Friday, December 30, 2011

Cool Technology of the Week

This week's post is not about a specific company's technology, but about a concept.

My wife did something very cool for me for Christmas.

Given that 2011 was filled with Hurricanes, Earthquakes, Tornados, Floods, and Fires around the world, she decided to create something that would make us more prepared for whatever the future may bring.

She created a disaster pack for the front hall closet using a Black Diamond Speed 30 mountaineering pack as a "grab and go" answer to any disaster that strikes.   It contains 72 hours of food/water, basic medical supplies. a solar powered radio, tools that can be used to harvest wood/start a fire, and extra clothes.

From the point disaster strikes to the point we're in a car with our supplies driving away could be under 60 seconds.

Think about the time it would take to assemble food/water, clothing, and medical gear after disaster strikes - 15 minutes?  Half an hour?

I highly recommend a "grab and go" pack as part of your family disaster preparedness plans.   Thanks Kathy for building one for us - that's cool!

Thursday, December 29, 2011

Our Cancer Journey - Week 2

It's been two weeks since my wife said "I have cancer" to my daughter.

It's been a week since we described our workup thus far on my blog.

Reaction to our blog post was diverse, ranging from the HISTalk blog to the Boston Globe.

It's a time of anxiety and unanswered questions.   The diagnosis and staging phase has been described as one of the two major tension points in  cancer.   The other is the time after remission, when the worry about recurrence is a constant burden.  One of our doctors recommended we keep a "family bottle" of anti-anxiety medication ready for those times when the stress exceeds our capacity to cope.   Cancer is truly a family disease and the emotional impact extends from the patient to family caregivers.

Many friends and colleagues have offered prayers and support.   A few have lamented that care coordinated by a physician-husband at a Harvard-associated hospital in Boston lacks equity since every wife/mother/daughter may not receive the same care throughout the US.  Kathy and I agree.   We posted these comments in response to those who speculated that Kathy's care consumes an asymmetric amount of healthcare resources.

John writes:
"At the same time I'm focused on Kathy's care, I'm also deeply committed to quality, safety, efficiency, and equity in healthcare across the country.   In the upcoming weeks, I'll describe how the electronic records that coordinate Kathy's treatment provide the same protocols to every BIDMC patient, regardless of insurance status, profession, or income.    My goal is the 'right care' - not too much nor too little - that follows best practices based on evidence.   Decision support driven 'right care' is the only way we can hope to improve outcomes while bending the cost curve of healthcare spending that threatens the US economy.   Universal healthcare supported by universal adoption of electronic and personal health records must be our guiding vision."

Kathy writes:
"My life with John has been entwined for 32 years, so to say "we have cancer" cannot be more completely and utterly correct. True that physically, only one of use has the obvious organic symptoms, but our close partnership has been irrevocably changed by the diagnosis. Whatever lies ahead, it is impossible to go back to that innocent moment before hearing the word "cancer".

I am luckier than most - I have health insurance, and access to a major urban medical center that is also a teaching and research hospital. But, as I encourage John to document our progress publicly in his blog, I am also keeping the memory of a friend close to my heart. She did not have health insurance (as a part time adjunct instructor of art). With this financial barrier, she unwittingly waited until the cancer had spread before seeking medical care, and although she fought bravely, she lost her battle with breast cancer.

Throughout my life, I have not needed medical resources beyond occasional primary care visits and the birth of one child.  My first weeks negotiating the barrage of new terminology, new tests, and new doctors was significantly eased by my access to a personal health record. The hospital's electronic health record is important to me, since it empowers my doctors to work as a team with open access to all my clinical data, enabling the team to make the best decisions for my health. As I recall my lost friend, I also think about all patients with a breast cancer diagnosis, or other serious illnesses, and  how they manage their care journey if they worry about health insurance, or have no access to a personal health record."

This week we continued the staging process in anticipation of finalizing our care plan (chemotherapy, surgery, radiation oncology) in early January.

On Friday, Kathy went to the operating room for a sentinel node biopsy.  This is now the recommended standard of care for cancer staging as it uses radio-isotopes to identify those lymph nodes that directly drain the tumor.  The surgeons harvested lymph nodes that were positive for radioactivity and one nearby node that was non-radioactive.

After the surgery I took Kathy home and the first thing she wanted to do was re-expand her lungs, avoiding post operative atelectasis.   We walked a few miles around Lake Waban, watched the sunset, and discovered a family of Muskrats seeking their evening meal.

Her post operative pain was helped by gentle exercise and stretching.   She took 2 Tylenol before bed.  Although the anxiety of the workup has interrupted her sleep - she wakes at 3am and has a hard time failing back to sleep - her post operative course has been uneventful.

On Tuesday night, we received the pathology report from the sentinel node biopsy.   It showed one lymph node (directly draining the tumor) with micrometastasis (0.1 cm) and one lymph node (not directly draining the tumor) without malignancy.

We're guessing that the staging will indicate T3, N1, M0 - a HER2 negative ER/PR positive 5cm tumor, with positive but minimal lymph node involvement, and no distant spread.   This may imply Stage IIIA, but we will await a definitive statement from the care team, since staging is complex and multi-factorial.

The tumor is very aggressive.   Less than a month ago, there was no lump.   Today, her left breast shows skin and shape changes.   We're meeting with the oncologist this afternoon to document the physical changes.       In general, research indicates that outcomes are the same regardless of the order of treatment - chemotherapy followed by surgery verses surgery followed by chemotherapy.   However, rapid growth and skin involvement may warrant chemotherapy as the first step.    Since Kathy is continuing to heal from the sentinel node biopsy, we have to time next steps carefully.   It's likely that chemotherapy will reduce her ability to heal, so we do not want to start it too soon.  However, the tumor is growing rapidly, so we want to start it as soon as possible.

Mentally, cancer can be overwhelming.   It is important to think about cancer treatment as "fitting into your life and schedule" verses letting the cancer control you.    The care journey will take time and there are many steps ahead.  

Thanks so much to all who have offered their encouragement.   Kathy and I are emotional and analytic people.  Our endless optimistic is only occasionally punctuated with sadness.   To paraphrase Robert Frost, the forest ahead is dark and deep, but there are promises to keep and there are miles to go before we sleep.   We're ready.

Wednesday, December 28, 2011

A Look Back at 2011

2011 was a year of change and tumult.   For a day by day look at the top stories of 2011, check out this impressive chart from the UK Guardian.

It was a year in which the economy sputtered worldwide, the Arab Spring toppled several regimes, and unprecedented acts of nature (severe weather, earthquakes) caused billions in worldwide damage.

What about the world of healthcare IT?

In 2011, Meaningful Use and Certification accelerated healthcare IT adoption and doubled implementation of EHRs throughout the country.    Every aspect of the industry was stressed along the way
*Vendors were challenged to add the features necessary for certification resulting in some "haste makes waste" lack of usability and workflow integration.   GE admitted its faults and should be congratulated for its honesty, since many other vendors had the same problems but did not communicate them.
*IT organizations created productivity miracles to meet meaningful use timeframes with limited staff and limited budgets.   Many organizations will apply their meaningful use payments to general operations and not IT department budget increases, so the sacrifice of IT staff may remain unrecognized.
*Providers had to radically change workflows to accommodate new business processes, resulting in staff turnover and short term frustration.

However, I would argue that we achieved David Blumenthal's goal of moving the "escalator" fast enough to create rapid change but not so fast that people fell off.   The one year delay in Stage 2 gives breathing room to all stakeholders to recover from Stage 1 and for laggards to catch up.

The Standards work needed for Stage 2 was completed and although there is still substantial work ahead, I believe that "good enough" content, vocabulary, and transport implementation guides are no longer the rate limiting step to healthcare information exchange.

The Policy work needed to support privacy, quality measurement, and patient engagement made significant strides.  As a country, we studied the PCAST report and incorporated its best ideas into existing federal efforts.

ONC itself matured in 2011, solidifying its operations under Farzad Mostashari, transforming from largely strategic to highly tactical, implementing the HITECH programs per the regulations written in 2010.  The Standards and Interoperability Framework filled the gap created when HITSP was sunseted.

In 2011, States were challenged to implement Regional Extension Centers, Healthcare Information Exchanges, and in some cases Beacon Communities, Challenge grants, and SHARP research programs. 

I believe there will be shining examples of success in some States, while others will provide lessons learned - political and technical - that will refine future work.

The REC program has been largely successful.   The HIE program is still an evolving work in progress, since HIE is technically and politically challenging, with limited alignment of incentives and few sustainability models.  

