The elephant in the living room is what we’re trying to do is the small physician practice. That’s the hardest part, and it will bring this effort to its knees if we fail.
David Brailer, MD, February 15, 2005, as quoted in The New York Times by Steve Lohr, “Health Industry under Pressure to Computerize”
Our health care system is as huge and cumbersome as an elephant, and all the players — like the blind men in the story — see the elephant differently. Doctors holding the tail perceive the system as constraining as a rope, purchasers touching the leg find it as immovable as a tree, and plans holding the trunk see it as devious and unmanageable as a snake.
We're blind to the system's true shape, and what we can't see is killing us. It's also crushing us financially, but we can't move it — can't fix it — until we can see it. The system is opaque, abstruse, variable, incredibly complex, and weirdly fragmented. Its very nature makes vision of the whole impossible, say experts.
Martin Sipkoff, “Can Transparency Save Health Care? “Managed Care Magazine, 2004
Just over two years ago, David Brailer, MD, then national health information coordinator for the U.S. Department of Health and Human Services, commented small practices were the “The Elephant in the Room.”
He meant that unless small practices adopted electronic health records, the government’s plan to establish an interoperable computer system linking all U.S. health system components might fail.
At the time Brailer made his remarks, among groups of 50 or more physicians, two thirds (68%) had adopted electronic health records. For groups of five or fewer, only 12% had EHRs, and among solo doctors or doctors in groups of two, only 1% had such records. Yet these small groups of five or less made up half of practicing physicians in the U.S.
Past and Present
I was reflecting back on the “Elephant in the Room” when I ran across this paragraph in the “In Brief” section of the March 19, 2007, issue of the American Medical News.
A survey by the consulting giant Accenture finds that two-thirds of patients say the use of electronic medical records is an important factor in choosing a physician – and half say they would pay a “reasonable” extra fee to see a physician who uses them. Meanwhile the same survey found 11% of physicians using EMRs. Accenture surveyed 600 patients and 100 doctors.
Apparently, independent patients and independent doctors don’t always see eye-to- eye.
Independent Patients
Meanwhile I came upon this paragraph in the March 15 Online Wall Street Journal in article bearing the title “Many Americans Disregard Doctors’ Course of Treatment”.
A quarter of America’s patients have a drug prescription unfilled because they felt it was unneeded and a fifth obtained a second opinion because they felt their doctors recommendations were too aggressive
The Wall Street Journal piece brought to mind to report by the Boston Consulting Group in 2003 Finding a Cure for Unfilled Prescriptions and Missed Drugs.
Briefly that report indicated 33% of patients took drugs less often than prescribed, 25% said they delayed taking the drug, 20% stopped taking the drug because of perceived side-effects, 17% said the drugs were too costly, and 14% believed they didn’t need the drug,
They viewed themselves, not their doctor, as the ultimate judge of what drugs they need. Fully 24% said “forgetfulness” had nothing to do with their failing to comply (italics mine). Apparently independent patients felt perfectly capable of making judgments about their own care, regardless of what their doctors said.
In the same time frame, a March 16 piece of mine (not to be confused with piece of mind) appeared in Healthleadersmedia.com news, "Pay for Performance and Quality Outcomes: Buzz, Metrics, and Human Nature." I said patients often act independently when outside the doctors immediate sphere of influence. Consequently, I reasoned, pay for performance for clinical outcomes in the outpatient arena wasn’t likely to cut costs or improve long term outcomes. Americans’ penchant for individualism and deciding for themselves what was best for their health isn’t necessarily good for their health.
Dispersed Care by Multiple Practitioners
Meanwhile, the March 15 edition of New England Journal of Medicine contained an article “Care Patterns in Medicare and Their Implications for Pay for Performance” by a group from the Center for Studying Health Care Change in Washington, D.C,, and an editorial “Paying for Care Episodes and Care Coordination” by Karen Davis, PhD, head of the Commonwealth Fund in New York City.
Here are the results and conclusions the group from the Center for Studying Health Care Change reached after studying 1.79 million fee-for-service Medicare beneficiaries.
Results: Beneficiaries saw a median of two primary care physicians and five specialists working in four different practices. A median of 35% of beneficiaries' visits each year were with their assigned physicians; for 33% of beneficiaries, the assigned physician changed from one year to another. On the basis of all visits to any physician, a primary care physician's assigned patients accounted for a median of 39% of the physician's Medicare patients and 62% of Medicare visits. For medical specialists, the respective percentages were 6% and 10%. On the basis of visits to primary care physicians only, 79% of beneficiaries could be assigned to a physician, and a median of 31% of beneficiaries' visits were with that assigned primary care physician.
Conclusions: In fee-for-service Medicare, the dispersion of patients' care among multiple physicians will limit the effectiveness of pay-for-performance initiatives that rely on a single retrospective method of assigning responsibility for patient care.
An Elephant Poem
These results and conclusions, showing that patients, acting independently, often chose multiple physicians from whom to receive care, led me to look up the poem by John Saxe (1816-1887) on an Indian legend of six blind men who felt different parts of an elephant’s anatomy.
I‘ve modified the poem for this essay’s purposes. Think of the six blind men as various health system fix-it gurus, each in their own way seeking Nirvana, and the elephant as a conglomeration of interacting independent doctors in small fee-for-service practices and their independent patients, the combined mass of which comprise our health system’s bulk.
The Six Blind Men of Nirvanastan and the Health Care Elephant
There was six men of Nirvanastan
To learning much inclined,
Who went to see the Elephant
(Though all of them were blind),
That each by observation
Might satisfy his mind.
The First, A Universal Coverage Sage,
approach'd the Elephant
And happening to fall
Against his broad and sturdy side,
At once began to bawl:
"God bless me! but the Elephant
Is very like a wall!"
“The sage roared, it’s clear what all we need to do.
It’s my comprehensive compassionate moral view,
That we put all inside and behind a common wall,
For this, everyone will be held in absolute thrall.”
The Second, A Market-Medicine Man,
feeling of the tusk,
Cried, -"Ho! what have we here
So very round and smooth and sharp?
To me 'tis mighty clear,
This wonder of an elephant
Is very like a spear!"
“It’s obvious to me what must be done,
Make all patients consumers to be won,
When they seek lower prices at the spear of care.
Price shopping will make care fair and square.”
The Third, An Ivory Tower Elitist,
approach'd the animal,
And happening to take
The squirming trunk within his hands,
Thus boldly up and spake:
"I see," -quoth he- "the Elephant
Is very like a snake!"
“Hence, spake the elitist, we must end greed,
It’s clear government price controls we need,
All physicians are nothing but slithering snakes,
We simply must control the money each makes.”
The Fourth, A Consummate Capitalist,
reached out an eager hand,
And felt about the knee:
"What most this wondrous beast is like
Is mighty plain," -quoth he,-
"'Tis clear enough the Elephant
Is very like a tree!"
“Consider this huge tree’s branching side,
Health care’s an economic engine we must ride,
It accounts for one-fifth of our huge economy,
Let patients and doctors have their autonomy.”
The Fifth, A Savvy Systems Savant,
who chanced to touch the ear,
Said- "E'en the blindest man
Can tell what this resembles most;
Deny the fact who can,
This marvel of an Elephant
Is very like a fan!"
“Said he, simply fan out and apply statistics,
Manage, measure, and do the basic heuristics,
It comes down to total systems engineering.
Which will make variables go disappearing.”
The Sixth, A Practicing Pragmatist,
no sooner had begun
About the beast to grope,
Then, seizing on the swinging tail
That fell within his scope,
"I see," -quoth he,- "the Elephant
Is very like a rope!"
“Look, stop thinking in terms of some overall system,
Requiring patients and their doctors to act in tandem.
As individualists, give each of them some rope,
Each by themselves in their own way will cope.”
And so these men of Nirvanastan
Disputed loud and long,
Each in his own opinion
Exceeding stiff and strong,
Though each was partly in the right,
And all were in the wrong!
So, oft in philosophic wars
The disputants, I ween,
Rail on in utter ignorance
Of what each other mean;
And prate about an Elephant
Not one of them has seen!
