Thursday, June 30, 2016

Electronic Health Record Software Fatigue
Physicians are sick and tired of electronic health records(EHRs).
Supposedly, doctors are told, EHRs will.

·         Reduce medical records.
·         Narrow disparities in care delivery 

·         Engage patients in their own care.

·         Spark coordination of care.

·         Give access to best practice management.

·         Enhance communication across the health care spectrum.

Instead, doctors complain, EHRs;

·         Aren’t ready for prime time. 

·         Slow productivity.

·         Decrease revenues.

·         Show no return on investment. 

·         Don’t communicate with other EHRs.

·         Distract with time spend with patients. 

·         Are limited as communication tools.

·         And are, many other ways, including expense of  hiring and training staff to enter data and to code, a PITA (Pain in the Ass).

 Another Complaint

Now doctors have another complaint -  the number of alerts, alarms, and reminders popping up on EHR screens are overwhelming and are resulting  in a bad case of  “alert fatigue.
According to  a June 15 story in Kaiser Health News “Screen Flashes and Pop-Up Reminders: Alert Fatigue Spreads Though Medicine.”
“When  physicians are  hit with too much information, the result can be a health hazard. The electronic patient records that the federal government has been pushing — in an effort to coordinate health care and reduce mistakes — come with a host of bells and whistles that may be doing the opposite in some cases.”
“Electronic health records increasingly include automated alert systems pegged to patients’ health information. One alert might signal that a drug being prescribed could interact badly with other medications. Another might advise the pharmacist about a patient’s drug allergy. But they could also simply note each time that a patient is prescribed painkillers — useful to detect addiction but irrelevant if, say, someone had a major surgery and is expected to need such meds. Or they may highlight a potential health consequence relevant to an elderly woman, although the patient at hand is a 20-something man.”
“The number of these pop-up messages has become unmanageable, doctors and IT experts say, reflecting what many experts call excessive caution, and now they are overwhelming practitioners.”
“ ‘Clinicians ignore safety notifications between 49 percent and 96 percent of the time,’said Shobha Phansalkar, an assistant professor of medicine at Harvard Medical School.’When providers are bombarded with warnings, they will predictably miss important things,’ said David Bates, senior vice president at Brigham and Women’s Hospital in Bosto
In any event physicians are responding to deluge of medical alerts and alarms by simply  ignoring and overriding them most of the time.   
As the old Aesop story went,  when the shepherd boy called “Wolf! Wolf!” too many times, when the wolf finally came, no one would pay any attention to his calls for help.

Wednesday, June 29, 2016
The utopium of the people.
Professor Arthur Case (1894-1946), commenting on promises of welfare state
Health 2.0 is the premiere showcase and catalyst for the advancement of new health technologies. Through a global series of conferences, developer competitions, and leading market intelligence, Health 2.0 drives the innovation and collaboration necessary to transform health and health care.
Self-Definition, by Health 2.0
How have promises of the health reform law and potentials of Internet applications impacted patients and physicians at the site of care?    How have private sector efforts, as exemplified by the Health 2.0, advanced health reform?   Has the craze for more algorithms, guidelines,  protocols,  lists of tests doctors can and cannot do,  pay for performance based on data gone awry or just contributed to more clinician hassles at the point of care?  And has IT, as far we know, lowered health costs, expanded access, and improved quality and outcomes?
Health 2.0 and the Health Care Blog         
Health 2.0 is a powerful and impressive movement that considers itself “a leading showcase of cutting-edge innovation since 2007.” 
Indeed it is.  This fall Health 2.0, an Internet-related company, will stage its 10 annual conference.  It expects over 2000 participants.   It was co-founded in 2007 by Matthew Holt. 
Holt also co-founded The Health Care Blog in 2003. It has 50,000 to 150,000 readers each month.  
Among these readers are patients, caregivers, physicians, health information companies, and venture capitalists. Its goals include deployment of data to judge the value of health care, defined as outcome/price.
The Health Care Blog and Health 2.0 have been successful enterprises.   Its founders recognized the Information Age had arrived full force and would be vigorously applied to health care.    Given the reality that the government-medical-industrial complex is a $300 billion industry, the prospects for IT applications to transform health care are limitless. 
The world is moving fast on Internet time, and an innovative private sector, in conjunction with government,   had a powerful role to play.      The Obama administration acknowledged this reality as well,  and  led to its belief that an interoperable, all-purpose, all-reaching, all-the-time available, online system connecting all major health care players holds  the key to improving access and quality of the American health  system. 
Health 2.0 personified concepts like collaboration, openness, participation, and social networking.   It is concerned with software licensing and delivery and cloud-based technologies and their applications on multiple devices. Health 2.0 describes the integration of these into much of general clinical and administrative workflow in health care. About 3,000 companies offer with venture capital funding of over $ 2.5 billion.
A Technologically-Incorrect Mindset
But how has IT technologies and their broad applications affected patients and physicians, who are the key to any successful health reform?
As the author of 4350 Medinnovation and Health Reform blogs since 2006 and  three book Innovation-Driven Health Care (Jones and Bartlett, 2007), Obama, Doctors, and Health Reform (2009),  and The Health Reform Maze (2011).   I have reservations about the limits of the health care information revolution.   
HealthReform 2.0  is another mindset.    It is a loose term describing the limitations of Internet applications and how humans react to the cyber-revolution.
I accept the power of the Net and its applications to shape and power of  health reform, I  am  techno-skeptic.   Data isn’t everything,  it isn’t  the only thing,  it is one of many things, including skepticism about total reliance on data as the main indicator of what constitutes a health or a health-conscious society.  
Internet-driven care may be oversold as a tool to improve health care, implement reform, cut costs, and empower patients. Useful, yes, but over-hyped as the Holy Grail, as the OSHA (Our Savior Has Arrived) of heath reform.
Taking a Step Back
The time has come to step back, taking a deep breath, and to stop being breathless about the unlimited prospects of cyber-apps as the principle agent and Holy Grail for transforming health care.    It is time for perspective on the merits and shortfalls of web-driven information technologies.
Not Alone
I am not alone in my skepticism about the limitations of health reform.
·         In 2007 Jerome Groopman, MD, a Harvard oncologist,  wrote in his book  How Doctors Think, “A doctor can’t think with one eye on the clock and another on the computer screen… a movement is afoot to based all treatment decisions stt5icktly on statistically proven data.  This so-called evidence based medicine is rapidly become the canon... But today’s rigid reliance on evidence-based risks, having the doctor chooses care passively, solely on the number isn't realistic. Statistics can’t substitute for the human been before you; statistics embody averages, not individuals.”