It's too early in the lifecycle of the research grants to assess their success.  Much hard work is being done to explore vocabularies, security, modular applications, and novel healthcare information exchange approaches.

In Massachusetts, all stakeholders - payers, providers, patients, employers, academia, and government aligned their efforts by forming an open, transparent state Advisory Committee (similar to a Federal Advisory Committee) to guide all state healthcare IT activities.  The energy and commitment from all the volunteers is inspiring.

2011 at BIDMC was a year of compliance - meeting new regulatory requirements of Meaningful Use, 5010, code 44 (short stay/observation verses inpatient), ICD-10, and the Fair Labor Standards Act (FLSA).    Major IT initiatives automated workflows to support these programs.

Infrastructure continued to grow with storage, bandwidth, and virtual machine enhancements to support Big Data.

Security challenges accelerated with more malware, more sophisticated hacking, and more regulatory penalties for data breaches.   In 2011, BIDMC had two publicly reported breaches, both of which were beyond our control, as they were caused by business associates on infrastructure we did not manage.   The emotional and monetary costs of breach reporting were very significant.

As I said in my post about the Joy of Success,  I believe that all my direct reports accomplished everything I asked them to do - we achieved meaningful use, addressed compliance requirements, and kept the IT staff stable/happy despite the stresses of the year.   They're heroes.

Harvard Medical School
In 2011, I continued to oversee the IT operations of Harvard Medical School during the CIO search process.   My goals have been to keep the IT staff happy, the infrastructure stable, and the budgets on track.   So far, so good.   My staff at Harvard also deserve a big thank you for a job well done.  My teaching, writing, and community service as a Harvard Professor continue at a brisk pace, but I've reduced my travel to the minimum possible to better balance my work and family life.

In December 2011 my wife was diagnosed with breast cancer, so my personal life has focused on family.   I'm supporting my wife by helping her prepare her artist studio and art gallery business for the 6-8 month hiatus ahead.   I've helped my daughter balance her college life, home life, and travel (she's in Japan now for a brief winter semester abroad) in the weeks following Kathy's cancer diagnosis.  I've put aside all my own pursuits including search for Vermont farmland.

On the positive side, the first semester at Tufts transformed my daughter into a self-reliant young woman.   My parents are healthy.  My own physical and mental health are good.   Our home and garden are well maintained and unlikely to cause a distraction over the next year.   Kathy and I continue to simplify our lives, reducing our belongings, and focusing on a lifestyle that is sustainable, low impact, and fulfilling.

In summary, 2011 was filled with high highs and low lows.   The pace was faster than any year in my life to date.  More happens every day in healthcare IT than the human brain can comprehend and I'm working harder than ever to filter the incoming data (and email) into knowledge and wisdom.

2012 will be a year of healthcare reform, new business intelligence/analytics tools, automating remaining paper processes, and creating the standards/policy/infrastructure necessary to accelerate health information exchange locally, regionally, and federally.     My only wish (beyond my wife's health) is that everyone will celebrate the problems we overcome rather than the focus on the challenges that persist.   Hard work is great if everyone around you is aligned for a successful journey rather than protecting themselves from blame when roadblocks appear along the way.

Tuesday, December 27, 2011

The Joy of Success

As the year ends, I've spoken to many CIOs.   2011 was a hard year filled with Meaningful Use (including many upgrades to certified systems or self-certification),  5010 (the deadline for upgrading billing systems is January 1, 2012), accelerating compliance demands,  new security threats, rapidly evolving technologies, and unprecedented demand for new projects driven by the consumerization of IT.

At the same time that CIOs and IT professionals are running marathons, they are being held accountable for events that are not directly under their control.   They are not being congratulated for the miracles they create every day, but are being criticized for not moving faster.

What do I mean?

One CIO received a negative audit report because new generations of viruses are no longer stopped by state of the art anti-virus software.   Interesting.  The CIO cannot control the virus authors, nor the effectiveness of anti-virus software.    No one in the industry has solved the problem, but audit firms revel in creating fear, uncertainty and doubt at the Board level as it enhances the reputation of the auditor.

Another CIO was held accountable for infrastructure demands that were not forecasted, planned, or communicated.   CIOs do their best to be proactive, but in the world of Big Data, past trends may not predict future needs.

Another CIO was was given 10 goals and 5 unplanned urgent projects.   She completed 8 of the planned goals and all the urgent projects, yet was told she only met 80% of expectations.

In a world that expects leaders to continuously perform miracles with constrained resources in limited time,  we all need to step back and take our own steps to stop the madness.

With your own staff, celebrate the joy of success and focus on what really matters.

Did you achieve Meaningful Use?

Did you support compliance requirements on time to meet regulatory deadlines?

Did you maintain employee satisfaction and minimize turnover?

If so, you're an IT Leadership hero.

Did your Board or senior management note that a new application or website launched a few weeks late because you wanted additional testing time to minimize risk?

No one will ever remember.

Did you defer a "nice to have" project because an unplanned "must have" occurred mid year?

Good for you.

Did you have a brief infrastructure failure that led to a major improvement in security, reliability, and maintainability because the staff rallied around a tricky problem caused by a combination of rapid technology change and exponential increases in customer demand?

You'll be stronger in the future because of it.

We have to break the cycle of negativity that makes IT leadership so challenging.  Create a culture that thrives on the projects you did well and does not focus on what remains undone because of circumstances beyond anyone's control.

Leaders at all levels - from Board members to team leaders need to realize that shouting louder does not make the rowing staff move the boat faster.

So celebrate the accomplishments achieved by your and your staff in 2011.   It was one of the hardest years in the history of IT and we doubled EHR adoption in the US from 20% to 40%. We need to focus on that success, leveraging our energy and optimism to finish the 60% that remains.

Friday, December 23, 2011

Cool Technology of the Week

In a previous post I described the capabilities of the Microsoft Kinect technology.

I've written about sterilizing iPads and iPhones for use in the operating room and that does work, but there are challenges with subjecting electronics to sterilization.

However, there's another cool option for examining medical records and digital images in the OR - a touch screen you do not touch.  Check out this gestural interface to EHRs and PACS systems that uses an Xbox and Kinect.

Traverse pages, select tabs, and zoom into images using only body movements.

The system, called TedCas, was recently named one of the top applications for Kinect.

That's cool!

Thursday, December 22, 2011

A Litmus Test for Elected Officials

by Brian Klepper and David C. KibbeSix months ago, who could have imagined that a large percentage of rank-and-file Americans would support the Occupy Wall Street (OWS) against special interests’ rigging of the American dream? So why not go to the next step? Why not pointedly ask political candidates, “Will you take money from lobbyists?” and “If elected, what will you do to stop special interest

We Have Cancer

Cancer.  It's a word that creates fear and uncertainty.   Many of the doctors I know use the word "hate" whenever they discuss their feelings about cancer.

Last Thursday, my wife Kathy was diagnosed with poorly differentiated breast cancer.    She is not facing this alone. We're approaching this as a team, as if together we have cancer.  She has been my best friend for 30 years.  I will do whatever it takes to ensure we have another 30 years together.

She's has agreed that I can chronicle the process, the diagnostic tests, the therapeutic decisions, the life events, and the emotions we experience with the hope it will help other patients and families on their cancer treatment journey.

Here's how it all started.

On Monday, December 5, she felt a small lump under her left breast.   She has no family history, no risk factors, and no warning.   We scheduled a mammogram for December 12 and she brought me a DVD with the DICOM images a few minutes after the study.   On comparison with her previous mammograms it was clear she had two lesions, one anterior and one posterior in a dumbbell shape.    I hand carried the DICOM images to the Breast Center team at BIDMC.

On December 13 she had an ultrasound guided biopsy which yielded the diagnosis - invasive ductal carcinoma, grade 3.

We assembled an extraordinary team of Harvard faculty - a primary care provider (Dr. Li Zhou), a surgeon (Dr. Mary Jane Houlihan), a medical oncologist (Dr. Steve Come), a radiation oncologist (Dr. Abram Recht),  a pathologist (Dr. James Connolly), and a skilled breast imaging team.   I also contacted my associates from the genomics research community.

On December 16, after my daughter's last final exam at Tufts, Kathy told Lara about the diagnosis.   Lara immediately offered her love and support.   We also told the grandparents.

Today, Kathy completed a bone scan and chest/abdominal CT.   Both are negative for metastases.

We also received the receptor studies from the tumor tissue.