Concluding Remarks
Many management and policy experts purporting to have answers to U.S. health system woes have never been inside a busy solo or small practice primary physician’s office for a day. Nor have many ventured inside the minds of independent American consumers who frequent small practices.
Consumers want the best of all possible worlds – a close personal relationship with their doctor, access to the latest in life-saving and function-restoring technologies, individual freedom with unlimited choice, high value, and low prices; and financial security – a wonderful combination in Nirvana. Physicians, by and large, want the freedom to make their own clinical judgements based on their knowledge of the patietn.
Blind experts feeling different parts of the elephant tend to think they can manage and coordinate various parts of system into one coordinated, functioning, interrelated elephantine whole.
These experts talk of imposing outside solutions, varying from: universal government-run coverage, across-the-board pay for performance, herding hordes of physicians out of fee-for-service into salaried employment inside integrated health systems, coordinating care by using patient health records and electronic health records, lumping all individual payments into bundled payments for episodes of care, assigning all patients to one single primary care quarterback, shifting costs to consumers so they will take responsibility for health and shop for the best care in one huge health care marketplace; and, of course, achieving the Mother of Nirvana Dreams – total transparency.
These management and policy experts are each partly right and partly wrong, but they often neglect patient behavioral and choice sides of the patient-doctor equation, and desire of patients to be ultimate and independent judges of their own medical care – drugs they will take, physicians they will see, and personal functional outcomes they seek.
These purblind pundits may also overestimate the power of economic incentives compelling independent doctors to join virtual or centralized integrated systems for the common and organizational good.
I don’t mean to rain on the parade of these well-intentioned experts. Many of their ideas work well under the right circumstances in certain organizations and in certain parts of this vast continental nation. But, short of massive protests in the streets filled with righteous indignation over the 47 million uninsured, or a natural disaster, a World War, or a global recession, I doubt if universal coverage, and its stepchild, or universal coordination will come soon.
Desire for independence, choice, and personal self-regulation are powerful ingredients in America’s cultural soul. Even in the face of oft-heard protests that the “system” is “broken” and needs to be “fixed,” most Americans seem to prefer a multi-payer pluralistic system – a system allowing individualism and choice among various participants.
For the near future, I expect America to continue to have a blended mix of federal, public, and private subsystems – each with its special demands, each requiring different skills and management, and each having different elephants in examining rooms.
Tuesday, March 20, 2007
Clinical innovations - Ed Roberts, MD, The Doctor Who Gave Bill Gates III His Start
It was the Altair 8800, on the January 1975 cover of Popular Electronics, that really set off the (personal computer) boom. A company called MITS, in Albuquerque, sold the Altair for $395 as a kit and $495 assembled. Within three months 4,000 people had ordered it.
Landmarks in Digital Computing: A Smithsonian Pictorial History, 2007
I see by the March 8, 2007 Forbes Magazine that Bill Gates III, 52, founder of Microsoft, is the world’s man for the seventh year in a row with a net worth of $56 billion.
Contrast this with the economic lot of Ed Roberts, MD, a 65 year old solo internist in Cochran, Georgia, who is struggling to keep his practice going because of low Medicare and Medicaid reimbursements.
Cochran is a rural community with a population of 4,455 – 55% white and 42% black-- with a high rate of Medicare and Medicaid patients and a below average annual income of $24,000. Cochran is 120 miles southwest of Atlanta and 37 miles from Macon.
Robert’s financial situation is ironic because he's the person who gave Bill Gates his start in 1975. Roberts, then an electrical engineer, developed one of the first personal computers, the Altair 8800, which was the prototype that Bill Gates and his fellow Harvard drop-out, Paul Allen, 54, now #19 on the list of the world’s top billionaires with a net worth of $18 billion, adopted to start the Microsoft empire.
The economic contrast between these two billionaires and Dr. Roberts reminds me of a personal experience. Several years back, I was invited to give a talk in Seattle. I was told by a struggling Seattle primary care physician that Microsoft employees were driving German and Japanese luxary cars, while the doctors were driving American economy cars.
You’d think Roberts' medical office would be filled with computers, the latest medical software, digital assistants and other hightech gadgets. After all, 32 years ago, Roberts helped develop one of the world's first personal computers, the Alstair 8800. Roberts turned medical doctor in 1986, the year he graduated from Mercer University Medical School in 1986. He did his internal medicine residency there. He ended up in Cochran, where, he observes, "I wanted to make a difference."
The truth is Roberts now spends very little time working with computers. That's because time is precious for this doctor who says he's too busy to devote much time to computers. He records patient records on a computer, but beyond that doesn’t fuss much with computers and doesn’t have any fancy electronic health record system.
And he says he's not convinced that existing software with its awkward, often irrelevant, features will make his practice operate more efficiently.
"One of the mistakes being made right now is that software is being written with the idea that everything has to be on the computer." Roberts says. "You don't work that way, you are not taught to think that way, and it is a cumbersome way to go."
Such comments may be common for physicians reluctant to dive into the digital age. But for a man whose expertise spans the sciences of both electronics and medicine, it comes as a surprise.
The Road Roberts Traveled
Today, Roberts, 65, is an internist serving Cochrane, Georgia., a small rural town. That's a long way from where he was in the late 1960s and early 1970s working as an electrical engineer in Albuquerque, New Mexixo.
Assigned to a weapons lab with the U.S. Air Force after he graduated college at Oklahoma State University, Roberts was in Albuquerque when he formed his first company, Micro Instrumentation Telementry Systems (MITS).
"We built telemetry equipment for rockets. That was in 1968 and 1969. We didn't do too well because there was not much demand for our product, but we learned a lot about setting up a company and marketing," Roberts recalls.
"By that time, the large scale and medium scale integrated circuits were becoming available. And I became intrigued about building a calculator. But my partners said there was no market for home calculators, so we parted company and I bought them out. Before I got into the calculator business, large-scale integrated circuits became available. And I built the first large-scale calculator for the market."
Known as the MH 16 Calculator, it wasn't anything like the slim, pocket-sized calculators available today. It was about as big as a sheet of paper and sold as a kit for about $170.
From the calculator, sprang for the idea of creating a home computer. So Roberts and his company developed the Altair 8800, a breadbox-sized contraption that also sold in a kit and was one of the first computers designed for personal use.
An article on the Altair 8800 appeared in Popular Electronics magazine in January 1975.
"Project Breakthrough!" read the magazine cover's bold red headline. "World's First Minicomputer Kit to Rival Commercial Models ... 'Altair 8800"'
Overwhelming Response
The response was overwhelming. Computer buffs began calling MITS to find out more about the computer and how it worked. One call came from two Harvard undergraduates who saw the article and got excited: Bill Gates and Paul Allen.
"We were getting ten calls a day from other software people, as well. It became difficult to distinguish. who was real and who wasn't," Roberts recalls. At the time, the company was searching for programs and software to run on the Altair 8800.
"I made the decision that the software had to be in BASIC programming language. And the first person to show up in Albuquerque with a workable BASIC program would have the contract," Roberts says. "There were probably thirty or forty people who were candidates. Paul Allen called and said he had a system he wanted to demo. That was the spring of 1975."
Allen quickly arrived in New Mexico, ready to show off his BASIC software to Roberts and the MITS staff.
"I picked him up at the airport. He was maybe 21. I took him to the hotel in Albuquerque, and he said he didn't have any money to pay the hotel bill so I gave him my credit card so he could stay in the hotel that night," Roberts says.
"The next day, we loaded up his software, but then it crashed. Paul knew what the problem was, so he called Bill (Gates) and they cut a new tape. They sent it out airfreight, and we loaded it and it played. It had a lot of bugs in it, but for a brand new piece of software that had been developed without ever seeing the Altair, it worked, and I was impressed.
"What those guys had done, instead of the usual approach, which was brute force design of software, they had taken the time to design an emulator.
...They had the power to simulate the Altair system. That's the standard way things are done now, but it was unprecedented then, and that was the genius of what they did."
Roberts liked what he saw with Allen and Gates, so they set up shop at MITS and wrote the BASIC programming for the Altair.
What's Roberts' view of Gates, the multi-billionaire who heads Microsoft today?
