolished and replaced by new organisations.

Public hospital reform had two elements. In most states it included increased local autonomy through introduction of local boards, and increased services with expanded rehab being the best example. At the national level it included a new alignment of Commonwealth and state interests in controlling hospital costs.

From June 1, 2014, the Commonwealth will meet 45% of the costs of increased hospital activity, but only up to an independently determined “efficient price”. This is a good reform, because could have ended the blame game between Commonwealth and states over money by locking the former into funding increased health state health spending. But these changes will be undone in 2017.

So come 2017, most evidence of health reform will have vanished. There will be some ongoing structures and services, but the big aspirations to address the big problems will have fizzled out.

The problems won’t go away, however. Innovation and system reform will still be required. If anyone is around to issue the next score-keeper’s report it will undoubtedly show worse performance, including longer waiting times, across the health system. There’ll then be more calls for reform and the whole cycle will start again, but with wasted years in the meantime.

data saving lives, health market quality, healthcare, policy, politics, rapid learning health systems

Scruitiny starts to land in healthcare…

“When hospital administrators meet with doctors, we talk in great platitudes, and it’s easy for physicians to say, ‘Well, my patients are sicker.’ Data takes out the emotion. It can be a moment of shock.“

They key to delivering information unemotionally is using a physician leader as the messenger. 

“The important mental transition that has to occur within physicians is, ‘This is about a team concept and approach to care. It’s not just about me and why I think is best for my patient.’ That’s a problem some physicians have.”

http://www.healthleadersmedia.com/print/PHY-305709/Physicians-Feel-Reforms-Tight-Scrutiny

Physicians Feel Reform’s Tight Scrutiny

Jacqueline Fellows, for HealthLeaders Media , June 19, 2014

Thanks to healthcare reform, there are now more eyes on how doctors treat their patients and more opinions on how they should be treating them. But one physician leader says the pressure doesn’t necessarily mean that doctors have to be on the defensive.

All working professionals, from writers to physicians, have a preference for the way their work gets done, but a doctor’s penchant for how he or she cares for a patient is increasingly coming under scrutiny.

First, there are cost and quality pressures from hospitals, health systems, and payers as a result of the value-based healthcare transition that affects how physicians practice, not to mention public pressure on how much physicians get paid with the recent release of Medicare payment data.

Then there are the efforts to standardize patient care among providers in hospitals, group practices, and health systems in an effort to improve quality.

All of it leads to more eyes (and opinions) on how doctors care for patients, which can be uncomfortable.

Kevin Wheelan, MD, chief of staff and co-medical director of cardiology for Baylor Heart and Vascular Hospital, a joint venture hospital within Dallas-based Baylor Scott & White Health, says the pressure doesn’t necessarily mean that doctors have to be on the defensive, or have an adversarial relationship with leaders.

Rather, Wheelan looks at the issue through a different lens. Without uniformity of care, quality can suffer, and patients leave confused. “Ten different sets of discharge instructions sets up [the hospital] for inconsistency,” he says. “If the patient doesn’t leave the hospital with a well-articulated game plan, that could lead to an unscheduled visit to the ER.”

That’s code for readmissions and possible penalties. Reducing both requires better communication with the patient, which Wheelan says has improved at BHVH with better and easier-to-understand discharge instructions.

“The tools have improved in terms of more detailed collateral materials as a resource for patients to refer back to,” says Wheelan.

In addition, Wheelan says BHVH has also enhanced medication reconciliation by having both a nurse and a physician review what medicine a patient is taking at home that could interfere with medication prescribed upon release.

The post-discharge appointment is also a more focused discussion, says Wheelan.

“Instead of telling a patient, ‘See you within 30 days,’ for example, the goal is to have a follow up appointment scheduled, so it’s not a nebulous concept of when they’re returning.”

Follow-up phone calls also help reduce readmissions and anxiety from patients. The phone calls are also a data mining exercise that shows variance among physicians. It’s not intended to be an exercise in checking up on physicians, but it has helped standardize care and reinforce a culture of teamwork.

“We keep track of all of these phone calls,” says Wheelan. “We have a document typed up, blinded to the patients’ names, and those results are provided back to the physician leader and the physician practices for an opportunity for improvement issue.”

Using data to show a variance can take some of the sting out of a difficult conversation with a physician. It helps, says Wheelan, that physicians see exactly what a patient is saying.

“It gives [physicians] a different insight,” he says. “The doctors get to see types of concerns the patients have.”

Wheelan says BHVH’s system isn’t not perfect. There are still difficulties with weekend discharges, but he says setting a specific follow-up appointment time is the biggest change since BHVH opened in 2002. But it didn’t happen easily because of physician preference.

“It’s an issue of compromise,” says Wheelan. “You have a group of physicians who say, ‘I need to see a patient two days post-op,’ and another group who says they need five days. So we have to come to an agreement that we will see the patient within 2–5 days.”

Getting standardization among physicians is difficult, admits Wheelan, but it’s also an opportunity for physician leaders to emerge because “someone has to be a champion,” willing to track down the other physicians and get buy in for clinical protocols.

Using data to accompany a potentially hard conversation about performance is an approach that is also used at Southwest General Health Center, a 354-bed hospital in Middleburg Heights, OH.