HER-2/neu gene amplification - Not Amplified
Estrogen Receptor - Strong
Progesterone Receptor - Strong

Our next step is to complete the staging via an ambulatory surgical procedure on Friday - a sentinel node biopsy to determine if the lymph nodes closet to the tumor have evidence of malignant cells.

Summarizing what we know thus far - the tumor is less than 5 cm, poorly differentiated/fast growing, not yet spread to bones or organs, HER-2 negative and Estrogen/Progesterone Receptor positive.   Once the staging is completed we'll be able to finalize a treatment plan and determine an estimated 5 year survival rate.

Likely, she'll begin with chemotherapy to be followed by a left mastectomy in early 2012.

We'll also explore her genome to understand the risk factors and determine if a bilateral mastectomy reduces future risk.

We'll face many decisions ahead and many emotions.   We've already assembled a community of supporters.

1 in 8 women will develop breast cancer in their lifetime.   We never thought we'd be the one.

My Thursday blogs for the next 6 months will document our progress on the healing journey.

Thank you for your prayers and support.

Wednesday, December 21, 2011

Accountable Care Organization Measures

On December 19, CMS announced the selection of 32 Pioneer ACO organizations, five of which are Boston-based:  Beth Israel Deaconess, Mt. Auburn, Steward, Atrius, and Partners Healthcare.

To participate in the shared savings model, we'll need to compute 33 different quality metrics and submit them via survey, claims or the group practice reporting web interface (GPRO).

What are these metrics?

7 measure the Patient/Caregiver Experience based on survey
6 measure Care Coordination/ Patient Safety 6 based on claims or submissions to the GPRO web interface
8 measure Preventative Health based on submissions to the GPRO web interface
12 measure care to At Risk Population based on submissions to the GPRO web interface

Here's a comprehensive list of what needs to be computed, how, and when.

At Beth Israel Deaconess, we'll use our all-payer claims warehouse and quality data center.   My role as CIO has been to prepare the necessary analytics for panel and population health, as described in this overview

As I posted from IHI, our challenge ahead will be navigating the new business model while still maintaining the stability of the old business model during the transition.

From a CIO perspective, use this simple equation: ACO = HIE + Analytics  and you'll be ready for whatever tomorrow will bring.

Tuesday, December 20, 2011

The Standards Work Ahead in 2012

The December HIT Standards Committee included a discussion of the work ahead for the next year based on the priorities we've heard from stakeholders.    We'll have 10 in person and 2 telephonic meetings in 2012.   Our topics by quarter will be as follows

1.  Assuming that the Meaningful Use Stage 2 Standards and Certification Notice of Proposed Rulemaking will be published in early 2012, the HIT STandards Committee will need to review any comments submitted.   In the meantime, we'll continue work on testing criteria and will ensure any test scripts are piloted before they are finalized.

2. Quality Measurement standards
As I've mentioned in other posts, there are three key elements of work needed to improve quality measure computation and submission.   First, quality measures need to be simplified so they are based on data elements that exist in EHRs and are captured during normal workflow.   Second there needs to be a simple mechanism for submitting numerators and denominators (or the de-identified records that make up numerators and denominators) to CMS.   Finally, there needs to be a simple query language created so that new quality measures can be designed without have to write new code.

3.  NwHIN Exchange refinement
Previous analysis by the NwHIN Power Team included recommendations for improving the NwHIN Implementation Guides especially the Patient Discovery Specification and ebXML metadata.

4. Value sets/vocabulary mapping
Ideally the National Library of Medicine will host all the necessary vocabularies and crosswalks needed for Meaningful Use Stage 2 including ICD9, ICD10, SNOMED-CT, LOINC, RxNorm, and value sets (language, gender, smoking status etc)

1.  NwHIN portfolio  - the Direct and Exchange projects require supporting components such as provider directories.   We need to finalize specifications for these items.

2.  Query Health review - in the December HIT Standards Committee meeting we heard about Query Health and sending questions to data rather than aggregating data centrally.   We'll need to finalize the standards for defining medical concepts used in queries, the query language itself, and responses.

3,  Radiology Standards - DICOM is a non-standard standard.  Many manufacturers of image modalities, PACS, and viewing software extend the standard in proprietary ways.   If we want HIEs to support image exchange, we'll need a single, constrained implementation guide for image content.   Ideally we'll separate content standards from transport standards.  At present DICOM mixes the two.

4.  Governance - We need to ensure alignment between the S&I Framework, HIT Standards Committee and SDOs.   Setting common priorities, aligning the work, and coordinating the products of multiple SDOs will take creative governance.

1. Detailed Clinical Models -  as we consider simplified transition of care summaries such as GreenCDA, we also need to consider simplifications to the HL7 RIM such as Stan Huff's CIMI initiative.

2. Consumer-mediated information exchange - HIE needs to include provider to provider and provider to patient models so that we have a patient centered architecture that more easily supports privacy preferences for data exchange.

3. One-stop-shop for resources - HITSP specifications were challenging for implementers because they were based on indirection - a HITSP guide pointed to an IHE guide which pointed to a password protected SDO website.   We need one stop shopping with all the intellectual property necessary for implementation in one place that developers can easily access.   We need to finalize the plan and resources to do this.

4. GreenCDA - Simplified XML that eliminates any need for implementers to know the HL7 RIM  significantly reducing barriers to writing HIE software.   We need to finalize the standard tags for  Green CDA.

1. Maintenance strategy for standards - Once we complete the implementation guides for Meaningful Use, there will need to be ongoing maintenance and improvement by SDOs and other organizations.  We need to figure out how that will be done.

2. Public Health - As new approaches for public health evolve, such as Biosense 2.0 in the Amazon Cloud, we'll need to ensure the standards are available to support them.

3. Data/Practice Portability from EHR to EHR - To date, Meaningful Use has not included the complete export of data from one EHR and the complete import of data into another EHR needed for a clinician to change vendors.   Enabling "EHR portability" would be a great service to the provider community.

4.  APIs/tools such as conformance testing and HIE validation - to support implementers, we'll need  tools that validate the correct implementation of content, vocabulary, and transport standards.

Every year, the national standards activities expand, refine, and constrain implementation specifications.   Although there will always be work to do, we're on a great trajectory in 2012.

Monday, December 19, 2011

Managing Guest Wireless

BIDMC has two million square feet of wireless coverage using over a thousand 802.11n/a/g access points.   We operate two separate networks - a secure network for clinical applications and a guest network for visitors.

The guest network is physically separate from the secure network and uses a commercial 14 megabit per second DSL line from Sprint for internet services, reducing BIDMC's responsibility for malware control and digital millennium copyright act violations.    Like any public, unrestricted network, the guest network offers the freedom to download malware, broadcast viruses, and use insecure applications.

In a world of Netflix and YouTube,  compounded by bandwidth consumptive standards such as MPEG4, the demands on the guest network are infinite.    Can the hospital afford to provide free bandwidth to every visitor (inpatient, outpatient, families, students etc) when 80% of the traffic is streaming video?

If we do provide infinite free bandwidth, will employees and clinicians use the guest network instead of the Enterprise WPA secured clinical network because configuration is easier?    Mixing malware infected guest traffic with secure hospital applications is something we want to avoid.

Historically, we've only used one approach to discourage our BYOD staff from using the guest wireless - keep the bandwidth limited so that the secure network offers a better user experience.    This is an imperfect solution because it means that patients and visitors compete with each other from the shared megabits.   Two months ago, we restricted streaming video 8a-5pm Monday-Friday so that guest network users can reliably check their email and communicate via social networks.

What are other hospitals doing with their guest networks?    I asked several CIOs in Massachusetts:

Hospital A
"We limit the bandwidth of each user on the guest network to ensure a consistent experience.

We can't really block employees from accessing the guest network when they can bring in their own device  It's slow though. We have about 300-400 guests using wireless per day, sharing 5Mbps.

No corporate resources are available on the guest network without a VPN"

Hospital B
"We do not limit the bandwidth of each user on the guest network.  We do web content filtering and block adult content, peer-to-peer traffic, and illegal activities.  We do have the guest network configured for Bronze quality of service level, which is the lowest setting we could give it."

Hospital C
"We do not limit the bandwidth of each user on our guest network.  We do run web content filtering,
block in`ppropriate sites, and try to block torrents to limit our Digital Millennium Copyright Act exposure."