"Bill is an extremely bright guy, but as far as his technical ability, he isn't unique and that's not why he is where he is," Roberts says. "He has enormous business skills. He has a genius for business, and he would not like to admit this, but luck was a big part of his great success.
To his credit, Roberts displays no resentment or jealousy of Gates’ and Allen’s financial success. “I still touch base with them from time to time,” he says. Roberts is philosophical. He muses, “They saw what they had to do, and they did it.” Which sounds a bit like the Chinese proverb, “To know and not to do is not to know.” Or it smakes of that quote from Napolean Hill in his 1937 motivational classic, Think and Grow Rich! “What the mind can conceive and believe in, the mind can achieve.”
Two Morals Followed by Two Questions
This tale has two morals:
1) Fortunes go to those who sell the world, not to those who concieve the first idea or who develop the first product. The reality is that it takes business smarts and a management team to market an innovative concept to a wider world.
2) Life isn’t necessarily fair for primary care physicians who work in the clinical trenches in rural regions seeing 30 or more Medicare and Medicaid or uninsured patients each day in low income populations.
A 2006 Merritt Hawkins and Associates survey of 285 medical graduating medical residents indicated none (0%) would choose to practice in a community of 10,000 or less.
The two questions are:
Who will replace the Dr. Ed Roberts of rural America?
Who will care for the rural sick?
Landmarks in Digital Computing: A Smithsonian Pictorial History, 2007
I see by the March 8, 2007 Forbes Magazine that Bill Gates III, 52, founder of Microsoft, is the world’s man for the seventh year in a row with a net worth of $56 billion.
Contrast this with the economic lot of Ed Roberts, MD, a 65 year old solo internist in Cochran, Georgia, who is struggling to keep his practice going because of low Medicare and Medicaid reimbursements.
Cochran is a rural community with a population of 4,455 – 55% white and 42% black-- with a high rate of Medicare and Medicaid patients and a below average annual income of $24,000. Cochran is 120 miles southwest of Atlanta and 37 miles from Macon.
Robert’s financial situation is ironic because he's the person who gave Bill Gates his start in 1975. Roberts, then an electrical engineer, developed one of the first personal computers, the Altair 8800, which was the prototype that Bill Gates and his fellow Harvard drop-out, Paul Allen, 54, now #19 on the list of the world’s top billionaires with a net worth of $18 billion, adopted to start the Microsoft empire.
The economic contrast between these two billionaires and Dr. Roberts reminds me of a personal experience. Several years back, I was invited to give a talk in Seattle. I was told by a struggling Seattle primary care physician that Microsoft employees were driving German and Japanese luxary cars, while the doctors were driving American economy cars.
You’d think Roberts' medical office would be filled with computers, the latest medical software, digital assistants and other hightech gadgets. After all, 32 years ago, Roberts helped develop one of the world's first personal computers, the Alstair 8800. Roberts turned medical doctor in 1986, the year he graduated from Mercer University Medical School in 1986. He did his internal medicine residency there. He ended up in Cochran, where, he observes, "I wanted to make a difference."
The truth is Roberts now spends very little time working with computers. That's because time is precious for this doctor who says he's too busy to devote much time to computers. He records patient records on a computer, but beyond that doesn’t fuss much with computers and doesn’t have any fancy electronic health record system.
And he says he's not convinced that existing software with its awkward, often irrelevant, features will make his practice operate more efficiently.
"One of the mistakes being made right now is that software is being written with the idea that everything has to be on the computer." Roberts says. "You don't work that way, you are not taught to think that way, and it is a cumbersome way to go."
Such comments may be common for physicians reluctant to dive into the digital age. But for a man whose expertise spans the sciences of both electronics and medicine, it comes as a surprise.
The Road Roberts Traveled
Today, Roberts, 65, is an internist serving Cochrane, Georgia., a small rural town. That's a long way from where he was in the late 1960s and early 1970s working as an electrical engineer in Albuquerque, New Mexixo.
Assigned to a weapons lab with the U.S. Air Force after he graduated college at Oklahoma State University, Roberts was in Albuquerque when he formed his first company, Micro Instrumentation Telementry Systems (MITS).
"We built telemetry equipment for rockets. That was in 1968 and 1969. We didn't do too well because there was not much demand for our product, but we learned a lot about setting up a company and marketing," Roberts recalls.
"By that time, the large scale and medium scale integrated circuits were becoming available. And I became intrigued about building a calculator. But my partners said there was no market for home calculators, so we parted company and I bought them out. Before I got into the calculator business, large-scale integrated circuits became available. And I built the first large-scale calculator for the market."
Known as the MH 16 Calculator, it wasn't anything like the slim, pocket-sized calculators available today. It was about as big as a sheet of paper and sold as a kit for about $170.
From the calculator, sprang for the idea of creating a home computer. So Roberts and his company developed the Altair 8800, a breadbox-sized contraption that also sold in a kit and was one of the first computers designed for personal use.
An article on the Altair 8800 appeared in Popular Electronics magazine in January 1975.
"Project Breakthrough!" read the magazine cover's bold red headline. "World's First Minicomputer Kit to Rival Commercial Models ... 'Altair 8800"'
Overwhelming Response
The response was overwhelming. Computer buffs began calling MITS to find out more about the computer and how it worked. One call came from two Harvard undergraduates who saw the article and got excited: Bill Gates and Paul Allen.
"We were getting ten calls a day from other software people, as well. It became difficult to distinguish. who was real and who wasn't," Roberts recalls. At the time, the company was searching for programs and software to run on the Altair 8800.
"I made the decision that the software had to be in BASIC programming language. And the first person to show up in Albuquerque with a workable BASIC program would have the contract," Roberts says. "There were probably thirty or forty people who were candidates. Paul Allen called and said he had a system he wanted to demo. That was the spring of 1975."
Allen quickly arrived in New Mexico, ready to show off his BASIC software to Roberts and the MITS staff.
"I picked him up at the airport. He was maybe 21. I took him to the hotel in Albuquerque, and he said he didn't have any money to pay the hotel bill so I gave him my credit card so he could stay in the hotel that night," Roberts says.
"The next day, we loaded up his software, but then it crashed. Paul knew what the problem was, so he called Bill (Gates) and they cut a new tape. They sent it out airfreight, and we loaded it and it played. It had a lot of bugs in it, but for a brand new piece of software that had been developed without ever seeing the Altair, it worked, and I was impressed.
"What those guys had done, instead of the usual approach, which was brute force design of software, they had taken the time to design an emulator.
...They had the power to simulate the Altair system. That's the standard way things are done now, but it was unprecedented then, and that was the genius of what they did."
Roberts liked what he saw with Allen and Gates, so they set up shop at MITS and wrote the BASIC programming for the Altair.
What's Roberts' view of Gates, the multi-billionaire who heads Microsoft today?
"Bill is an extremely bright guy, but as far as his technical ability, he isn't unique and that's not why he is where he is," Roberts says. "He has enormous business skills. He has a genius for business, and he would not like to admit this, but luck was a big part of his great success.
To his credit, Roberts displays no resentment or jealousy of Gates’ and Allen’s financial success. “I still touch base with them from time to time,” he says. Roberts is philosophical. He muses, “They saw what they had to do, and they did it.” Which sounds a bit like the Chinese proverb, “To know and not to do is not to know.” Or it smakes of that quote from Napolean Hill in his 1937 motivational classic, Think and Grow Rich! “What the mind can conceive and believe in, the mind can achieve.”
Two Morals Followed by Two Questions
This tale has two morals:
1) Fortunes go to those who sell the world, not to those who concieve the first idea or who develop the first product. The reality is that it takes business smarts and a management team to market an innovative concept to a wider world.
2) Life isn’t necessarily fair for primary care physicians who work in the clinical trenches in rural regions seeing 30 or more Medicare and Medicaid or uninsured patients each day in low income populations.
A 2006 Merritt Hawkins and Associates survey of 285 medical graduating medical residents indicated none (0%) would choose to practice in a community of 10,000 or less.
The two questions are:
Who will replace the Dr. Ed Roberts of rural America?
Who will care for the rural sick?