·          Robert Wachter, MD a West-Coast medical school professor, explained in his book The Digital Doctor: Hope, Hype, and Harm at the Dawn of the Computer Age (2015) that electronic heath record use could bring harm... A 2013 study found that the electronic health record was a dominant culprit in bringing harm.   A 2013 study found that emergency room doctors clicked a mouse 4,000 times during a 10-hour shift. Computer systems, noted Wachter,  "have become the dark force behind quality measures.”….evidence has mounted that even superb and motivated professionals had come to believe that the boatloads of measures, and the incentives to ‘look good, had led them to turn away from the essence of their work.”  

·         Andrew Keen, a denizen of Silicon Valley, executive director of Silicon Valley's FutureCast, and a regular commentator on all things digital, asserted in this book The Internet Is Not The Answer (2015), that that data and it computer applications,   were oly part of the answer for improving society, but they were not the total answer and were often destructive in undermining our culture and our economy. He examined the dimensions of its worldwide networks, showed how had destroyed many major industries, created a culture of personal narcissism, destroyed personal privacy, and caused deepening economic and social inequalities.  “Creative destruction” is part and parcel of capitalism, but it has its downsides.

·         In 2016,  Andy Slavitt, acting CMS director,  after he and his team  interviewed  thousands of physicians about their perception of the utility of electronic health records said  he believes that the measurement craze has had its negatives. He said doctors feel all the data entry “took time away from patients and provided nothing or little back in return. Physicians are baffled by what feels like the ‘physician data paradox,’” he said. “They are overloaded on data entry and yet rampantly under-informed.”But the rest of Slavitt’s statement reveals he has no idea how to solve the “data paradox.” He asserted that “technology that works for doctors and patients” is the ideal solution but it offends many physicians.   He added, “We have to get the heart and minds of physicians back.  I think we’ve lost them.”   Because of widespread physician resistance,  Slavitt  announced the end “meaningful use” EHR mandates.