Thus, the common practice seems to be
1.  Use web content filtering to block inappropriate sites
2.  Block Peer to Peer traffic/Bit Torrent.
3.  Consider user bandwidth limitations
4.  Provide "bronze" quality of service at the network level
5.  Require VPN to reach clinical applications from the guest network

We already have web content filtering and peer to peer blocks in place.  What can we do to enhance the patient/visitor experience while limiting the use of clinical BYOD devices on the guest network?

Our next step is to evaluate the costs of increasing our guest bandwidth,  to simplify configuration when connecting to the secure network, and to educate our providers about the evils of the guest network and joys of the secure network.

And, yes, we have to ensure those BYOD devices are protected while using the secure network.

Although wireless broadband such as 3G CDMA/UMTS and 4G LTE may provide the technical capability for smartphone users to stream video to their devices, the end of the "all you can use" data plans is likely to further motivate users to seek guest wifi networks.

I predict that any capacity increases we purchase will soon be overwhelmed and we'll have to again impose some kind of user bandwidth, quality of service, or time of  day restrictions.

Feel free to share your experience with managing guest network demand.  All comments are welcome.

Friday, December 16, 2011

Cool Technology of the Week

Many of my posts lately have described the challenge of securing and managing consumer devices brought from home.

In the past, I've discussed the products from Good Technologies.

I recently polled the CIOs of Massachusetts hospitals and found two other products that are gaining traction - Fixmo and MobileIron

Fixmo creates a secured, encrypted container, the SafeZone, providing secure mobile messaging and data for businesses.

Companies allow mobile devices into their own SafeZone and can restrict application and data access ensuring device integrity and compliance. A safe, sandboxed environment is created in which mobile devices can run and access network resources without compromising the internal network's safety.

With SafeZone, employees can use all the features on their iPhones and Androids while a section of those devices is secure for sensitive company data. Data within SafeZone is certified FIPS 140-2 AES 256-bit encryption and encrypted within a company's infrastructure to keep data at rest and in-transi

MobileIron enables companies to manage multiple operating systems at a granular level, support corporate and personal devices, enforce controls, and create a private enterprise application storefront for employees.

I predict that many new companies will enter this marketplace over the next year, but for now, Good, Fixmo, and MobileIron are cool answers to the BYOD problem.

Thursday, December 15, 2011

Distracted Doctoring

I've written about some of the perils of using consumer devices on hospital networks .

Now add to that risk, the distraction of mixing personal activities with patient treatment.

Blogs are filling with debates about patient safety in a multitasking connected world.

Even the New York Times has published an article about the possible negative consequences of mobile devices.

In that context, AHRQ asked me to write a balanced commentary looking at the quality, safety, and efficiency pros and cons of using multitasking mobile devices for healthcare.

I hope you enjoy it and draw your own conclusions about how these devices are best used in your hospital of professional office setting.

Wednesday, December 14, 2011

Paul Ryan and Ron Wyden Blow the Medicare Reform Debate Wide Open!

House Budget Chair Paul Ryan (R-WI) and Senator Ron Wyden (D-OR) have embraced a Medicare reform plan that in concept borrows heavily from one championed by former New Mexico Senator Pete Domenici and former Clinton budget chief Alice Rivlin.Specifically, Wyden and Ryan are proposing to alter the earlier Ryan Medicare plan by:Continuing to offer the traditional Medicare plan—Ryan would have

Monday, November 21, 2011

The Super Committee Failure—What’s Next?

The stock market today was shocked, simply shocked, that the Super Committee didn’t come up with a debt deal.I don’t know why. Republicans can’t vote for more taxes unless they're willing to get “primaried” from the right and risk losing their seat. Ditto for Democrats who would face the same punishment from their base if they voted to change the sacred defined benefit entitlements without at

Wednesday, October 26, 2011

Romney Jumps on the Waiver Bandwagon--And Creates Even More Uncertainty Over the New Health Care Law

Republican presidential frontrunner Mitt Romney has pledged to end “Obamacare.” Upon taking office, he would immediately begin the process by granting the states waivers from having to implement it:“I’ll grant a waiver on Day One to get repeal started. On Day One, granting a waiver for all 50 states doesn’t stop it in its tracks entirely. That’s why I also say we have to repeal Obamacare, and I

Wednesday, September 28, 2011

The Ryan Health Care Proposals—Not Your Congressman’s Health Plan

Update: The New Wyden-Ryan Plan - Paul Ryan and Ron Wyden Blow the Medicare Reform Debate Wide Open! In a speech at the Hoover Institution today, Representative Paul Ryan (R-WI) argued again that his proposal to reform Medicare, and now his tax credit proposal for replacing the Democratic health care law for those under-age 65, would guarantee to citizens “options like the ones members of

Tuesday, September 27, 2011

The Health Leadership Council Medicare Proposal: Too Much Responsibility on Beneficiaries and Not Enough on Providers

The Health Leadership Council (HLC), a coalition of CEOs from many of the leading health care companies, has created a list of Medicare reform recommendations for the Super Committee tasked with finding at least $1.2 trillion in budget savings.As we begin the national debate over what to do about Medicare's unsustainable costs, I will suggest that the HLC proposal gives us one, of what will have

Tuesday, September 20, 2011

The Debt Super Committee—Will We Get a Deal?

It’s back to work in Washington, DC and all the attention is now on the Super Committee and their goal of cutting spending by at least $1.2 trillion over ten years.If the committee fails to come up with a plan that passes the Congress, there would be $1.2 trillion in automatic cuts. The health care special interests have reason to hope they will fail—the fallback cuts would only impact Medicare

Sunday, August 7, 2011

Self-Tracking, Psychiatric Ethics, and the Changing Patient-Doctor Relationship

A recent New York Times article - "A Dashboard for Your Body" - led me to nose around the web to learn more about developments in what is often called "self-tracking."

It's a fascinating area that is likely to change medical practice, the patient-physician relationship, and even the ways in which we think about ourselves.

Home monitoring devices are already letting clinicians - and perhaps more importantly, family members - keep a virtual eye on the frail elderly and homebound people with chronic illnesses. When our dispersed lives keep family members and close friends from keeping a literal eye on a person in need, devices with internet connectivity allow tracking of vital signs, blood sugar, movement in the living space, eating, and more.

These capacities would have been useful to me, an only child, and my father, in his 80s and legally blind from macular degeneration, during the years he lived in Florida, a thousand miles away. The telephone, and the front desk in the building he lived in, were the tools we had to rely on. Applied wisely, the emerging technologies will make it easier and safer for folks with reduced capacity for self-care to live at home, which is what most prefer.

My search led me to a fascinating article - "The Data-Driven Life" - that describes how some obsessive young technophiles monitor and chart their moods, alertness, uses of time, and much much more. While some of the self-monitoring verges on lunacy, some is potentially transformative.

In medical practice, we do a lot of data collection with our patients (think of the "blood pressure check" or monitoring drug levels). We also spend a lot of time encouraging patients to monitor themselves. The new devices shift the locus of control, power, and knowledge from physicians to patients. In place of coming to the office for a blood pressure check or a blood draw, the new technologies let patients do these themselves. In place of the physician's office notes the patient has his own medical record.

Some years ago a patient of mine with depression (working with her on that was my job) and brittle diabetes, consulted me about problems with her medical team. She had created spread sheets correlating glucose levels, insulin dosage, and other factors. These led her to hypotheses about her regimen. Her team didn't explicitly call her "uppity," but they didn't respond well to her wish to share the driver seat with them. Here my job was to coach her on how to shape a new form of collaboration with her team. Happily, it worked.

Self-tracking may turn out to be especially useful for psychiatry and behavior change. In mental health treatment, patients often relate to clinicians the way our forebears related to oracles. They pose questions like "why did I feel that way?" and "what put that idea into my head?" These are important questions, but seeing the clinician as the all-knowing source of insight is disempowering.

The article on "The Data-Driven Life" identifies implications for future psychiatric practice:
"...a 26-year-old filmmaker named Toli Galanis, [reported] 'I know that immediately after watching a bad movie I am more apt to be negative about my career prospects as a filmmaker'...tracking has made him better able to detect the influence of seemingly trivial circumstances on his mood and decisions.