Monday, March 19, 2007
Doctor patient relationships - Who Should Health Care Consumer Trust?
Friedrich Hayek, 1974 Nobel Laureate in economics, won his prize by arguing self-organizing free-market capitalism is the best system for governing.
Centralized government agencies like Medicare, Hayek believed, simply didn’t and couldn’t know enough about patient-doctor relationships to regulate on the ground transactions. Attractive as centralized planning sounds on paper, and as seductive as it is for providing financial security, Hayek maintained government simply wouldn’t and couldn’t work in health care marketplaces. Hayek concluded a policy for freedom of individual patients and physicians “is the only truly progressive policy.”
Wall Street Journal OP-ED Article
Which brings me to Wall Street Journal OP-ED piece by Scott Gottlieb, MD, deputy commissioner of the FDA from 2005 to 2007, now a resident fellow at the American Enterprise Institute.
Gottlieb asserts government health agencies don’t trust doctors to choose the right drugs for their patients, or for that matter, for patients to decide what drugs are right for them (“Prescription for Trouble,” The Wall Street Journal, March 6, 2007).
Here are Gottlieb’s words:
Inside the federal agencies that oversee parts of the health-care system, there is a palpable view that doctors can no longer be trusted to do the right thing.
The Food and Drug Administration, Medicare and even the Justice Department all believe they cannot rely on many doctors to heed safety warnings, wisely weigh new medical information, or follow therapeutic approaches that maximize health benefits or lower health benefits.
Reflecting this pervasive distrust of medical practitioners, Medicare is increasingly tying payments to choices doctors make, compensating doctors more to follow certain cookie-cutter treatments or practice guidelines that are promoted by the agency because they are believed by government experts to maximize benefits and reduce health-care costs.
Who to Trust?
So who can you trust, your government or your doctor?
Here are your choices,
• Government experts holding forth in bureaucratic cathedrals in Washington, D.C., issuing position papers and perusing data output sheets, far removed from clinical medicine.
• Local medical practitioners seeing patients every day in the clinical trenches at ground zero.
• Some outside source, which can increasingly be found on the Internet
• Yourself.
Gottlieb’s Answer
Gottlieb’s answer is that Medicare treatment guidelines, issued from on high inside the Beltway, are not the right answer for everyone “because there is a need for judgment that attunes treatments to individual variations and preferences.”
Direct regulation will not, Gottlieb says, fix anything but will sacrifice medical autonomy and patient choices, a medical stew with so many permutations and combinations that no one, least of all government “experts,” know what’s going on or foresee consequences of regulating health consumer/doctor interactions. Gottlieb favors physician organizations, working in concert with government, to develop guidelines.
What to Do?
So what’s a health consumer to do?
In the first place, don’t dismiss government out of hand. Trust the government’s judgment on certain drugs with huge databases covering hundreds of thousands of patients. Government is more likely to pick up evidence of untoward effects of a few recently released drugs than a single doctor, seeing a mere handful of patients. Vioxx-induced heart attacks are an example. Another may be the latest FDA warning that erythropoietin, or Procrit, may cause heart attacks if given in too high a dose.
Still government can’t regulate every transaction or predict every complication in every patient, even if it issues thousands of regulations and guidelines in hundreds of manuals.
Personally I trust my doctor in most situations. I know him. He knows me. And he is doing the best he can under sometimes difficult circumstances, including government interventions into clinical situations for which it knows nothing but statistics. People may not be reflected in overall statistics; people are variable individuals. The live and die as individuals, not as statistics.
Go Directly to Revolutionhealth.com
Or you can proceed directly to revolutionhealth.com. Steve Case, who founded American Online, has moved on to found another company, the Revolution Health Group. He and his management team has assembled a group of expert specialists to answer your questions. Go to revolutionhealth.com, and its home page will come up. On the left hand side of that page, you will see a green box with the heading, ”How can we help you?” The box contains this list.
• Compare and rate doctors and hospitals
• Learn about a condition
• Discover tips to lead a healthier life
• Find drugs and treatment options
• Check a symptom
• Get support and exchange insights
• Learn about our membership programs
Click on “Get support and exchange insights,” and you can read blogs of specialists, or you can post a topic or question that personally concerns you. You can pick from 45 topics or questions arranged alphabetically, and, depending on which one you choose, you will be directed towards a specialist whose opinion you can trust.
In The End, Trust Yourself
In the end, trust may come down to trusting your own judgment. There are no easy answers. In other words, sometimes you must trust yourself rather than the government or your doctor.
• You can ask your doctor if you really need this drug, e.g. antibiotics for “bronchitis” or a viral disease.
• You can go to a website like healthgrades.com to check the credentials of your doctor (It will cost you $7.50).
• You can check around the community to see what neighbors and others think of your doctor.
• You can go to a respected health facility, or a group practice, within your community, which generally plays by the regulatory rules.
• You can go to google.com to see what the side effects of a drug are.
• You can take a list of your current medications to your local pharmacist to see if any potential drug interactions might be.
My Bias
My bias is towards a trusting personal relationship with your doctor. He or she is more likely to know your history, your condition, and your family than any faceless bureaucrat in Washington, even with the best of intentions and the best of statistics.
My bias is towards a open-ended partnership with your doctor, who is willing to answer your questions candidly and to direct you towards reliable Internet sources. My bias is towards autonomous physicians, rather than physician automatons blindly following Medicare guidelines.
In free-market capitalistic system like the United States, trust holds us all together. Trust makes a market-based system work. This trust is important in health care. For better or worse, we’re all in this together.
In the story of the hedgehog and the fox, the fox knows many things and hedgehog knows one thing. I’m a hedgehog. I believe in a free-market capitalistic society, trust lifts all boats. With the help of savvy consumers, leaks will be plugged. Government may pug some leaks, but not many, and it can’t plug all leaks. It’s too far removed from care sites and can’t foresee, much less manage, all variables.
Centralized government agencies like Medicare, Hayek believed, simply didn’t and couldn’t know enough about patient-doctor relationships to regulate on the ground transactions. Attractive as centralized planning sounds on paper, and as seductive as it is for providing financial security, Hayek maintained government simply wouldn’t and couldn’t work in health care marketplaces. Hayek concluded a policy for freedom of individual patients and physicians “is the only truly progressive policy.”
Wall Street Journal OP-ED Article
Which brings me to Wall Street Journal OP-ED piece by Scott Gottlieb, MD, deputy commissioner of the FDA from 2005 to 2007, now a resident fellow at the American Enterprise Institute.
Gottlieb asserts government health agencies don’t trust doctors to choose the right drugs for their patients, or for that matter, for patients to decide what drugs are right for them (“Prescription for Trouble,” The Wall Street Journal, March 6, 2007).
Here are Gottlieb’s words:
Inside the federal agencies that oversee parts of the health-care system, there is a palpable view that doctors can no longer be trusted to do the right thing.
The Food and Drug Administration, Medicare and even the Justice Department all believe they cannot rely on many doctors to heed safety warnings, wisely weigh new medical information, or follow therapeutic approaches that maximize health benefits or lower health benefits.
Reflecting this pervasive distrust of medical practitioners, Medicare is increasingly tying payments to choices doctors make, compensating doctors more to follow certain cookie-cutter treatments or practice guidelines that are promoted by the agency because they are believed by government experts to maximize benefits and reduce health-care costs.
Who to Trust?
So who can you trust, your government or your doctor?
Here are your choices,
• Government experts holding forth in bureaucratic cathedrals in Washington, D.C., issuing position papers and perusing data output sheets, far removed from clinical medicine.
• Local medical practitioners seeing patients every day in the clinical trenches at ground zero.
• Some outside source, which can increasingly be found on the Internet
• Yourself.
Gottlieb’s Answer
Gottlieb’s answer is that Medicare treatment guidelines, issued from on high inside the Beltway, are not the right answer for everyone “because there is a need for judgment that attunes treatments to individual variations and preferences.”
Direct regulation will not, Gottlieb says, fix anything but will sacrifice medical autonomy and patient choices, a medical stew with so many permutations and combinations that no one, least of all government “experts,” know what’s going on or foresee consequences of regulating health consumer/doctor interactions. Gottlieb favors physician organizations, working in concert with government, to develop guidelines.