“Physicians tend to be logical, numbers-driven people,” says Jill Barber, director of managed care operations and revenue integrity for Southwest General. “When hospital administrators meet with doctors, we talk in great platitudes, and it’s easy for physicians to say, ‘Well, my patients are sicker.’ Data takes out the emotion. It can be a moment of shock.”

Also like BHVH, Southwest General uses verbatim comments from patients to give physicians insight into patient satisfaction. “By sharing with them the actual comments, it brings it home,” says Barber.

They key to delivering information unemotionally is using a physician leader as the messenger. It’s what BHVH and Southwest General rely on because it is peer-to-peer, and more “collegial” rather than punitive, says Barber.

Physicians also have to think differently in a value-based era of healthcare, explains Wheelan.

“The important mental transition that has to occur within physicians is, ‘This is about a team concept and approach to care. It’s not just about me and why I think is best for my patient.’ That’s a problem some physicians have.”

It’s a problem they’ll likely have to grow out of, too, in order to withstand the pressure, opinions, and eyes that are watching.

Jacqueline Fellows is an editor for HealthLeaders Media.

complex adaptive systems, data saving lives, health market quality, healthcare, healthy habits, policy, politics, rapid learning health systems

Cth Fund Country Comparisons

 

http://www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror

PPT: Exhibit_ES1_CthFund

Mirror, Mirror on the Wall, 2014 Update: How the U.S. Health Care System Compares Internationally

Executive Summary

The United States health care system is the most expensive in the world, but this report and prior editions consistently show the U.S. underperforms relative to other countries on most dimensions of performance. Among the 11 nations studied in this report—Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States—the U.S. ranks last, as it did in the 2010, 2007, 2006, and 2004 editions of Mirror, Mirror. Most troubling, the U.S. fails to achieve better health outcomes than the other countries, and as shown in the earlier editions, the U.S. is last or near last on dimensions of access, efficiency, and equity. In this edition of Mirror, Mirror, the United Kingdom ranks first, followed closely by Switzerland (Exhibit ES-1).

Expanding from the seven countries included in 2010, the 2014 edition includes data from 11 countries. It incorporates patients’ and physicians’ survey results on care experiences and ratings on various dimensions of care. It includes information from the most recent three Commonwealth Fund international surveys of patients and primary care physicians about medical practices and views of their countries’ health systems (2011–2013). It also includes information on health care outcomes featured in The Commonwealth Fund’s most recent (2011) national health system scorecard, and from the World Health Organization (WHO) and the Organization for Economic Cooperation and Development (OECD).

Overall health care rankingClick to download Powerpoint chart.

The most notable way the U.S. differs from other industrialized countries is the absence of universal health insurance coverage.5 Other nations ensure the accessibility of care through universal health systems and through better ties between patients and the physician practices that serve as their medical homes. The Affordable Care Act is increasing the number of Americans with coverage and improving access to care, though the data in this report are from years prior to the full implementation of the law. Thus, it is not surprising that the U.S. underperforms on measures of access and equity between populations with above- average and below-average incomes.

The U.S. also ranks behind most countries on many measures of health outcomes, quality, and efficiency. U.S. physicians face particular difficulties receiving timely information, coordinating care, and dealing with administrative hassles. Other countries have led in the adoption of modern health information systems, but U.S. physicians and hospitals are catching up as they respond to significant financial incentives to adopt and make meaningful use of health information technology systems. Additional provisions in the Affordable Care Act will further encourage the efficient organization and delivery of health care, as well as investment in important preventive and population health measures.

For all countries, responses indicate room for improvement. Yet, the other 10 countries spend considerably less on health care per person and as a percent of gross domestic product than does the United States. These findings indicate that, from the perspectives of both physicians and patients, the U.S. health care system could do much better in achieving value for the nation’s substantial investment in health.

Major Findings

  • Quality: The indicators of quality were grouped into four categories: effective care, safe care, coordinated care, and patient-centered care. Compared with the other 10 countries, the U.S. fares best on provision and receipt of preventive and patient-centered care. While there has been some improvement in recent years, lower scores on safe and coordinated care pull the overall U.S. quality score down. Continued adoption of health information technology should enhance the ability of U.S. physicians to identify, monitor, and coordinate care for their patients, particularly those with chronic conditions.
  • Access: Not surprisingly—given the absence of universal coverage—people in the U.S. go without needed health care because of cost more often than people do in the other countries. Americans were the most likely to say they had access problems related to cost. Patients in the U.S. have rapid access to specialized health care services; however, they are less likely to report rapid access to primary care than people in leading countries in the study. In other countries, like Canada, patients have little to no financial burden, but experience wait times for such specialized services. There is a frequent misperception that trade-offs between universal coverage and timely access to specialized services are inevitable; however, the Netherlands, U.K., and Germany provide universal coverage with low out-of-pocket costs while maintaining quick access to specialty services.
  • Efficiency: On indicators of efficiency, the U.S. ranks last among the 11 countries, with the U.K. and Sweden ranking first and second, respectively. The U.S. has poor performance on measures of national health expenditures and administrative costs as well as on measures of administrative hassles, avoidable emergency room use, and duplicative medical testing. Sicker survey respondents in the U.K. and France are less likely to visit the emergency room for a condition that could have been treated by a regular doctor, had one been available.
  • Equity: The U.S. ranks a clear last on measures of equity. Americans with below-average incomes were much more likely than their counterparts in other countries to report not visiting a physician when sick; not getting a recommended test, treatment, or follow-up care; or not filling a prescription or skipping doses when needed because of costs. On each of these indicators, one-third or more lower-income adults in the U.S. said they went without needed care because of costs in the past year.
  • Healthy lives: The U.S. ranks last overall with poor scores on all three indicators of healthy lives—mortality amenable to medical care, infant mortality, and healthy life expectancy at age 60. The U.S. and U.K. had much higher death rates in 2007 from conditions amenable to medical care than some of the other countries, e.g., rates 25 percent to 50 percent higher than Australia and Sweden. Overall, France, Sweden, and Switzerland rank highest on healthy lives.