The idea that our mental life is affected by hidden causes is a mainstay of psychology. Facility in managing the flow of thought and emotion is a sign of happiness and good adjustment. But how is it done? Nearly every therapeutic prescription involves an invitation to notice, to pay attention. Once we have a notion in our sights, we can attack it with an arsenal of tools: cognitive, psychoanalytic, even spiritual. But none of these will tell us if we’ve missed something. You may simply have failed to notice a debilitating habit, a negative correlation, a bad influence."
This next vignette shows how self-tracking can be combined with social support:
"Jon Cousins is a 54-year-old software entrepreneur and former advertising executive who was given a diagnosis in 2007 of bipolar affective disorder. Cousins built a self-tracking system to help manage his feelings, which he called Moodscope; now used by about 1,000 others, Moodscope automatically sends e-mail with mood-tracking scores to a few select friends. 'My life was changed radically,' Cousins told me recently in an e-mail message. 'If I got the odd dip, my friends wanted to know why.' Sometimes, after he records a low score, a friend might simply e-mail: '?' Cousins replies, and that act alone makes him feel better. Moodscope is a blended system in which measurement is supplemented by human sympathy. Self-tracking can sometimes appear narcissistic, but it also allows people to connect with one another in new ways. We leave traces of ourselves with our numbers, like insects putting down a trail of pheromones, and in times of crisis, these signals can lead us to others who share our concerns and care enough to help."
Toli Galanis shows how to use self-tracking as a source of insight to guide self-management. Jon Cousins shows how to use self-tracking to strengthen social support. Developing insight, improving self-management, and strengthening constructive relationships, are central components of virtually every form of psychotherapy. Tools that provide these functions will allow some potential "patients" to be their own therapists, and will enable others to come to therapy having done valuable "pre-work."

When I did my training, our patients' families and friends were often seen as intruders on the therapeutic process. In subsequent decades psychiatry and psychology wised up and learned to work with patients in the context of their social environment - using it when it was constructive and trying to change it when it was not. I foresee a time in the not-too-distant future when we'll be working with their iPads as well!

Thursday, August 4, 2011

Rethinking the Value of Medical Services

by Brian Klepper and David KibbeOne of American politics’ most disingenuous conceits is that health care must cost what we currently pay. Another is that the only way to make it cost less is to deny care. It has been in industry executives’ financial interests to perpetuate these myths, but most will acknowledge privately that the way we value and pay for medical services is a deep root of

Tuesday, August 2, 2011

How a Well-Intended FDA Policy on Colchicine is Harming Patients

The road to hell is paved with good intentions.

The FDA has reaffirmed the truth of this aphorism with its policy about Colchicine. Here's the story:

I recently spoke with a friend who has a family member suffering from Familial Mediterranean Fever (FMF), an auto-inflammatory disorder, most commonly seen in eastern Mediterranean populations. The condition is characterized by recurrent painful inflammation of the abdomen, chest and joints, accompanied by fever. FMF is associated with mutation of a gene on chromosome 16 involved with regulating Pyrin, a protein that is part of the inflammatory response. There is no specific test for the disease. Diagnosis is made on the basis of symptoms, family history, and ruling out other conditions.

Since the 1960s, Colchicine, a plant extract first used for treatment of gout two thousand years ago, has been used for treating FMF. As an ancient treatment widely used prior to formation of the FDA, Colchicine did not require FDA approval as a new drug.

In 2009, the FDA granted approval to URL Pharma for Colcrys, its version of Colchicine, based on randomized controlled trials the company conducted. Because Colchicine had never been subjected to the FDA approval process, Colcrys was, in a technical sense, a "new" drug approved for a "new" indication - treatment of gout and FMF - despite the centuries of prior use.

Here's where the well-intended harm comes in. The FDA is allowed to give market exclusivity to a new drug for new indications, as an incentive for pharmaceutical companies to conduct tests and seek FDA approval. In September 2010 the FDA did just that - it ordered all other manufacturers to cease production and marketing of their versions of Colchicine.

Generic Colchicine cost ten cents per dose. Colcrys costs close to five dollars. The company defends the price increase as (a) necessary to support its research and (b) offset for vulnerable patients by a support program for circumstances of hardship.

The FMF community, however, has documented that FMF patients respond differently to different preparations of Colchicine. Apart from the financial impact of a fifty-fold price increase, many who were stable on a previously available form of the drug relapsed on Colcrys.

That's what happened to my friend's family member - a series of severe fevers and inflammatory reactions, leading to emergency room visits and hospitalization.

An editorial in the New England Journal of Medicine argued that URL Pharma's research added no significant benefit to public health of the kind that would justify the reward of market exclusivity. (See here for a vigorous response from URL Pharma.) But apart from the financial hardship market exclusivity creates for patientr and insurers, banning the alternative forms of Colchicine injures patients who respond to those forms and not to Colcrys.

My friend is resourceful, and was able to find "contraband" Colchicine. When it was administered, it did the job for his family member.

Encouraging research and true innovation is a social good. But so is preventing recurrences of FMF! A policy that does not allow exceptions to prevent avoidable harms is an unethical policy. Given that alternative forms of Colchicine are no longer manufactured and sold in the U.S., the FDA should make provision for importation from abroad for patients like my friend's family member.

(See here for an excellent article on FMF and the impact of the FDA policy by Dr. Janine Jagger, an epidemiologist who suffers from the condition.)

Monday, August 1, 2011

The Debt Deal: There Will Be Blood on the Floor on November 23rd

The debt deal is finally done. But it really isn’t an agreement on what cuts will be made, just the process that will be used to make them.The real work is left to the Congressional appropriators for the first $917 billion and for a super-committee of Congress for the second $1.2 trillion to $1.5 trillion in ten-year cuts.That second tranche is where health care will make its contribution. The

Friday, July 29, 2011

Improving Nursing Home Ethics

A recent conversation with a friend about his father's nursing home experience taught an important lesson about nursing home ethics. Here's the story:

His father suffered from severe Alzheimer's and required full time supervision. A local nursing home that had a mediocre reputation some years back was said to have improved, and the family placed his father there.

The nursing home was in another part of the country, so my friend could visit only intermittently. On each visit he was impressed with the attentive, loving care the residents received.

His father lived in the nursing home for a few years before his death. When my friend made a final visit to collect his father's belongings and to thank the staff, he was invited to look at the nursing record. The final entry said it all with regard to the ethical ethos of the home:
May God grant peace to his gentle soul!
I teared up when he told me this and teared up again as I wrote it.

My friend spoke with the administrator who had turned the home around. He asked how this had been accomplished. Here's my reconstruction of what the administrator told him:
When I came here, we weren't caring for the residents the way I wanted it to be. I made a point of getting to know everyone on the staff in a personal way. I listened to their impressions and concerns about the home, and what they hoped for. I tried to treat everyone the way I would want to be treated, in the spirit we wanted our residents to receive. When I decided who we should build our future around and who had to go, the staff understood what I was doing, and felt I was being fair.
Improving quality doesn't need to be rocket science. My friend's father was cared for the way the staff was cared for. Ethically guided, respectful treatment of staff cascaded through to the residents, right up to the blessing my friend's father received at the end of his life.

Wednesday, July 27, 2011

We Are Reaping What We Have Sown—The Debt Standoff

On this blog a month ago, I said the politicians were starting to scare me with the apparent eagerness of some to actually take the government to default to make a political point.For weeks we have heard political leaders on both sides tell us there would be no default.But the two sides have so backed themselves into opposite corners that they have left no opportunity to meet in the middle.

Sunday, July 24, 2011

Moving Towards a Single Payer in Vermont

If you're interested in Vermont's plan for a single payer system, you'll want to look at an article in this week's New England Journal of Medicine.

According to Anya Rader Wallack, Ph.D., special assistant for health reform to Governor Shumlin, the Vermont program will include "a global budget for health care expenditures, guaranteed coverage that is not linked to employment, and a single system of provider payments and administrative rules."

The health system will be overseen by a new public entity - the Green Mountain Care Board. Here's how Dr. Wallack describes the powers of the board:
The board can wield traditional tools such as fee-for-service rate setting, controls on the acquisition of technology, and reviews of both health insurers’ rates and hospitals’ budgets. However, the law also provides explicit direction to the board to create a global budget for health care spending and develop new payment models that create incentives for providers to stay within the budget.... The board is charged with implementing payment methods that encourage high quality and efficiency and provide the impetus for fundamental changes in the structure of the delivery system. It will apply these methods across all payers, private and public (we will seek permission from the federal government to include Medicare), and will monitor the effects of payment changes on both cost growth and quality indicators. (emphasis added)
The beleaguered Independent Payment Advisory Board (IPAB), created by the federal health reform law, has much less power than the Green Mountain Care Board, but it's under attack as a socialist monstrosity. It's at best touch and go as to whether the IPAB will ever see the light of day.

Our federal paralysis is why states are the most important laboratories for health reform in the U.S.