What to Do?
So what’s a health consumer to do?
In the first place, don’t dismiss government out of hand. Trust the government’s judgment on certain drugs with huge databases covering hundreds of thousands of patients. Government is more likely to pick up evidence of untoward effects of a few recently released drugs than a single doctor, seeing a mere handful of patients. Vioxx-induced heart attacks are an example. Another may be the latest FDA warning that erythropoietin, or Procrit, may cause heart attacks if given in too high a dose.
Still government can’t regulate every transaction or predict every complication in every patient, even if it issues thousands of regulations and guidelines in hundreds of manuals.
Personally I trust my doctor in most situations. I know him. He knows me. And he is doing the best he can under sometimes difficult circumstances, including government interventions into clinical situations for which it knows nothing but statistics. People may not be reflected in overall statistics; people are variable individuals. The live and die as individuals, not as statistics.
Go Directly to Revolutionhealth.com
Or you can proceed directly to revolutionhealth.com. Steve Case, who founded American Online, has moved on to found another company, the Revolution Health Group. He and his management team has assembled a group of expert specialists to answer your questions. Go to revolutionhealth.com, and its home page will come up. On the left hand side of that page, you will see a green box with the heading, ”How can we help you?” The box contains this list.
• Compare and rate doctors and hospitals
• Learn about a condition
• Discover tips to lead a healthier life
• Find drugs and treatment options
• Check a symptom
• Get support and exchange insights
• Learn about our membership programs
Click on “Get support and exchange insights,” and you can read blogs of specialists, or you can post a topic or question that personally concerns you. You can pick from 45 topics or questions arranged alphabetically, and, depending on which one you choose, you will be directed towards a specialist whose opinion you can trust.
In The End, Trust Yourself
In the end, trust may come down to trusting your own judgment. There are no easy answers. In other words, sometimes you must trust yourself rather than the government or your doctor.
• You can ask your doctor if you really need this drug, e.g. antibiotics for “bronchitis” or a viral disease.
• You can go to a website like healthgrades.com to check the credentials of your doctor (It will cost you $7.50).
• You can check around the community to see what neighbors and others think of your doctor.
• You can go to a respected health facility, or a group practice, within your community, which generally plays by the regulatory rules.
• You can go to google.com to see what the side effects of a drug are.
• You can take a list of your current medications to your local pharmacist to see if any potential drug interactions might be.
My Bias
My bias is towards a trusting personal relationship with your doctor. He or she is more likely to know your history, your condition, and your family than any faceless bureaucrat in Washington, even with the best of intentions and the best of statistics.
My bias is towards a open-ended partnership with your doctor, who is willing to answer your questions candidly and to direct you towards reliable Internet sources. My bias is towards autonomous physicians, rather than physician automatons blindly following Medicare guidelines.
In free-market capitalistic system like the United States, trust holds us all together. Trust makes a market-based system work. This trust is important in health care. For better or worse, we’re all in this together.
In the story of the hedgehog and the fox, the fox knows many things and hedgehog knows one thing. I’m a hedgehog. I believe in a free-market capitalistic society, trust lifts all boats. With the help of savvy consumers, leaks will be plugged. Government may pug some leaks, but not many, and it can’t plug all leaks. It’s too far removed from care sites and can’t foresee, much less manage, all variables.
Sunday, March 18, 2007
Blogging, general -On Blogging and the Self Escaping into the Open
Early each morning I have a ritual.
• I enter my daily blog,
• check my email,
• down a cup of coffee,
• read the health care news in the Wall Street Journal and the New York Times, • turn to healthleadersmedia.com – the reigning queen of health news aggregation and analysis web sites.
On occasion, I visit the websites of two rival health news sites -- fiercehealthcare.com, “the healthcare industry’s daily monitor,” and AIShealth.com, “specialized business information for health care managers.”
Healthleadersmedia.com Site
Each week day the healthleaders site displays feature news stories. Today, March 16, I glom onto the site because my article “Pay for Performance and Quality Outcomes: Buzz, Metrics, and Human Nature” made its maiden appearance as the lead story. Bringing attention to my Healthleaders piece isn’t why I blog today. I blog because a Healthleaders newspaper story this day from The Detroit Free Press, dated March 14, is entitled “ Is Doctor Blogging Too Much of a Risk?”
Do Doctors Blog Too Much?
The Detroit Free Press news piece tells of doctors who may divulge too much about patients, including graphic and gruesome clinical details. Critics fear doctor bloggers may be breaking rules of confidentiality and tenets of HIPPA (Health Insurance Portability and Privacy Act)– that aptly named government generated bureaucratic hippopatmus designed to protect patient privacy.
No Blogging Ground Rules
The news story goes on to say no blogging ground rules exist for what’s acceptable. It quotes a neonatologist, now getting 800 hits a day after saying,
“I don’t mind it so much when a young single woman comes in with her first pregnancy because anyone can make a mistake. But when the young woman gets pregnant repeatedly, time after time, she degrades herself and her children, condemning herself and them to a life of dependency and irresponsibility.”
Offending Some, Pleasing Others
Although the neonatologist blogger didn’t reveal names or further clinical details, his message offended some, including secular progressives who believe anything and everything goes, and blogs are no place to cast moral judgments. Other observers said they saw no evidence doctor bloggers were breaking moral codes or violating HIPPA rules, or saying things out of school that should not be said.
One doctor-blogger-friendly soul commented,
“People forget doctors are people. There’s a tendency to think they’re either God or people who just want to shove pills down your throat. When you’re in their blogs, you see they’re real people. Also, in these blogs, comments are open. If you have a concern, you can easily leave a comment. It’s a wonderful way for patients to have access to doctors.”
Blogs as Springboards for Physician Creativity
Blogs are also great springboards for unleashing physician creativity – for revealing latent gut feelings about the real world behind those white coats. Physician blogs sometimes remind me of this passage from The Elements of Style by William Strunk and E.B. White (second edition, McMillan Publishing Company, 1972)
The mind travels faster than the pen. Consequently, writing becomes a question of learning to take occasional wing shots , bringing down the bird of thought as it flashes by. A writer is a gunner, sometimes waiting in his blind for something to come in, sometimes roaming the countryside to scare something up.”
That’s a good definition for medical blogging, in essence a form of health care gunning.
White proceeds to take this wing shot.
Every writer, by the way he uses the language, reveals something of his spirit, his habits, his capacities, his bias. This is inevitable as well as enjoyable. All writing is communication, creative writing is communication through revelation – it is the Self escaping out into the open. No writer can remain long incognito.
The Inevitable Concluding Verse
The last quote leads inevitably to this perverse verse:
There once was a prolific medical blogger named Al Frito,
Who tried methodically and doggedly to remain incognito.
He fought to conceal his inherent bias.
He sought to reveal himself as pious.
But try as he may, in his blog, his basic bias
he could not pocket veto.
• I enter my daily blog,
• check my email,
• down a cup of coffee,
• read the health care news in the Wall Street Journal and the New York Times, • turn to healthleadersmedia.com – the reigning queen of health news aggregation and analysis web sites.
On occasion, I visit the websites of two rival health news sites -- fiercehealthcare.com, “the healthcare industry’s daily monitor,” and AIShealth.com, “specialized business information for health care managers.”
Healthleadersmedia.com Site
Each week day the healthleaders site displays feature news stories. Today, March 16, I glom onto the site because my article “Pay for Performance and Quality Outcomes: Buzz, Metrics, and Human Nature” made its maiden appearance as the lead story. Bringing attention to my Healthleaders piece isn’t why I blog today. I blog because a Healthleaders newspaper story this day from The Detroit Free Press, dated March 14, is entitled “ Is Doctor Blogging Too Much of a Risk?”
Do Doctors Blog Too Much?
The Detroit Free Press news piece tells of doctors who may divulge too much about patients, including graphic and gruesome clinical details. Critics fear doctor bloggers may be breaking rules of confidentiality and tenets of HIPPA (Health Insurance Portability and Privacy Act)– that aptly named government generated bureaucratic hippopatmus designed to protect patient privacy.