Summary and Implications

The U.S. ranks last of 11 nations overall. Findings in this report confirm many of those in the earlier four editions of Mirror, Mirror, with the U.S. still ranking last on indicators of efficiency, equity, and outcomes. The U.K. continues to demonstrate strong performance and ranked first overall, though lagging notably on health outcomes. Switzerland, which was included for the first time in this edition, ranked second overall. In the subcategories, the U.S. ranks higher on preventive care, and is strong on waiting times for specialist care, but weak on access to needed services and ability to obtain prompt attention from primary care physicians. Any attempt to assess the relative performance of countries has inherent limitations. These rankings summarize evidence on measures of high performance based on national mortality data and the perceptions and experiences of patients and physicians. They do not capture important dimensions of effectiveness or efficiency that might be obtained from medical records or administrative data. Patients’ and physicians’ assessments might be affected by their experiences and expectations, which could differ by country and culture.

Disparities in access to services signal the need to expand insurance to cover the uninsured and to ensure that all Americans have an accessible medical home. Under the Affordable Care Act, low- to moderate-income families are now eligible for financial assistance in obtaining coverage. Meanwhile, the U.S. has significantly accelerated the adoption of health information technology following the enactment of the American Recovery and Reinvestment Act, and is beginning to close the gap with other countries that have led on adoption of health information technology. Significant incentives now encourage U.S. providers to utilize integrated medical records and information systems that are accessible to providers and patients. Those efforts will likely help clinicians deliver more effective and efficient care.

Many U.S. hospitals and health systems are dedicated to improving the process of care to achieve better safety and quality, but the U.S. can also learn from innovations in other countries—including public reporting of quality data, payment systems that reward high-quality care, and a team approach to management of chronic conditions. Based on these patient and physician reports, and with the enactment of health reform, the United States should be able to make significant strides in improving the delivery, coordination, and equity of the health care system in coming years.

us health care ranks last

complex adaptive systems, data saving lives, health market quality, healthcare, policy, politics, rapid learning health systems

Selecting health insurance based on value of care covered…

A solid idea.

Allowing consumers to pick how “fruity” they want their cover to be. This takes self-serving autonomy from the clinicians and places it back with the patients, who no longer have to cross-subsidise silly, exorbitant care.

 

http://www.nytimes.com/2014/06/10/upshot/how-to-pay-for-only-the-health-care-you-want.html

How to Pay for Only the Health Care You Want

Magoz

By Austin Frakt andAmitabh Chandra

One reason health insurance is expensive is that most plans cover just about every medical technology — not just the ones that work, or the ones that are worth the price. This not only drives up costs, but also forces many Americans into purchasing coverage for therapies they may not value. But there’s no reason things couldn’t be different, and better for consumers.

Consider the latest technology for treating prostate cancer: the proton beam. It’s delivered with a football field-size machine costing well over $100 million. Per treatment, this therapy costs at least twice as much as alternative approaches, but is no more effective. Many health plans cover it and other therapies of low or uncertain value because they pay for anything that physicians deem medically necessary even when evidence suggests otherwise. And, without even knowing it, Americans pay for it in higher premiums.

It doesn’t have to be this way. If plans could compete on the basis of the therapies they cover, consumers could decide what they wish to pay for. This sounds complicated, but it need not be.

Health plans could define themselves at least in part by the value of technologies they cover, an idea proposed by Professor Russell Korobkin of the U.C.L.A. School of Law. For example, a bronze plan could cover hospitalizations and visits to doctors for emergencies and accidents; genetic diseases; and prescription drugs that keep people out of hospitals. A silver plan could cover what bronze plans do but also include treatments a large majority of physicians find useful. A gold plan could be more inclusive still, adding coverage, for instance, for every cancer therapy shown to improve patient outcomes (no matter the cost) as long as it was delivered at a leading cancer center. Finally, a platinum plan could cover experimental and unproven cancer therapies, including, for example, that proton beam.

This way, nothing would be concealed or withheld from consumers. Someone who wanted proton-beam cancer treatment coverage could have it by selecting a platinum policy and paying its higher premiums. Someone who did not want to pay higher premiums for lower-value care, in turn, could choose a bronze or silver plan. This gives a different, but more useful, meaning to the terms “gold,” “silver” and “bronze” than they have in the new insurance exchanges today.