Vermont is small (625,000), by U.S. standards has a remarkably civilized form of political debate, is the first state to allow same-sex civil unions, and has the only "out" socialist legislator in Washington - Senator Bernie Sanders. It's hardly typical of the current U.S. mainstream.

But Saskatchewan wasn't typical of Canada in 1946, when it passed the first provincial single payer legislation in Canada. It took 38 years to move from the Saskatchewan Hospitalization Act to the Canadian Health Act in 1984. It's easy to pontificate about ethics and policy, but change on the ground takes a long time, huge amounts of work, an iterative political process, and a public learning curve.

A lot of the future of the U.S. health system is riding on the Vermont experiment. If Vermont succeeds, open-minded conservatives (despite what we're currently seeing in debt limit "debate," they do exist!) will kick the tires of Green Mountain Care and conclude that a single payer system doesn't destroy health and human liberty. Vermont represents only 0.2% of the U.S. population, but it may turn out to be the mouse that roared for health system change!

Wednesday, July 20, 2011

Obesity, Alcohol, Tobacco, and Primary Care

I'm in Vermont, telecommuting and enjoying the Green Mountains while my wife teaches at the Bread Loaf School of English, a Middlebury College program in which students, mainly K-12 teachers, can get a Masters degree in the course of five summers.

Students and faculty have meals in a building that served as a summer Inn a century ago. Last night at dinner two faculty members I was sitting with began to talk about how many Weight Watcher "points" the different foods had. They graciously allowed me to grill them on their experience with weight management. Here's what I learned:

Neither had succeeded in maintaining weight loss on his own. While they did not care for the meetings associated with the Weight Watcher program, both found the weekly "check in" helpful. I probed.

Did they have an extended conversation with the person who weighed them? No.

Was it always the same person? Yes, usually. But they did not appear to find the relationship itself important. It was the public weighing that supported their motivation.

One of the two men followed the recommendation that he keep a daily log of what he ate. This made him more conscious of the act of eating. He'd ask himself - "do I really want to eat XYZ, or am I just on automatic pilot?"

Both had achieved and maintained significant weight loss. Their health (blood pressure, cholesterol) and energy had improved.

We shifted to smoking. One had smoked heavily while in graduate school. A group of friends vowed to quit, and promised to pay the others $50 each if they lapsed. My friend reported - "I was too cheap to pay out all that money, and I haven't smoked since."

I told them how medical education teaches us a lot about how to deal with the downstream wreckage caused by obesity, alcohol , and tobacco, but little about the upstream self-management approaches for prevention. In my own experience as a psychiatrist, I'd learned pathetically little about alcoholism in medical school and residency. Luckily, to prepare myself for teaching primary care and psychiatry residents, I'd gone to a number of AA meetings myself, and, with permission from the groups, took students to meetings. I was able to talk with patients about the embarrassment I'd felt when the receptionist at the entrance to a facility I visited to scope out a meeting asked me where I was going - sometimes it helped them with their own dis-ease about exploring AA.

Every time a patient mentioned an AA or NA meeting I'd get them to describe it. When and where did it meet? Who was the group best for? Who might be uncomfortable there? I'd write down the information and put it into a progressively larger file. Then when talking about AA or NA with patients I was encouraging to explore the program I took out the file and thumbed through it. My sense was that apart from the information it contained, the "evidence" of my serious interest in AA and NA, and the echo of the voices of other patients that came through my notes, often had power.

No companies monitor us for effective referrals to AA, NA, Weight Watchers and other support and self-management programs the way the pharmaceutical industry monitors our prescribing habits. There's no money in it and no high tech glamour.

All there is is the intrinsic satisfaction from helping people improve their capacity to promote their own health and well being!

Monday, July 18, 2011

Writing about Patients (and research subjects)

Last week I read a fascinating book by Charles Bosk - "What Would You Do? Juggling Bioethics and Ethnography."

Bosk's first book - "Forgive and Remember: managing medical failure" - a brilliant field study of surgical training, made him famous when the first edition was published in 1979. I can't evaluate his skills as an ethnographic field worker, but he's a terrific writer.

In a chapter on "Irony, Ethnography, and Informed Consent," Bosk reports the intense distress a genetic counselor experienced on seeing how he'd written about her and reflects on the nature of informed consent in ethnographic research. The ethnographer is not doing an experiment for which the risks and benefits can (and should) be described clearly to those who are being asked to participate. But he describes how ethnography characteristically seeks to "debunk" (his word) conventional social constructions, and he comments that ethnographers often write with irony. (That's part of what makes his writing so engaging.) The chapter reflects on whether the risk of reactions like that of the genetic counselor can be conveyed to folks in the environment the ethnographer hopes to study.

This is a tough question. How many potential "subjects" would agree to the study if the would-be-researcher came to the group and said: "I would like to observe you to understand how you function. I will write up my observations and may well debunk your own views of yourselves and what you are doing. I will write with irony, and you may feel misunderstood and condescended to."

Not many. I'm a great fan of ethnographic literature and have learned a lot from it. But if an ethnographer wanted to study me in action, I'd (a) agree if I had "must approve" rights to review any and all proposed public presentations that could possibly be connected to me or else (b) I would run for my life.

Over the years I've often used experience with patients in writings and lectures. I've applied this rule of thumb to the way I developed the material: The patient's closest friends shouldn't recognize who the story is about, and the patient should feel respected by the way he is talked or written about.

The most interesting experiences I've had in writing about patients involve communicating with other physicians. The group I practiced with used an electronic medical record. If I wanted to write to another physician involved in the patient's care, I often composed the note collaboratively with my patient. In one situation, after a lot of nudging and nagging on my part, a patient of mine finally acknowledged that alcohol was a big problem for him. He agreed that his primary care physician ought to be told. We sat in front of the monitor together. He balked when I wrote "X now recognizes that he suffers from alcoholism." We negotiated and agreed to substitute "X now recognizes that alcohol is a problem for him." The discussion itself was part of the work that goes into the first of the twelve AA steps - acknowledging the problem itself.

I don't know how contemporary ethnographers handle informed consent. Quite apart from what an IRB might say, I would not feel justified in writing about people in any way that could be connected to them without their "sign-off" on what I'd written. That was the agreement for the field work that went into the two health policy books I've written with colleagues. And in the grant proposals for funding the studies we stated that we thought of those we observed and spoke with in the field as "colleagues," not "subjects."

Bosk sees the issue of informed consent in utilitarian terms. Respect for those who will be observed and written about calls for robust informed consent, with full explication of the potential risks of the ethnographic study. But the potential value of the study itself pushes against informing about risks in a way that is likely to squelch the study. I may have misunderstood him, but it looked to me as if he came down on different sides of this equation in different chapters.

Apart from federal regulations about human subjects research, I vote for an open process of informed consent. Discussing risks may indeed squelch promising projects, but my optimistic view is that transparency will, over time, enrich the kind of research Bosk exemplifies so well. Negotiating with those one is observing (or, for clinicians, treating) can itself be a rich source of insight. And for ethnographers, that process may lead to less determination to be "debunkers," and to a writing style that depends less on irony about the subjects to engage the reader. A writer as good as Bosk doesn't require a put-down mode to make the story he tells vivid and alive.

Thursday, July 14, 2011

Should Researchers Criticize their Peers in Public?

The Chronicle of Higher Education recently reported that University of Pennsylvania psychiatrist Jay Amsterdam has accused his department chair and four colleagues of publishing an article that was (a) ghost written by a contractor for GlaxoSmithKline and (b) biased in favor of the GSK antidepressant Paxil. Amsterdam complained that the article "was biased in its conclusions, made unsubstantiated efficacy claims, and downplayed the adverse event profile of Paxil." He contends that "data from his study was effectively stolen from him, manipulated, and used in a ghostwritten article" designed "to advance a marketing scheme by GlaxoSmithKline to increase sales of Paxil."

I'm writing this post without any insider knowledge about what's going on in the Department of Psychiatry at the University of Pennsylvania. Dr. Amsterdam's faculty profile, last updated 16 months ago, shows him to be a specialist in treating depression. The Chronicle post reports that he has been on leave since August. Clearly, there's been conflict and turmoil within the department.

In the medical profession, part of our claim to authority and trustworthiness (since I'm a physician, I say "our" not "their") is that we will police ourselves and expose unacceptable performance by colleagues. Over the years we've fallen down on this job. Our tendency is to circle the wagons rather than point the finger!