No Blogging Ground Rules
The news story goes on to say no blogging ground rules exist for what’s acceptable. It quotes a neonatologist, now getting 800 hits a day after saying,
“I don’t mind it so much when a young single woman comes in with her first pregnancy because anyone can make a mistake. But when the young woman gets pregnant repeatedly, time after time, she degrades herself and her children, condemning herself and them to a life of dependency and irresponsibility.”
Offending Some, Pleasing Others
Although the neonatologist blogger didn’t reveal names or further clinical details, his message offended some, including secular progressives who believe anything and everything goes, and blogs are no place to cast moral judgments. Other observers said they saw no evidence doctor bloggers were breaking moral codes or violating HIPPA rules, or saying things out of school that should not be said.
One doctor-blogger-friendly soul commented,
“People forget doctors are people. There’s a tendency to think they’re either God or people who just want to shove pills down your throat. When you’re in their blogs, you see they’re real people. Also, in these blogs, comments are open. If you have a concern, you can easily leave a comment. It’s a wonderful way for patients to have access to doctors.”
Blogs as Springboards for Physician Creativity
Blogs are also great springboards for unleashing physician creativity – for revealing latent gut feelings about the real world behind those white coats. Physician blogs sometimes remind me of this passage from The Elements of Style by William Strunk and E.B. White (second edition, McMillan Publishing Company, 1972)
The mind travels faster than the pen. Consequently, writing becomes a question of learning to take occasional wing shots , bringing down the bird of thought as it flashes by. A writer is a gunner, sometimes waiting in his blind for something to come in, sometimes roaming the countryside to scare something up.”
That’s a good definition for medical blogging, in essence a form of health care gunning.
White proceeds to take this wing shot.
Every writer, by the way he uses the language, reveals something of his spirit, his habits, his capacities, his bias. This is inevitable as well as enjoyable. All writing is communication, creative writing is communication through revelation – it is the Self escaping out into the open. No writer can remain long incognito.
The Inevitable Concluding Verse
The last quote leads inevitably to this perverse verse:
There once was a prolific medical blogger named Al Frito,
Who tried methodically and doggedly to remain incognito.
He fought to conceal his inherent bias.
He sought to reveal himself as pious.
But try as he may, in his blog, his basic bias
he could not pocket veto.
Saturday, March 17, 2007
Clinicial innovations - Doctor-Led Search Engine Innovations
“Attempt the end, and never stand to doubt,
Nothing’s so hard but search will find it out.
Robert Herrick 1591-1674
Seek and Find
When we speak of Internet influence on modern society and culture, we speak of ubiquity, instantaneity, and availability of information anywhere, everywhere, anytime. We speak of shrinking and irrelevancy of distance. We speak of universal transparency. We speak of individuality run amuck. We speak of universal expression of deeply felt emotions. We speak of blogging, media’s new frontier. We speak of a world powered by cyber-based search engines.
We speak of chaos, confusion, and complexity. In health care, physicians are pivotal in developing relevant, useful, and impactful clinical search engines. These new engines bring order to bear on seemingly intractable problems and put critical information at the fingertips at those responsible for cost and effectiveness of care when that information is most needed, when the patient is in the room and when the receptionist announced, “The doctor will see you now.”
Several years back a friend served as CEO of a doctor-founded search engine company. The company developed software for collecting and downloading clinical research from around the globe, and then, for a fee, within 24 hours of the research’s publication, bringing it topracticing doctors' fingertips at the click of a mouse.
This start-up failed, as most start-ups do, from multiple reasons, including inability to raise money, assemble a harmonious management team, lack of physician enthusiasm on the receiving end, and bad timing.
As every start-up entrepreneur knows, timing is everything. Now, for my friend, the timing might be right. It is never too late to innovate. It seems everybody is rushing into the search engine field – Kaiser Permanente, MedAI, Aetna, health plans of every ilk, WebMD, Revolution Health, Healthline, and now Microsoft – using and deploying such tools as data mining, predictive modeling, consumer monitoring, episode data aggregation, and customer relationship handling.
On February 27, Microsoft announced it was buying Medstory, Inc, a small startup founded by Alain Rappoport, MD, PhD, in 2000 in Foster City, California. The Medstory acquisition follows Microsoft’s purchase last year of Azyxii, Inc., a clinic software company displaying information form scanned documents, x-rays, MRI and CT scans, and ultrasound images. As an aside, I believe image transfer may monumentally transform medical practices. It is much easier to scan a document or image than to enter it digitally.
Medstory applies artificial intelligence techniques to medical and health information gleaned from medical journals, government documents, and the Internet.
Microsoft says it bought the company to improve the consumer experience in health care. The biggest story here is that Microsoft has decided to become a dominant player in the health care search engine field.
The two Microsoft acquisition were preceded by Aetna’s 2005 acquisition of ActiveHealth Management, Inc, founded by Lonny Reisman, MD, a New York City internist. Founded in 1998, ActiveHealth Management provides clinical decision support to physicians and members on an individualized basis and health care data analytics tools that enable customers to analyze the health care of their entire covered membership.
Clearly big innovations are afoot in the search engine and medical intelligence field. Kaiser believes, for example, that it is possible to use its Archimedes Project technologies to run clinical trials for patients without use of human subjects. In Kaiser’s case, the genius behind the scene is a doctor named Doctor David Eddy, who also has at PhD in mathematics.
Many search engine company founders are MDs. This should come as no surprise, since physicians know what other physicians need and what patients want.
Alain Rappaport, MD, founded Medstory. Medstory, he says, increases the efficiency of health care industry processes, from drug development to personalized medicine. Rappaport was previously (1985-1996) co-founder, President, and Chief Scientist of Neuron Data, Inc., a world leading company in artificial intelligence and other business-critical software components. He is currently Adjunct Faculty in the School of Computer Science and Robotics Institute, Carnegie Mellon University. From 1997-1999, he held an appointment as Senior Advisor, Office of the Director, Center of Excellence for Information Technology, National Aeronautics and Space Administration. He is a founding member of the Innovative Applications of Artificial Intelligence (IAAI) Conference.
Another physician leader who founded a search engine firm is Lonny Reisman, MD, who founded ActiveHealth Management in 1998, and which Aetna acquired in 2005. ActiveHealth Management’ products and services are designed to improve clinical care and outcomes and reduce medical costs. The system continually compares this patient data to the latest evidence-based medicine and standards of care, to identify treatment opportunities for those most at risk. These opportunities or suggestions - called Care Considerations - are then communicated to the treating physician and/or patient with the goal of improving the patient’s health.
Search Engine Drivers
One driver here is consumer-focused health care. The notion is that with shifts in demographics, economics, technology, and policy, more individuals will desire, or be forced to make decisions on treatment and provider-selection on their own. Aging baby boomers, used to having things their way, will want personal choice, and a strong say in how they’re treated. Besides, according to a study last year by the Pew Internet and American Project, eight million people every day search for health care information.
There’s another driving-factor as well: competition for the health engine dollar. Microsoft is going head-to-head with WebMD which has just announced a quarterly profit of $8.9 million on $80.6 million of revenue. Steve Case, who founded AOL, is said to have put up $500 million of his own money, though Case disputes this figure and puts it closer to $100 million, to back Revolution Health, hoping to use its website to empower consumers to take charge of their health care and its costs.
The Internet search engine frenzy reminds me of the child's verse about the Merry-Go-Round, “Faster and faster she goes, Where she stops, no one knows.”
Nothing’s so hard but search will find it out.
Robert Herrick 1591-1674
Seek and Find
When we speak of Internet influence on modern society and culture, we speak of ubiquity, instantaneity, and availability of information anywhere, everywhere, anytime. We speak of shrinking and irrelevancy of distance. We speak of universal transparency. We speak of individuality run amuck. We speak of universal expression of deeply felt emotions. We speak of blogging, media’s new frontier. We speak of a world powered by cyber-based search engines.
We speak of chaos, confusion, and complexity. In health care, physicians are pivotal in developing relevant, useful, and impactful clinical search engines. These new engines bring order to bear on seemingly intractable problems and put critical information at the fingertips at those responsible for cost and effectiveness of care when that information is most needed, when the patient is in the room and when the receptionist announced, “The doctor will see you now.”