A second concern is that as people become sick, they will prefer plans that cover more treatments, including experimental ones. As sick people disproportionately choose more generous plans, their expenses and premiums will have to rise. This phenomenon, known as adverse selection, is familiar in most health insurance markets, including those for employer-sponsored plans, private plans that participate in Medicare and in the Affordable Care Act’s new marketplaces. One common way to address it is to permit individuals to switch plans only once per year, during an open enrollment period. This locks people into their choice for some time, so they can’t suddenly upgrade their plan after getting sick. If a once-per-year enrollment period proves insufficient in this case, a longer period could be imposed.

Structuring health plans according to value would give Americans the ability to buy whatever health care technologies they choose — including, if they want it, unproven and expensive care — without forcing others to pay for that choice. This would help address the key, though under-recognized, problem in American health care today: not that Americans spend a lot on health care, but that they spend a lot without always getting good value for the money.

Austin Frakt is a health economist with several governmental and academic affiliations. He blogs at The Incidental Economist, and you can follow him on Twitter at @afrakt.

Amitabh Chandra is a professor of public policy at Harvard’s John F Kennedy School of Government. His government affiliations and financial disclosures are listed on hisHarvard website. Follow him on Twitter at @amitabhchandra2.

The Upshot provides news, analysis and graphics about politics, policy and everyday life. Follow us on Facebook and Twitter.

healthcare, management and leadership, musings, politics, rapid learning health systems

Vinod smashes up doctors (again)

 

But Khosla devoted his hour-long keynote speech Friday to his long-held belief that technology will replace 80 to 90 percent of doctors’ role in the decision-making process.

“Sufficient data used properly and reduced to the right insights does in fact make up for errors,” Khosla said. “I would rather have 1,500 EKGs (electrocardiograms, a test that checks for problems with the electrical activity of the heart) done much more poorly than two EKGs done a year very well, because the sources of errors in the current system are just too large. When I have two EKGs a year, I may not be symptomatic. I’m not arguing that these systems don’t have errors. I’m saying the volume of the data, properly applied, makes up for it.”

http://blog.sfgate.com/techchron/2014/05/23/vinod-khosla-doctors-cannot-compete-with-machines/

Vinod Khosla: Doctors cannot compete with machines

Venture capitalist Vinod Khosla thinks the best way to improve health care is to get rid of most doctors.

Human judgment simply cannot compete against machine-learning systems that derive predictions from millions of data points, Khosla told an audience Friday, the third and final day of Stanford University School of Medicine’s Big Data in Biomedicine Conference.

“Biological research will be important, but it feels like data science will do more for medicine than all the biological sciences combined,” he said. “I may be wrong on the specifics, but I think I will be directionally right.”

The Silicon Valley billionaire has been in the news this month for restricting access to a beach south of Half Moon Bay, a move that is being hotly debated in court.

But Khosla devoted his hour-long keynote speech Friday to his long-held belief that technology will replace 80 to 90 percent of doctors’ role in the decision-making process. His is one interpretation of the implications of big data — the popular term for the massive volumes of digital information generated by electronic health records, genetic sequencing, clinical trials and other sources.

“Sufficient data used properly and reduced to the right insights does in fact make up for errors,” Khosla said. “I would rather have 1,500 EKGs (electrocardiograms, a test that checks for problems with the electrical activity of the heart) done much more poorly than two EKGs done a year very well, because the sources of errors in the current system are just too large. When I have two EKGs a year, I may not be symptomatic. I’m not arguing that these systems don’t have errors. I’m saying the volume of the data, properly applied, makes up for it.”

It’s only a matter of time before health care accepts that technology can do a better job of predicting patients’ risks for diseases, diagnosing illnesses and pinpointing the most effective therapies, Khosla said. He noted that Wall Street analysts and pilots also at first resisted, before they embraced, data-driven machines.

In particular, he said, wearable medical sensors, like Fitbit, will give patients power to make informed health and health-related decisions on their own.

Not surprisingly, this argument didn’t go over smoothly with some of the physicians in the crowd.

“I don’t agree with 80 percent of your remarks,” one clinician told him.

Khosla acknowledged his view is often not a popular one, but did not back down.

“Humans are not good when 500 variables affect a disease. We can handle three to five to seven, maybe,” he said. “We are guided too much by opinions, not by statistical science.”

complex adaptive systems, data saving lives, health market quality, healthcare, healthy habits, musings, policy, politics, rapid learning health systems

A chat with Terry

An excerpt of a conversation with Terry Hannan on the business and bureaucracy of health and clinical care…

 

Terry, thank you for sharing those terrific papers by John Wennberg and Brent James… inspiring and affirming thinking.

 

Regarding your request for me to expand on how “true” priorities of the system are expressed:

My overarching thesis for eHealth and its myriad follies is that the systems built often correctly reflect the “true” priorities of the system. The only glitch is that these priorities are often so radically divorced from those stated by the system’s leaders and in turn expected by clinicians and/or the public.[I would like you to expand this # as I am not sure I entirely grasp your focus here.]