·         A  study on electronic medical records use by the California HealthCare Foundation, a philanthropic group, found that 15% of the 1,849 adults surveyed said they’d conceal information from a physician if “the doctor had an electronic medical record system” that could share that information  with other groups. Another 33% would “consider hiding information.”   This is an example of the garbage in, garbage out phenomenon when it comes to interpreting the reliability of algorithms to improve care.
The Internet Age is upon us, and it may well  in the end transform the health system for the betterment of all.    Information technologies have the potential of making health care more efficient and objective, improving the health and extending longevity,   identifying what is of value for each dollar spent,  decoding the genomic secrets of disease,  and  deciphering and streamlining the organizational and disease complexities.   
And yet, the Internet is no panacea, no cure-all for the problems, costs, and complexities of health care that beset and befuddle  humankind.  Medicine and health care are fiendishly complicated, and the Internet sometimes makes them more so. 
The Internet often intrudes into patient-doctor relationships, tends to decrease private and confidential relationships, and accumulating the data that feeds its algorithms and helps it reach its conclusions pose expensive, cumbersome, and distracting propositions for clinicians and patients alike on the front lines of care.   
One last comment. The extensive use of electronic health records has contributed to physician shortages, to physicians abandoning traditional practices to enter concierge practices to escape coding and other 3rd party electronic mandates,  to physicians accepting fewer Medicare, Medicaid, and ObamaCare exchange patients,  and to physician burnout. 
According to Mayo Clinic studies, EHRs are the leading cause of physician burnout, to wit, “Although electronic health records, electronic prescribing, and computerized physician order entry have been touted as ways to improve quality of car, these tools create clinical burden, cognitive burden, frequent interruptions and distraction – all of which contribute to physician burnout):”Electronic Tools Fan the Flames of Physician Burnout, “” Health Leaders Media, June 27, 2016).
In a recent Washington Post article “Why Doctors Quit,” Doctor Charles Krauthammer, psychiatrist, conservative commentator, and prominent health law critic, after attending his 40th Harvard Medical School reunion, quotes one of his classmates, “My colleagues who have already left practice all say they still love patient care, being a doctor. They just couldn’t stand everything else…. a never-ending attack on the profession from government, insurance companies, and lawyers... progressively intrusive and usually unproductive rules and regulations,” topped by an electronic health records (EHR) mandate that produces nothing more than “billing and legal documents” — and degraded medicine.” 

Sunday, June 26, 2016

Predicting and Preventing Later Death  from Cardiovascular Disease in Adolescents
This week an article in the New England Journal of Medicine  caught my eye:  “Body-Mass Index in 2.3 Million Adolescents and Cardiovascular Death in Adulthood.”   The article groups data on BMI, as measured  from 1967 to 2010 in 2.3 million Israeli adolescents (mean age 17.3),  and correlates  the number of deaths:  1497 from coronary artery disease,  528 from stroke, and 893 from sudden death.  
The authors used BMI (Body Mass Index), normal range 18.5 to 30, underweight, under 18.5;  normal weight 18.5 to 25,  overweight 25 to 30,  obese over 30,  as a predictive measure.  The BMI is calculated by  weight in kilograms /height squared in centimeters.
Those in overweight and obese categories had an increased hazard of dying suddenly or from coronary disease  4.9 times,  stroke 2.6 times , or sudden death  2.1 times, than others in the 40 years of follow-up.
Why Not?
These results got me to thinking – Why not alert adolescents to their risk of death using BMI data when all that is required is their weight and height?  Why not add to weight and height data,   BP levels, and certain lab tests like glucose and blood lipid values?    Why not accompany these data with document stating their relative health and their cardiovascular risk?
Perhaps I was oversimplifying.    But everybody knew, then and now, that obesity,  high blood pressure,  diabetes, and aberrant lipid values  are reliable  prognosticators of future fatal cardiovascular events.   And these measurements  weight, height,  blood glucose, and lipid values are easily obtained during routine visits to a doctor.
Not Optimistic
But I am not  optimistic about the use of routine data as a tool for preventing deaths or changing behavioral lifestyles
In the 1980s,  I developed something  called the “health quotient,”  normal range 80 to 120,  based on the BMI,  blood pressure, and routine blood test values for glucose and lipids.   We measured these things on thousands of patients, mostly non-adolescents,  and sent results to the patients.   We found roughly 30%-35% of  government employees  were pre-diabetic or diabetic,  hypertensive, and had worrisome lipid changes  that often precede heart attacks or stroke or sudden death.

But to little avail.   We learned patients were reluctant to acknowledge their  present and future health problems.  to have their problems  documented as part of their official health records,  or to change their life styles; employers were reluctant to pay for follow up studies;  and physicians were reluctant to heed results or to have the results imposed upon them when  they had not specifically ordered.  
For these and other reasons,  I am reluctant to  overstress the impact that predictive health data might have on the field of “population health,” which is the rage right now in improving the overall health of Americans.  Culture and life style are  difficult things to change, once they have been imbedded in your environment and your approach to health.



Perfect Political Storm
In 2010,  in November 210,   7 months after ObamaCare’s passage,  I wrote this blog.
“In 1997, Sebastian Junger, an author and journalist, wrote the best seller, The Perfect Storm, later a movie. The book told the story of fisherman off the New England Coast trapped by three converging weather systems.
Three Weather Systems

• Warm air from a low pressure system coming from one direction.