Several years back a friend served as CEO of a doctor-founded search engine company. The company developed software for collecting and downloading clinical research from around the globe, and then, for a fee, within 24 hours of the research’s publication, bringing it topracticing doctors' fingertips at the click of a mouse.
This start-up failed, as most start-ups do, from multiple reasons, including inability to raise money, assemble a harmonious management team, lack of physician enthusiasm on the receiving end, and bad timing.
As every start-up entrepreneur knows, timing is everything. Now, for my friend, the timing might be right. It is never too late to innovate. It seems everybody is rushing into the search engine field – Kaiser Permanente, MedAI, Aetna, health plans of every ilk, WebMD, Revolution Health, Healthline, and now Microsoft – using and deploying such tools as data mining, predictive modeling, consumer monitoring, episode data aggregation, and customer relationship handling.
On February 27, Microsoft announced it was buying Medstory, Inc, a small startup founded by Alain Rappoport, MD, PhD, in 2000 in Foster City, California. The Medstory acquisition follows Microsoft’s purchase last year of Azyxii, Inc., a clinic software company displaying information form scanned documents, x-rays, MRI and CT scans, and ultrasound images. As an aside, I believe image transfer may monumentally transform medical practices. It is much easier to scan a document or image than to enter it digitally.
Medstory applies artificial intelligence techniques to medical and health information gleaned from medical journals, government documents, and the Internet.
Microsoft says it bought the company to improve the consumer experience in health care. The biggest story here is that Microsoft has decided to become a dominant player in the health care search engine field.
The two Microsoft acquisition were preceded by Aetna’s 2005 acquisition of ActiveHealth Management, Inc, founded by Lonny Reisman, MD, a New York City internist. Founded in 1998, ActiveHealth Management provides clinical decision support to physicians and members on an individualized basis and health care data analytics tools that enable customers to analyze the health care of their entire covered membership.
Clearly big innovations are afoot in the search engine and medical intelligence field. Kaiser believes, for example, that it is possible to use its Archimedes Project technologies to run clinical trials for patients without use of human subjects. In Kaiser’s case, the genius behind the scene is a doctor named Doctor David Eddy, who also has at PhD in mathematics.
Many search engine company founders are MDs. This should come as no surprise, since physicians know what other physicians need and what patients want.
Alain Rappaport, MD, founded Medstory. Medstory, he says, increases the efficiency of health care industry processes, from drug development to personalized medicine. Rappaport was previously (1985-1996) co-founder, President, and Chief Scientist of Neuron Data, Inc., a world leading company in artificial intelligence and other business-critical software components. He is currently Adjunct Faculty in the School of Computer Science and Robotics Institute, Carnegie Mellon University. From 1997-1999, he held an appointment as Senior Advisor, Office of the Director, Center of Excellence for Information Technology, National Aeronautics and Space Administration. He is a founding member of the Innovative Applications of Artificial Intelligence (IAAI) Conference.
Another physician leader who founded a search engine firm is Lonny Reisman, MD, who founded ActiveHealth Management in 1998, and which Aetna acquired in 2005. ActiveHealth Management’ products and services are designed to improve clinical care and outcomes and reduce medical costs. The system continually compares this patient data to the latest evidence-based medicine and standards of care, to identify treatment opportunities for those most at risk. These opportunities or suggestions - called Care Considerations - are then communicated to the treating physician and/or patient with the goal of improving the patient’s health.
Search Engine Drivers
One driver here is consumer-focused health care. The notion is that with shifts in demographics, economics, technology, and policy, more individuals will desire, or be forced to make decisions on treatment and provider-selection on their own. Aging baby boomers, used to having things their way, will want personal choice, and a strong say in how they’re treated. Besides, according to a study last year by the Pew Internet and American Project, eight million people every day search for health care information.
There’s another driving-factor as well: competition for the health engine dollar. Microsoft is going head-to-head with WebMD which has just announced a quarterly profit of $8.9 million on $80.6 million of revenue. Steve Case, who founded AOL, is said to have put up $500 million of his own money, though Case disputes this figure and puts it closer to $100 million, to back Revolution Health, hoping to use its website to empower consumers to take charge of their health care and its costs.
The Internet search engine frenzy reminds me of the child's verse about the Merry-Go-Round, “Faster and faster she goes, Where she stops, no one knows.”
Friday, March 16, 2007
Physicians, Image of -Where Have All the Flowers Gone?
In Defense of Doctors, the Department of Defense, The U.S. Army Medical Corps, and The Veterans Administration
Where have all the flowers gone? Long time passing.
Where have all the flowers gone? Long time ago.
Where have all the flowers gone?
Young girls picked the , every one.
Oh, when will they ever learn?
Oh, when will they ever learn?
Where Have the Flowers Gone?
Words and Lyrics by Pete Seeger, 1961
Flowers come in all sizes, many colors, in varying seasons, and with unique, changing, and complex characteristics. There are glorious and anemic ones, bold and shy ones, adventuresome and retiring ones. All differ. Roses may be red, and violets may be blue, but dandelions get around more than the others do.
Whatever their characteristics, flowers symbolize hope, optimism, renewal, beauty, and life. On the wall of my office hangs a plaque. The plaque proclaims,” Don’t worry, don’t hurry, and don’t forget to smell the flowers.” I don’t forget, for flowers are what it’s all about.
We reward deeds well done with flowers. What do you give a diva to show how much you appreciate her aria? How do you tell people you care for them? With flowers, of course. I recall a sage old Connecticut family practitioners. When asked why he and his wife of fifty years had hit it off so well, he confessed, ”I send her flowers every Saturday to celebrate another week.”
Where have all the flowers gone in our society? Why don’t we send flowers anymore?
This is an anti-hero age. We no longer send bouquets or offer praise or optimism, beauty, life, or achievements.
Instead we doubt, dissect, disparage, analyze, impugn, question, and investigate.
Boy, do we investigate. We investigate Presidents, Vice-Presidents, Attorney Generals, Politicians, Army Generals, Priests, Physicians, and Establishment Institutions. The prevailing attitude is: if they or it have succeeded in our society, something must be wrong. Our most prominent heroes, even Mohammad Ali, have feet of Clay. So we send no flowers, only regrets that things are not perfect.
“Investigative” reporters “reveal” to us what we know already – that our leaders and the organizations they lead suffer from human frailties. The reporters “astonish” us each morning with mundane disclosures: Presidents dislike their political enemies. Partisan politics exists. Our enemies are bent on killing us – and it’s our own fault because we do not talk to them. Congressmen appease, and even try to please, their constituents. Supreme Court Justices, heaven forbid, argue among themselves over controversial issues. The Justices even maneuver in their cloakrooms to win over their brethren to their point of view. Goodness, learned lawyers act like they are made of flesh and blood. No flowers are bestowed upon them for lifetimes of hard work and solid accomplishments.
And physicians?
Well, they are the worst. Imagine. They err like other mortals. They occasionally misinterpret signs, symptoms, and results. They cannot guarantee perfect results under all circumstances. They cannot even repeal the Laws of Nature, or the inevitable Limits of Longevity. Physicians are not even omnipotent, omniscient, or omnipresent.
Take those Army doctors at Walter Reed or VA physicians everywhere. Can you believe it? They didn’t inspect all those moldy dormitories housing wounded veterans, and they did not respond immediately to all those complaints filtering up through the military medical bureaucracy, the largest medical-hospital complex in the world.
Sure, these military and VA doctors are saving more soldiers on the frontlines than in any other previous war. Sure, they have installed a universal electronic health record system linking all their hospital and physicians – a system that allows them to outperform the civilian sector for most quality indicators and is looked upon with wonderment by medical managers and medical executives. Sure, veterans are flocking to VA hospitals and clinics, for those $7 prescriptions Sure, the VA has launched a construction project called CARES. Sure, most military hospitals are fifty years old, compared to 12 year old in the civilian sector. Sure, heads had to roll, even heads that have devoted all of their lives to there military careers and their country.