 

Different stakeholders expect different returns from their investments. Roughly speaking (and apologies in advance for some of the generalisations that follow):

– politicians want to maximise votes in return for policy announcements

– bureaucrats want to maximise budget, status and power, and minimise risk in return to turning up to work

– public sector doctors want to maximise the health of their patients and status in return for turning up to work and working hard

– private sector doctors want to maximise income and status and minimise legal exposures in return for doing as much work as possible

– private hospitals want to maximise revenue in return for getting as many patients through their doors as possible

– nurses unions want to maximise members in return for negotiating improved work conditions

– not-for-profit (mutual) private health insurers want to maximise their perks by keeping doctors and private hospitals happy

– for-profit private health insurers want to maximise their profit margins by minimising doctor and hospital payments and maximising membership

– health researchers want to maximise their research capacity in return for increased publications

 

(Patients don’t even make my list of stakeholders, because they are not truly involved at present. An interesting remedy for this is citizen juries, a discussion for another time – did you ever engage with Prof Gavin Mooney before his untimely death?)

 

This suggests that each of these tribes wants a different “currency” in exchange for the “value” they deliver to the health system. They all use “patient interest” as the public justification for their claims on the system, but most of them are not actually remunerated in a currency that relates to the patient’s interest.

 

Indeed, in true “rent seeking” fashion, most of these stakeholders would rather not have to justify their remuneration to anyone – see this recent HLM news article.

 

At present, the easiest way to see what the system actually values is by looking at what it invests in. One “tell” that belies the health system’s “true” priorities is what it goes to the effort to properly records in electronic form i.e. billing data. This therefore suggests that money is the priority, and so it is what is tracked carefully.

 

If “patient interest” was truly the priority of the system, then far more effort and expense would be put into tracking patient outcomes, and in time, paying for them. On this, I am encouraged by the early shoots starting to sprout in the US around the development of ACOs, though I’m sure there are a lot more warts on it when seen up close.

 

My favourite “tale” of how to get there relates to how I’m told traditional chinese medical practitioners used to be paid. Everyone in the village would pay the practitioner as long as they were well, but stopped paying them whenever they ever got sick. This tight pecuniary alignment between patient and practitioner interest excites me, and makes me think there is still hope for ACO-style reform here. Indeed, my current health policy horizon doesn’t even involve hospitals and doctors, but rather looks at prevention efforts as the focus, as separate system with separate funding and separate participants.

 

I suspect this is best discussed over a long lunch or dinner, which I look forward to when the opportunity next arises.

 

Best regards, Paul

 

 

 

 

 

 

 

From: Hannan, Terry J (DHHS) [mailto:Terry.Hannan@dhhs.tas.gov.au]
Sent: Tuesday, 17 June 2014 9:07 PM
To: Paul Nicolarakis
Subject: RE: contact

 

See my inserted notes.

 

From: Paul Nicolarakis [mailto:pnicolarakis@cmcrc.com]
Sent: Tuesday, 17 June 2014 5:45 PM
To: Hannan, Terry J (DHHS)
Subject: RE: contact

 

Thanks for your forbearance Terry.

 

I’m inspired by your resilience and enthusiasm for the area, and quite certain that this particular eHealth conversation is going to yield some interesting insights. I present these ideas (which tend towards the political more than technical or clinical) to you in confidence, with a view to sharpening up the thinking. In light of my political experience, I would not want to offend any past masters as they were operating within some diabolical constraints.

 

My overarching thesis for eHealth and its myriad follies is that the systems built often correctly reflect the “true” priorities of the system. The only glitch is that these priorities are often so radically divorced from those stated by the system’s leaders and in turn expected by clinicians and/or the public.

 

Applying this analysis, it makes sense that an EMR purpose built to support HIV treatment in Africa would work because the only people involved in its development are dedicated clinicians, developers and minimal funding from similarly aligned entities with the specific purpose of improving the quality of care.

 

It also makes sense that physician led, integrated health systems (e.g. Regenstrief, Intermountain) that understand the “triple aim” nexus between high quality care and reduced costs would employ these systems successfully.

 

But finally, it also follows that systems built for governments in modern western democratic economies will never work because they are being built to get their political leaders re-elected, and make their vendors lots of money, but not really serve the community. The failure of these systems is ultimately guaranteed when the transparency they risk introducing into a system starts to threaten vested interests such as private medical providers and their associated institutions.

 

As per your slide from Blum, the red tail wags the yellow and blue dog because this is actually what matters in modern health care.

 

Microsoft learned this the hard way with their health solutions group efforts that I was involved in for a few years. The analytics software (Amalga) was quite impressive, initially developed by a group of keen, inquisitive (“data curious”) emergency physicians. They used the solution to monitor all sorts of clinical quality metrics across the business Washington Hospital Center service. Microsoft executives saw it, were impressed and acquired it. They then tried for 4 years to sell it to the world, only to discover that the “world” was not as interested in “clinical quality” as they were in bottom line revenues. What emerged from this experiment was the realisation that Microsoft had found itself ambushed by the gross conceit of modern healthcare i.e. stating that it was all about patient care, when in actual fact it was all about cash. Hence the highly administrative focus of most EMRs?

 

What has been terrific is to see US policy makers respond to this realisation by establishing “business models” around meaningful use and clinical outcomes. This is what seriously excites me now, though I suspect Australia is a decade away from adopting anything like what’s going on in the US at the moment.

 

One of the mantras we have here at the CRC (born in part out of our academic finance roots) is: “Healthcare is not a system, it’s a series of highly dysfunctional markets”. Applying this prism to healthcare really does start to clarify things, especially on the private side. On the public side, the currencies are sometimes different, but no less predictable.