Whatever the outcome of the investigation that's been undertaken, Amsterdam is setting an important example: speaking truth to power is a fundamental right and responsibility. Another recent example is the spine care experts who published a similar critique of work by colleagues on a Medtronic product that they see as biased and misleading. (See this article from the New York Times on the topic.)

Conservative professionals will warn that publicly airing intraprofessional conflicts will lead to an overly active anti-professional swing in public opinion. Unfortunately, they're right. I wish there were a less going-to-extremes way for public process to proceed. In small groups, with face-to-face contact, it's possible, But in a pluralistic society of 300 million, it's not.

(You can see Dr. Amsterdam's letter of complaint the Project on Government Oversight website.)

Monday, July 11, 2011

One Image: American Medicine Believes in Accretive, Not Disruptive, Innovation

Click to Enlarge  Source 

The current issue of Annals of Internal Medicine  has a great article on individualization of mammography recommendations -more on that in the next few days.

There is another article demonstrating that an inexpensive ultrasound machine that fits in a pocket is almost as good at certain measurements of heart anatomy as a conventional ultrasound machine - which would frequently generate a health care bill of $1500.

When I saw the abstract, I thought that Clay Christensen's predictions about disruptive innovation in health care were finally coming to pass - and we were going to use technology that was a little bit inferior to existing technology, but perfectly adequate for many indications - and save big bucks. This could be the cardiac imaging equivalent of the personal computer going up against mainframe computers!

Alas, this was not to be. The authors position the pocket echocardiograph to replace not the expensive conventional echocardiogram, but instead to replace the lowly stethoscope.  They don't want this to replace a $1500 scan, but instead to replace a low-tech device whose use is currently bundled into other cognitive services.  

While other industries produce more value with disruptive innovation, in medicine we use technology only to further escalate the medical arms race.  I think of this as accretive innovation.

Finding Nice Physicians

Here's the opening of a fascinating article in today's New York Times:
Doctors save lives, but they can sometimes be insufferable know-it-alls who bully nurses and do not listen to patients. Medical schools have traditionally done little to screen out such flawed applicants or to train them to behave better, but that is changing.

At Virginia Tech Carilion, the nation’s newest medical school, administrators decided against relying solely on grades, test scores and hour long interviews to determine who got in. Instead, the school invited candidates to the admissions equivalent of speed-dating: nine brief interviews that forced candidates to show they had the social skills to navigate a health care system in which good communication has become critical.
I'm embarrassed to acknowledge that although I've done a lot of interviewing, I'd never heard about the technique Virginia Tech Carilion is using - multiple mini interviews (MMI). Applicants are seen at multiple interview "stations," each of which presents them with a specific problem to to address, such as whether a pediatrician should support parents in their wish to have their baby boy circumcised or whether it is ethical to use unproven alternative treatments with a patient. The interviewer is trained in how to probe responses and in a standard form of assessment. Research suggests that multiple short "biopsies" are much better predictors of subsequent performance in the "soft" or "humanistic" components of medicine than standard interviewing is.

The technique was pioneered in 2001 by Dr. Harold Reiter at McMaster University in Ontario. In 2007 McMaster developed a spin-off company to disseminate the technology. The technique is being used at medical and other professional schools in Canada, the U.S. and elsewhere.

The trend towards MMI promotes medical ethics in two ways. First, it appears to improve our ability to identify applicants who are likelier to end up as humanistic
practitioners - in colloquial terms, "nice doctors." Second, it sends a message to prospective physicians that humane, thoughtful caring about others is a core value for the profession.

I have the privilege of participating in teaching medical ethics to first year Harvard Medical students. I think of the content of our course as a set of tools that a properly motivated physician can apply. I hope that the course itself models a set of attitudes and behaviors that students will want to apply in whatever area of medicine they end up in. But the phenomena for which we use terms like "caring," "integrity," "human decency," and "niceness" are partly hardwired in our nervous systems and inculcated by experience throughout our growing up. Courses can help to hone our humaneness, but the dispositions we have already formed and bring with us count for a lot.

Early in my practice I learned a lesson I've never forgotten. I inherited as a patient a man twice my age (I was 30, he was 60) who'd suffered from a serious psychiatric ailment throughout his adult life that had impeded his capacity for work and caused suffering for himself, his wife, and his children. By the time we met his condition was quiescent. I met with him and his wife every month or two, gave what counsel I could, and tinkered with his medications. But at heart I felt guilty - I liked him and his wife, and felt I was doing nothing for them.

My wife and I wrote off for tickets to an event. (This was in the pre-internet era.) I received a letter in response:
Dear Dr. Sabin:

There were no tickets left for this event, but when I saw who was asking, I managed to find two. You've been such a wonderful doctor for my parents that I wanted to do something for you.

Gratefully yours

The incident still brings tears to my eyes. At the same time that I was feeling guilty about how little I was doing for my patient, he and his wife had conveyed to their adult child how grateful they were for my ministrations. My "technical" offerings were essentially nil, but the letter I received showed just how much the "soft" element - liking, respecting, and caring about my patient and his wife mattered to them.

In medical school, a brilliant research hematologist was lecturing to us about a blood disease. He described the genetics, chemistry and physiology of the condition eloquently. A student asked him about what the condition meant to patients afflicted with it, how it affected them apart from physical impacts. In a sarcastic voice the lecturer responded - "This is hematology class! What do you think it is - psychiatry?"

In the intervening years, medicine, and medical schools, have caught on to the clinical importance of kindness and niceness. These attitudes and behaviors aren't fancy, but they matter a lot in determining what medical care can accomplish. It's good news to learn that medical schools are trying to do better in selecting students for these characteristics as well as for their braininess!

(For previous posts on this topic, see here and here.)

Oregon Medicaid Lottery Shows Benefit of Insurance

Today’s Managing Health Care Costs Indicator is 89,824

Click to enlarge.  Source 

Oregon realized it had resources to add about 10,000 beneficiaries to the Medicaid roles in 2008, and decided to hold a lottery to determine who would be awarded this Medicaid insurance.    89,824 Oregonians were eligible, 29.664 were randomized to be able to apply for Medicaid, and about 1/3 actually qualified.  (Reasons for not qualifying included not completing the paperwork or having income that was too high.).

Researchers at Harvard used this natural experiment to see what the impact of winning this Medicaid lottery really meant.   This natural experiment is ideal to determine the effect of gaining potential Medicaid eligibility – because the 30,000 who won the lottery (experimental group)  were randomly chosen, making it unlikely that they were significantly different than those who did not win the lottery (control group).

This is an especially important study because of the randomization, and because the researchers surveyed the experimental and control groups, and also looked at medical claims and credit reports to determine financial impact of insurance availability.

All of the conclusions are on an “intention to treat” basis – so that those who won the lottery but didn’t qualify for Medicaid are included in the “experimental” group. While this is necessary to make the “experimental: and “control” groups comparable, this approach likely  understates the effect of actually getting Medicaid because only 1/3 of the “experimental” group actually qualified for Medicaid.

What the researchers found

1)     People who won the lottery more care.  They don’t have fewer emergency department visits, they have more inpatient stays and outpatient visits.  It’s likely that there was some “pent up demand” from previous care foregone
2)     People who won the lottery have less life-changing medical debt. They are less likely to borrow money, and less likely to have a collection agency chasing them for medical debt.
3)     People who won the lottery get more preventive care
4)     People who won the lottery are more likely to report their health is good, and less likely to be depressed

The good news is that 16 million more Americans should be getting access to Medicaid as part of the Affordable Care Act.  There are, of course, two pieces of bad news.  Many states are chopping their current Medicaid programs, decreasing both eligibility and provider reimbursement.  Further, states are trying to wriggle out of their previous promises to expand Medicaid eligibility. Finally, many optimists thought that having more people insured would lower medical costs – reasoning  that people could get treated early preventing high costs from detection of late stage disease.   The Oregon natural experiment is short – so it’s possible that this will become evident in the future. It’s unlikely though.   

Access to health insurance improves health and decreases financial stress.  It doesn’t save money. 

Friday, July 8, 2011

A Conservative Judge Finally Gets Health Reform Right

Judge Jeffrey Sutton's finding on the health insurance mandate in the U.S. Court of Appeals (Sixth Circuit) gives hope that the right wing is not totally bonkers.

Before readers flame me for questioning Tea Party theology, here's what David Brooks, the conservative New York Times columnist, wrote about Republicans on Tuesday with regard to the debt ceiling "debate":
...the Republican Party may no longer be a normal party. Over the past few years, it has been infected by a faction that is more of a psychological protest than a practical, governing alternative.