And those civilian doctors? Reporters are stripping their petals one by one, complaining they are “too conservative,” or they don’t spend enough time with patients, or make too much money. They are too highly paid, the argument goes. Forget that average $100,000 medical education debt. Why should should complain? Sure, their incomes have not kept pace with inflation for a decade. Sure, the amount doctors are paid has dropped for the third year in a row and represents only 6% of all the money spent on health care in 2006. Sure, physicians are expected to receive significant cuts under Medicare’s pay formula for the next decade. Sure, managed care and Medicare forces doctors to spend only 15 minutes with patients in order to meet their bottom lines. Sure, the doctor shortage and economic squeeze leaves little time to answer patients’ questions. Sure, they are producing all medical innovations, new drugs, and new treatments that are lengthening longevity and making us functional into old ages. But medicine costs too much, and somebody has to sacrifice.
Maybe we should praise our doctors and their institutions, considered many to be “the best in the world.” That may be why the U.S. introduces 80% of the world medical innovations and wins 80% of the world’s Nobel Laureates in Medicine even though we only have 5% of the world’s doctors. Maybe we should give our doctors flowers, instead of defoliating them. Maybe they should be our heroes, rather than our villains. American doctors are not miracle workers, but given limited resources and Nature’s limitations, they are damn good.
Be fair. Put physician performance in perspective.
Smell the flowers. Show flower power. Plant a flower. Grant your favorite gastroenterologist a GI Bill of Right. Give Decorations to those who treat patients.
And remember. Those who throw dirt lose ground.
Criticism has its place. But so do flowers.
(In the interest of full disclosure, I am not a veteran. I do not have children or relatives in the Armed Forces. I do not receive pay from the VA. I did do part of my training at a VA hospital, as do more than half of American physicians.)
References
1. Brianigan, William, Dole, Shalala Pledge Full Investigation into Military Care, Washington Post, March 8, 2007.
2. Shanker, Thom, and Stout David, Chief Army Medical Officer is Ousted, New York Times, March 13, 2007.
3. 2008 Dems Vow to Reform Veteran Care, Associated Press, March 15, 2007.
4. Glendinning, Glen, Medicare Ripple Effect Linked to Dip in Spending Growth on Doctor Services, American Medical News, March 12, 2007.
5. Adams, Damon, Tight Schedules at Odds with Patient Demands, American Medical News, March 12, 2007.
Where have all the flowers gone? Long time passing.
Where have all the flowers gone? Long time ago.
Where have all the flowers gone?
Young girls picked the , every one.
Oh, when will they ever learn?
Oh, when will they ever learn?
Where Have the Flowers Gone?
Words and Lyrics by Pete Seeger, 1961
Flowers come in all sizes, many colors, in varying seasons, and with unique, changing, and complex characteristics. There are glorious and anemic ones, bold and shy ones, adventuresome and retiring ones. All differ. Roses may be red, and violets may be blue, but dandelions get around more than the others do.
Whatever their characteristics, flowers symbolize hope, optimism, renewal, beauty, and life. On the wall of my office hangs a plaque. The plaque proclaims,” Don’t worry, don’t hurry, and don’t forget to smell the flowers.” I don’t forget, for flowers are what it’s all about.
We reward deeds well done with flowers. What do you give a diva to show how much you appreciate her aria? How do you tell people you care for them? With flowers, of course. I recall a sage old Connecticut family practitioners. When asked why he and his wife of fifty years had hit it off so well, he confessed, ”I send her flowers every Saturday to celebrate another week.”
Where have all the flowers gone in our society? Why don’t we send flowers anymore?
This is an anti-hero age. We no longer send bouquets or offer praise or optimism, beauty, life, or achievements.
Instead we doubt, dissect, disparage, analyze, impugn, question, and investigate.
Boy, do we investigate. We investigate Presidents, Vice-Presidents, Attorney Generals, Politicians, Army Generals, Priests, Physicians, and Establishment Institutions. The prevailing attitude is: if they or it have succeeded in our society, something must be wrong. Our most prominent heroes, even Mohammad Ali, have feet of Clay. So we send no flowers, only regrets that things are not perfect.
“Investigative” reporters “reveal” to us what we know already – that our leaders and the organizations they lead suffer from human frailties. The reporters “astonish” us each morning with mundane disclosures: Presidents dislike their political enemies. Partisan politics exists. Our enemies are bent on killing us – and it’s our own fault because we do not talk to them. Congressmen appease, and even try to please, their constituents. Supreme Court Justices, heaven forbid, argue among themselves over controversial issues. The Justices even maneuver in their cloakrooms to win over their brethren to their point of view. Goodness, learned lawyers act like they are made of flesh and blood. No flowers are bestowed upon them for lifetimes of hard work and solid accomplishments.
And physicians?
Well, they are the worst. Imagine. They err like other mortals. They occasionally misinterpret signs, symptoms, and results. They cannot guarantee perfect results under all circumstances. They cannot even repeal the Laws of Nature, or the inevitable Limits of Longevity. Physicians are not even omnipotent, omniscient, or omnipresent.
Take those Army doctors at Walter Reed or VA physicians everywhere. Can you believe it? They didn’t inspect all those moldy dormitories housing wounded veterans, and they did not respond immediately to all those complaints filtering up through the military medical bureaucracy, the largest medical-hospital complex in the world.
Sure, these military and VA doctors are saving more soldiers on the frontlines than in any other previous war. Sure, they have installed a universal electronic health record system linking all their hospital and physicians – a system that allows them to outperform the civilian sector for most quality indicators and is looked upon with wonderment by medical managers and medical executives. Sure, veterans are flocking to VA hospitals and clinics, for those $7 prescriptions Sure, the VA has launched a construction project called CARES. Sure, most military hospitals are fifty years old, compared to 12 year old in the civilian sector. Sure, heads had to roll, even heads that have devoted all of their lives to there military careers and their country.
And those civilian doctors? Reporters are stripping their petals one by one, complaining they are “too conservative,” or they don’t spend enough time with patients, or make too much money. They are too highly paid, the argument goes. Forget that average $100,000 medical education debt. Why should should complain? Sure, their incomes have not kept pace with inflation for a decade. Sure, the amount doctors are paid has dropped for the third year in a row and represents only 6% of all the money spent on health care in 2006. Sure, physicians are expected to receive significant cuts under Medicare’s pay formula for the next decade. Sure, managed care and Medicare forces doctors to spend only 15 minutes with patients in order to meet their bottom lines. Sure, the doctor shortage and economic squeeze leaves little time to answer patients’ questions. Sure, they are producing all medical innovations, new drugs, and new treatments that are lengthening longevity and making us functional into old ages. But medicine costs too much, and somebody has to sacrifice.
Maybe we should praise our doctors and their institutions, considered many to be “the best in the world.” That may be why the U.S. introduces 80% of the world medical innovations and wins 80% of the world’s Nobel Laureates in Medicine even though we only have 5% of the world’s doctors. Maybe we should give our doctors flowers, instead of defoliating them. Maybe they should be our heroes, rather than our villains. American doctors are not miracle workers, but given limited resources and Nature’s limitations, they are damn good.
Be fair. Put physician performance in perspective.
Smell the flowers. Show flower power. Plant a flower. Grant your favorite gastroenterologist a GI Bill of Right. Give Decorations to those who treat patients.
And remember. Those who throw dirt lose ground.
Criticism has its place. But so do flowers.
(In the interest of full disclosure, I am not a veteran. I do not have children or relatives in the Armed Forces. I do not receive pay from the VA. I did do part of my training at a VA hospital, as do more than half of American physicians.)
References
1. Brianigan, William, Dole, Shalala Pledge Full Investigation into Military Care, Washington Post, March 8, 2007.
2. Shanker, Thom, and Stout David, Chief Army Medical Officer is Ousted, New York Times, March 13, 2007.
3. 2008 Dems Vow to Reform Veteran Care, Associated Press, March 15, 2007.
4. Glendinning, Glen, Medicare Ripple Effect Linked to Dip in Spending Growth on Doctor Services, American Medical News, March 12, 2007.
5. Adams, Damon, Tight Schedules at Odds with Patient Demands, American Medical News, March 12, 2007.
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