 

I’ll pause here for fear of triggering some sort of global terrorist alert and/or offending you? Needless to say, I look forward to seeing where this conversation goes!

 

Best regards, Paul

 

 

 

From: Hannan, Terry J (DHHS) [mailto:Terry.Hannan@dhhs.tas.gov.au]
Sent: Tuesday, 17 June 2014 2:15 PM
To: Paul Nicolarakis
Subject: Re: contact

 

Take your time you just spark my enthusiasm. The fact that you are interested is such joy. Terry

Sent from my iPhone Terry Hannan
On 17 Jun 2014, at 1:40 pm, “Paul Nicolarakis” <pnicolarakis@cmcrc.com> wrote:

Please bear with me Terry… I’ve got lots on at work… will respond soon… Paul

 

From: Hannan, Terry J (DHHS) [mailto:Terry.Hannan@dhhs.tas.gov.au]
Sent: Monday, 16 June 2014 2:12 PM
To: Paul Nicolarakis
Subject: RE: contact

 

Paul, thank you for the taking the time to write to me and if you think about it this is the first time in our long association where we have done a bit of eHealth “together”.

Based on your enthusiasm in the text I will now send you some materials which should further extend our discussions.

 

Firstly I have attached nan short slide set that I had prepared for the Sydney meeting-just in case.

The next slide is explained in the text flowing it.

<image001.png>

 

This slide is taken from B. Blum’s Clinical Information Systems and you can see the small RED Administrativebox in the top left which is where most HIS funding and management comes from and they try to meet the needs of the most important cost generator Clinical Decision Making.

This is confirmed by the work in cost reduction in CDSS as shown in the slide set attached by Tierney in Regenstrief.

Also in the references below.

1.         Slack WV. Cybermedicine, How Computing Empowers Doctors and Patients for Better Health Care. 2nd ed. San Francisco: Jossey-Bass; 2001 2001.

2.         Tierney WM, Fitzgerald JF, Miller ME, James MK, McDonald CJ. Predicting inpatient costs with admitting clinical data. Med Care. 1995;33(1):1-14. Epub 1995/01/01.

3.         Tierney WM, Overhage JM, Takesue BY, Harris LE, Murray MD, Vargo DL, et al. Computerizing guidelines to improve care and patient outcomes: the example of heart failure. J Am Med Inform Assoc. 1995;2(5):316-22. Epub 1995/09/01.

 

In addition these results from institutions such as Regenstrief, Intermountain Health (HELP System), Brigham’ and Women’s Hospital and Beth Israel Deaconess Hospitals confirm these findings and show that the current funding models by governments are incorrect.

 

I am attaching two summary papers from the Kenyan project.

I hope I have not burdened you.

 

Terry

Dr Terry J. Hannan MBBS;FRACP;FACHI;FACMI
Consultant Physician
Clinical Associate Professor  School of Human Health Sciences, University of Tasmania Department of Medicine, Launceston General Hospital
Charles Street Launceston 7250

Moderator: http://www.ghdonline.org/

Ph. 61 3 6348 7578
Mob. 0417 144 881
Fax 61 3 6348 7577
Email terry.hannan@dhhs.tas.gov.au

Skype: thehannans

 

From: Paul Nicolarakis [mailto:pnicolarakis@cmcrc.com]
Sent: Monday, 16 June 2014 1:33 PM
To: Hannan, Terry J (DHHS)
Subject: RE: contact

Paper (PDF): Are docs the weakness in the ehealth building

Dear Terry,

Thank you for sharing the paper and referring me to ghdonline.org – I’ve just signed up.

The paper touches on many issues close to my heart, but two that I am particularly interested in is the exploration of “healthcare as business” vs “the business of clinical care”.

I won’t commit my dismal views to this email for fear of offending due to lack of context, but would welcome an opportunity to a vigorous discussion with you when we next have an opportunity? To the discourse I would like to add “healthcare as a bureaucracy” and “the bureaucracy of clinical care” as I believe this frame paired with “business” frame are particularly explanatory of most things that happen (or in the case of e-health, don’t happen) in the sector. Needless to say, the clinical and information systems you helped to establish in Africa represent something of an ideal in my mind for an end-goal of a “lite”, modern, effective health system following the “less is more” maxim.

Looking forward to continuing the conversation.

Best regards, Paul

I’ve now seen the Australian health system laid bare while working for the Minister, and many other health systems up close while working internationally at Microsoft. I’ve concluded that with rare exceptions, health care represents “just another unremarkable business” or “just another unremarkable

bureaucracy” depending on the type of funding system that is used.

facts & data points, healthcare, quotes & aphorisms, rapid learning health systems

Good news on health care performance in the US

This means more people alive and less money spent on complications. We can squabble endlessly about how to define value in health care, but deaths avoided and dollars saved? That’s the real thing.

http://www.commonwealthfund.org/publications/blog/2014/apr/drop-in-infections

Reflecting on Health Reform: Good News! High Performance in Action

Wednesday, April 16, 2014
David Blumenthal
By David Blumenthal, M.D.
Sometimes the news is good.