The members of this movement do not accept the logic of compromise, no matter how sweet the terms. If you ask them to raise taxes by an inch in order to cut government by a foot, they will say no. If you ask them to raise taxes by an inch to cut government by a yard, they will still say no.

The members of this movement do not accept the legitimacy of scholars and intellectual authorities. A thousand impartial experts may tell them that a default on the debt would have calamitous effects, far worse than raising tax revenues a bit. But the members of this movement refuse to believe it...
Judge Sutton's conservative credentials are impeccable! He clerked for Justice Scalia in 1991-1992. He was nominated to the court by George W. Bush and confirmed after a contentious debate by a 52-41 Senate vote. His well-reasoned, well-written decision has set conservative ideologues on their heels.

Judge Sutton's reasoning won't surprise anyone who understands the health system. He concludes that health insurance is a national enterprise, appropriately subjected to the Commerce Clause. He further concludes that to expand access while maintaining a market-based approach to insurance, the mandate is required - otherwise we'd all wait until we needed care and only then start paying our premiums. .

Here's how Judge Sutton structures the analysis:
the [mandate] provision regulates economic activity that Congress had a rational basis to believe has substantial effects on interstate commerce. In addition, Congress had a rational basis to believe that the provision was essential to its larger economic scheme reforming the interstate markets in health care and health insurance...our task is to determine whether self-insuring for the cost of health care services is an economic activity, and whether Congress had a rational basis to conclude that, in the aggregate, this activity substantially affects interstate commerce.
He concludes, obviously correctly, that Congress did indeed have a rational basis, consistent with the Constitution and established law, for its conclusion.

And with regard to Tea Party fury at being penalized for the "inaction" of not buying insurance, the Judge, in effect, agrees with David Brooks that the outrage is a psychological symptom, not a rational argument:
...the constitutionality of the minimum coverage provision cannot be resolved with a myopic focus on a malleable label. The vast majority of individuals are active in the market for health care delivery because of two unique characteristics of this market: (1) virtually everyone requires health care services at some unpredictable point; and (2) individuals receive health care services regardless of ability to pay.

...Call this mandate what you will—an affront to individual autonomy or an imperative of national health care—it meets the requirement of regulating activities that substantially affect interstate commerce...No one is inactive when deciding how to pay for health care, as self-insurance and private insurance are two forms of action for addressing the same risk. Each requires affirmative choices; one is no less active than the other; and both affect commerce.
It's very important that Judge Sutton clearly empathizes with the libertarian component of American values. He's writing as a good conservative, not a liberal egghead, and he doesn't like the mandate. But he makes clear that not liking it, even being offended by it, doesn't make it Constitutional invalid:
That brings me to the lingering intuition—shared by most Americans, I suspect—that Congress should not be able to compel citizens to buy products they do not want. If Congress can require Americans to buy medical insurance today, what of tomorrow? Could it compel individuals to buy health care itself in the form of an annual check-up or for that matter a health-club membership?... And if Congress can do this in the healthcare field, what of other fields of commerce and other products?

These are good questions, but there are some answers. In most respects, a mandate to purchase health insurance does not parallel these other settings or markets. Regulating how citizens pay for what they already receive (health care), never quite know when they will need, and in the case of severe illnesses or emergencies generally generally will not be able to afford, has few (if any) parallels in modern life. Not every intrusive law is an unconstitutionally intrusive law. And even the most powerful intuition about the meaning of the Constitution must be matched with a textual and enforceable theory of constitutional limits, and the activity/inactivity dichotomy does not work with respect to health insurance in many settings, if any of them. (emphasis added)
Judge Sutton's opinion supports David Brooks's distinction between rational, admirable conservatism and irrational, often pathological, Tea Party ideology. He places his faith in facts and time, not ideological passion. Hats off to the judge for bringing sanity and thoughtfulness into the health reform debate:
Time assuredly will bring to light the policy strengths and weaknesses of using the individual mandate as part of this national legislation, allowing the peoples’ political representatives, rather than their judges, to have the primary say over its utility.

Wednesday, July 6, 2011

CMS 2012 Draft Payment Rules: Automatic Triggers Cause Huge MD Fee Cut

Today’s Managing Health Care Costs Indicator is $330 billion

The Centers for Medicare and Medicaid Services issued its draft 2012 payment rules yesterday. The  payment rules give modest increases to ambulatory facility fees, tie ambulatory surgery fees to quality reporting, and make some much-needed changes in imaging reimbursement.  

The headline is that these draft payment rules cut physician fees by almost a third, as required by the sustainable growth rate formula.   This is the automatic trigger that has been overridden by Congress every year (or more) since 2002.   Just about no one thinks this is a good idea.  Physician payment increases in Medicare have been substantially less than those offered by other payers, and in some communities it's hard to find a physician taking new Medicare patients.  

Click to Enlarge  Ginsburg, New England Journal 12/10 

The cost of physician services keeps on going up, and no efforts to lower utilization have worked - so the blunt instrument of threatened massive payment cuts continues to hang over physicians' heads.  The 10 year cost of eliminating the SGR payment cuts would be $330 billion.  

There's a lot of talk in Washington about establishing automatic triggers to prevent the government from overspending.   The SGR is an example of such an automatic trigger that has been in place for some time, through Democratic and Republican administrations and Congressional majorities.   We've proven in health care already that these triggers only work if they make sense and there is enormous political will to support them.  A singular problem with the SGR is that cutting physician unit payments is not an especially effective way to lower overall health care costs.

There has been an enormous amount of lobbying to reverse these cuts over the past decade.  We should expect a similar response to future cuts in government spending triggered automatically, especially those that don't make political or economic sense.

The Awful Dichotomy Between Health Care Politics and Policy

Amy Goldstein has an important article in today’s Washington Post detailing the place Don Berwick, the Medicare and Medicaid administrator, finds himself in.It is all but certain he will have to leave his post at year’s end, when his recess appointment expires, because the Senate will not confirm him for a lack of Republican support.Berwick is one of the most respected health care experts in the

Tuesday, July 5, 2011

Screening CTs for Lung Cancer

Today’s Managing Health Care Cost Indicator is $674,000

Last week’s New England Journal of Medicine  reported a landmark study showing that screening low-dose CT scans really can save lives in people at high risk for lung cancer. 

The study is unequivocal – those who got screening CT scans were substantially less likely to die of lung cancer. Further, all-cause mortality was lower – even though a few people with CT scan screening died of exploratory surgery when they were found not to have cancer.

This study enrolled only smokers or ex-smokers with at least 30 pack years of smoking history, and excluded those who had signs or symptoms of cancer already, such as weight loss or coughing up blood.   It was peformed by the National Cancer Institute, and did not have funding from either companies that manufacture scanners or from tobacco companies.

The authors don’t recommend that all smokers and ex-smokers start getting annual CT scans.   Even with low dose scans, some cases of cancer are likely to result from massive screening – especially breast cancer in women. 

The level of “false positives,” abnormal CT scans that did not represent lung cancer, was stunningly high.  Over a quarter of study participants were found to have a scan suspicious for cancer in years one and two, and almost one in six in year three.  Only 1 in 20 abnormal CT scans suspicious of cancer actually showed a cancer. The control group received annual chest radiographs, and the CT scan group had a total of 119 excess cancers found – out of  18,146 suspiciously abnormal scans over the three year screening cycle.  That’s an increased case finding rate of 0.66% for the CT group compared to the radiography group.

Here’s the big public policy problem.   This study included 3 CT scans (at annual intervals) for just under 27,000 patients. At $1000 per scan, that would be a cost of over $80 million for the scans alone.  The cost of workup of all those false positives was substantially more.    The cost of just scans per incremental cancer found would have been $673, 664! ($80 million divided by 119) 

This study shows clearly why screening is unlikely to save dollars in the health care system.  The study took a group of high risk individuals – and even in this group, the false positive rate was quite high, and the cost per additional case found was very high.   

From a public policy perspective, we have to either
1)     Get scans that cost $100, rather than $1000.  We’ll need major disruptive innovation to allow that.
2)     Develop a more specific screening test, without losing sensitivity – so there won’t be 19 false positives for every true positive
3)     Develop less invasive followup tests to minimize the cost of pursuing the many abnormal tests

Of course, the best approach is to continue to levy high taxes on cigarettes, reinvigorate counter-marketing, and make cigarettes difficult for teenagers to obtain.  

Screening for lung cancer is not nearly as good as preventing lung cancer – and screening is far, far more expensive.