Recently, the Centers for Disease Control and Prevention (CDC) released data showing that health care–acquired infections (HAIs) are decreasing in the nation’s hospitals. Dropping fastest are central line–associated blood stream infections (44 percent from 2008–12) and some surgical site infections (down as much as 20 percent). This means more people alive and less money spent on complications. We can squabble endlessly about how to define value in health care, but deaths avoided and dollars saved? That’s the real thing.

Now the questions are: how did we accomplish this and how can we build on success? The credit flows in many directions.Infections declining

Decades of scholarship have demonstrated the toll that medical mishaps, including preventable infections, take on patients; these avoidable complications cause tens of thousands of unnecessary deaths and injuries every year in U.S. hospitals. The 1999 Institute of Medicine report, To Err Is Human, was a landmark document that focused attention on patient safety, and thousands of studies since then have illuminated the specific problems that compromise patient safety and how to solve some of them.

Government research agencies, such as the Agency for Healthcare Research and Quality, funded many of these studies and have worked with private-sector groups, including hospital associations, the Institute for Healthcare Improvement, and a variety of regional improvement organizations and foundations to get the word out. Stakeholders hammered out valid, reliable, and widely accepted measures of infections that resulted in National Quality Forum–endorsed standards. The CDC has tracked infection rates, giving hospitals benchmarks against which to measure their own progress, and the Centers for Medicare and Medicaid Services has implemented new programs, established under the Affordable Care Act (ACA), that penalize hospitals with large numbers of preventable infections. The ACA also created a national network of hospitals to support improvements in patient safety.

health care acquired infections

The lesson: progress is possible when you have good scholarship documenting a really bad, solvable problem and then mobilize both the government and the private sector to take it on.

There is a lot more work to do. Some states are doing much better than others in tackling health care–acquired infections, as the infographic shows. Lagging states need to learn from leading ones. Progress is not uniform across the different types of infections. The number of catheter-associated urinary tract infections has actually increased slightly (3 percent).

But with so much to complain about in health care, we should take heart when science, government, and the private sector point the way toward a higher-performing health care system. And we should be realistic about what is required to maintain progress: we need government-supported scholarship to create a sound evidence base, private-sector leadership to implement new findings, and government regulations and incentives to spur that leadership on.

data saving lives, healthcare

Wired: AI telling doctors how to treat…

 

 

http://www.wired.com/2014/06/ai-healthcare/

Artificial Intelligence Is Now Telling Doctors How to Treat You

  • BY DANIELA HERNANDEZ, KAISER HEALTH NEWS
  •   |

Image: Courtesy of Modernizing Medicine

Long Island dermatologist Kavita Mariwalla knows how to treat acne, burns, and rashes. But when a patient came in with a potentially disfiguring case of bullous pemphigoid–a rare skin condition that causes large, watery blisters–she was stumped. The medication doctors usually prescribe for the autoimmune disorder wasn’t available. So she logged in to Modernizing Medicine, a web-based repository of medical information and insights.

Within seconds, she had the name of another drug that had worked in comparable cases. “It gives you access to data, and data is king,” Mariwalla says of Modernizing Medicine. “It’s been very helpful, especially in clinically challenging situations.”

The system, one of a growing number of similar tools around the country, lets Mariwalla tap the collective knowledge gathered from roughly 3,700 providers and more than 14 million patient visits, as well as data on treatments other doctors have provided to patients with similar profiles. Using the same kind of artificial intelligence that underpins some of the web’s largest sites, it instantly mines this data and spits out recommendations. It’s a bit like Amazon.com recommending purchases based on its massive trove of data about what people have bought in the past.

Using the same kind of artificial intelligence that underpins some of the web’s largest sites, it instantly mines this data and spits out recommendations.

Tech titans like Google, Amazon, Microsoft, and Apple already have made huge investments in artificial intelligence to deliver tailored search results and build virtual personal assistants. Now, that approach is starting to trickle down into health care, thanks in part to the push under the health reform law to leverage new technologies to improve outcomes and reduce costs–and to the availability of cheaper and more powerful computers. In an effort to better treat their patients, doctors are now exploring the use of everything from IBM’s Watson supercomputer, the machine that won at Jeopardy, to iPhone-like pop-up notifications that appear in your online medical records.

Artificial intelligence is still in the very early stages of development–in so many ways, it can’t match our own intelligence–and computers certainly can’t replace doctors at the bedside. But today’s machines are capable of crunching vast amounts of data and identifying patterns that humans can’t. Artificial intelligence–essentially the complex algorithms that analyze this data–can be a tool to take full advantage of electronic medical records, transforming them from mere e-filing cabinets into full-fledged doctors’ aides that can deliver clinically relevant, high-quality data in real time. “Electronic health records [are] like large quarries where there’s lots of gold, and we’re just beginning to mine them,” said Dr. Eric Horvitz, who is the managing director of Microsoft Research and specializes in applying artificial intelligence in health care settings.

Increasingly, physician practices and hospitals around the country are using supercomputers and homegrown systems to identify patients who might be at risk for kidney failure, cardiac disease, or postoperative infections, and to prevent hospital re-admissions, another key focus of health reform. And they’re starting to combine patients’ individual health data–including genetic information–with the wealth of material available in public databases, textbooks, and journals to help come up with more personalized treatments.

For now, the recommendations from Modernizing Medicine are largely based on what is most popular among fellow professionals–say, how often doctors on the platform prescribe a given drug or order a particular lab test. But this month, the system will display data on patient outcomes that the company has collected from its subscribers over the past year. Doctors will also be able to double-check the information against the latest clinical research by querying Watson, IBM’s artificially intelligent supercomputer. “What happens in the real world should be informed by what’s happening in the medical journals,” said Daniel Cane, CEO of Florida-based Modernizing Medicine. “That information needs to get to the provider at the point of care.”

‘Quick and Seamless’

Using homegrown systems, doctors at Vanderbilt University Medical Center in Nashville and St. Jude’s Medical Center in Memphis are getting pop-up notifications within individual patients’ electronic medical records. The alerts tell them, for instance, when a drug might not work for a patient with certain genetic traits. It shows up in bright yellow at the top of a doctor’s computer screen–hard to miss. “With a single click, the doctor can prescribe another medication. It’s a very quick and seamless process,” says Vanderbilt’s Dr. Joshua Denny, one of the researchers who developed the system there.

‘Computers are notoriously bad at understanding English. It’s a slow haul, but I’m still optimistic.’

Denny and others used e-medical records on 16,000 patients to help computers predict which patients were likely to need certain medications in the future. Take the anti-blood clot medication Plavix. Some people can’t break it down. The Vanderbilt system warns doctors to give patients likely to need the medication a genetic test to see whether they can. If not, it gives physicians suggestions on alternative drugs.

Doctors heed the computer’s advice about two-thirds of the time, figuring in, for example, the risks associated with the alternative medication. “The algorithm is pretty good,” says Denny, referring to its ability to predict who’s going to need a certain drug. “It was smarter than my intuition.”

So far, computers have gotten really good at parsing so-called structured data—information that can easily fit in buckets, or categories. In health care, this data is often stored as billing codes or lab test values. But this data doesn’t capture patients’ full-range of symptoms or even their treatments. Images, radiology reports, and the notes doctors write about each patient can be more useful. That’s unstructured data, and computers are less savvy at handling it because it requires making inferences and a certain understanding of context and intent.

That’s the stuff humans are really good at doing–and it’s what scientists are trying to teach machines to do better. “Computers are notoriously bad at understanding English,” said Peter Szolovits, the director of MIT’s Clinical Decision Making Group. “It’s a slow haul, but I’m still optimistic.”

The Challenge Ahead

Computers are getting better at reading unstructured information. Suppose a patient says he doesn’t smoke. His doctor checks ‘no’ in a box–structured data, easily captured by a machine. But then the doctor notes that the patient’s teeth are discolored or that there are nicotine stains on his fingers–a clue that the patient in fact does smoke. Soon a computer may be able to highlight such discrepancies, bringing to the fore information that otherwise might have been overlooked.

In recent years, universities, tech companies, and venture capital firms have invested millions into making computers better at analyzing images and words. Companies are popping up to capitalize on findings in studies suggesting that artificial intelligence can be used to improve care. “Artificial intelligence–ultimately that’s where the biggest quality improvements will be made,” says Euan Thomson, a partner at venture capital firm Khosla Ventures.

The data is often stored in servers at individual clinics or hospitals, making it difficult to build a comprehensive reservoir of medical information.

But many challenges remain, experts say. Among them is the tremendous expense and difficulty of gaining access to high-quality data and of developing smart models and training them to pick up patterns. Most electronic medical record-keeping systems aren’t compatible with each other. The data is often stored in servers at individual clinics or hospitals, making it difficult to build a comprehensive reservoir of medical information.

Moreover, the systems often aren’t hooked up to the internet and therefore can’t be widely distributed or accessed like other information in the cloud. So, unlike the vast amount of data on Google and Facebook, the information can’t be mined from anywhere by those interested in analyzing it. From the perspective of privacy advocates, this makes some good sense: A researcher’s treasure trove is a hacker’s playground. “It’s not the greatest time to talk about” health records on the web, given security scandals such as the Edward Snowden leaks and the Heartbleed bug, says Dr. Russ Altman, the director of Stanford University’s biomedical informatics training program.

Drawing the Line

Also standing in the way are concerns about how far computers should encroach on doctors’ turf. As artificial intelligence systems get smarter, experts say, the line between making recommendations and making decisions could become more murky. That could cause regulators to view the systems as a medical devices, subject to the review of the U.S. Food and Drug Administration.

Wary of the time and expense required for FDA approval, companies engineering the systems–at least for now–are careful not to describe them as diagnostic tools but rather as information banks. “The FDA would be down on them like a ton of bricks because then they would be claiming to practice medicine,” says MIT’s Szolovits.

At the moment, he said, the technology isn’t good enough to tell doctors with 100 percent certainty what the best course of treatment for a patient may be. Others agree. “It’s going to be a long road,” says Michael Matheny, a biostatistician at the Vanderbilt School of Medicine.

Back at her clinic in Long Island, Dr. Mariwalla is thankful for the information that the artificial intelligence system can provide. For the patient with that blistering skin condition, she took the machine’s suggestion for an alternative medication. The patient has recovered, Mariwalla says, but she’s careful to add that she made the call herself—based in part on her conversation with her patient. “That’s where medical judgment comes in,” she says. “You can’t [just] rely on a system to tell you what to do.”

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.