• Cool, dry air generated by a high pressure system coming from another direction.

• Tropical moisture provided by Hurricane Grace.

An Analogy

This is a good analogy for today’s perfect p health reform storm.

• Warm air, suddenly heating up as evidenced by the midterm elections, from a low pressure system coming from outside the Beltway, with conservative Americans calling for smaller government, less interference in their lives, lower taxes, less spending, less debt, and “taking our government back.”

• Cool, dry air provided by a high pressure, dispassionate, scientific, management-oriented Washington insider elites speaking in cool, dry terms about the need for a rational restructuring of the whole system from above.

• Tropical moisture (both sides claim the other side is all wet) producing a hurricane of opinionated bilateral rhetoric speaking in apoplectic and apocalyptic terms about the abyss that lies ahead if their respective opinions do not prevail.

Caught in the Middle

Caught in the middle of this perfect reform storm are physicians and patients who fear the worst, who feel they have no reform voice and no control over impending colliding weather systems.

On the one hand, American health consumers have high expectations, fueled by the high tech performance of the current system, and the promise of a new entitlement system providing more care at lower costs. They expect the best medicine has to offer at more “affordable” price. These twin expectations are central elements of the perfect storm.

On the other hand, a centralized government is saying the whole system must be overhauled and restructured, and physicians must offer less costly care under a system of expensive regulations with which they must comply at lower reimbursement rates without protection from tort reform.

On the third hand, sometimes called the third or the center-right way, there may be a middle way out the storm, through disruptive innovations using cheaper care at decentralized locations, like the home, provided by less sophisticated personnel using electronic , and downsizing of the whole medical enterprise.

Time Not on Side of Those in The Boat

The problem with all of these scenarios is that with an imminent perfect storm, time is not on your side, the reckoning is at hand, and physicians in the boat with patients, must cope with the consequences – the impact of the perfect storm on their professional and personal lives.”

Today’s  Political Storm

Which leads to the present blog.    The health reform storm I described  6 years ago now involves  3 world-wide weather systems  colliding with one another.

First  are forces of globalization, standardization, and socialism.  These forces call for international economic integration,    top— down remote  political  organizations  dedicated to leveling  and closing economic gaps  between nations,   all acting together in harmony   to  combat climate change,  and  to promote immigrations  across nations without borders- all led by experts and elites and bureaucrats using information from cyberspace  and deploying  algorithms to elucidate and  to crystallize complexities to make the world more efficient, rational, and equal.   The elites, the young,   the well-educated, and the IT-skilled tend to belong to this movement.

Second are forces of  nationalism and cultural preservation. These forces, sometimes marching under the banner of populism. maintain globalization has not delivered on its promises , is destroying national identities,   is stifling innovation and business with bureaucratic shackles, is ignoring common workers  and the middle class  while feathering nests of the elite,  does not meet the needs and destroys the traditional life styles of common folks  and  has little idea  how the real world works, and fail to realize mass integration changes their ways of life.   Older people, those left out by globalization, automation,  IT-displacement belong to this school.

Third are forces of economic reality.   These forces say there is something badly wrong  with current forces and trends ,  which have  produced  deep  unemployment , massive migrations,     a world-wide recession from which the West has yet to emerge,   political instability and uncertainty, and  rise of terrorism.   Something profound, even revolutionary,   has to happen.  This change can no longer be ignored or placed in the hands of traditional elites, who say the answer lies in patience with  the status quo and  incremental progressivism.     Hence the rise of Trump,  Brexit,   populist movements in Europe,  socialism among the young,  and  the call for a radical change of direction. 

The political question is:   Has the time come for fundamental change, or should it be steady as she goes with incremental fixes at the edge? 

Saturday, June 25, 2016

Sovereignty: Globalists and Nationalists, Patients and Physicians
My dictionary defines “sovereignty” as independent or self-governing power.
Synonyms for Sovereignty
You can call sovereignty  other things as well -  autonomy, self-governance, self-rule, self-determination,  freedom,  desire for privacy, rise of  populism,  revolt against powerful elites and remote bureaucracies,  resurgent nationalism,  and power to control one’s destiny on one’s  own terms.
The Brexit Example
Whatever name you wish to use,  sovereignty  is  significantly politically , as evidenced by Britain’s  vote to exit from the European Union, a revolt against being told what to do by faceless  European bureaucrats in Brussels.  Fraser Nelson , editor of the Spectator and columnist for the Daily Telegraph,  said Brexit was similar to other battles being fought in Western democracies,  “It is the jet-set graduates versus the working class, the metropolitans versus the bumpkins – and, above all, the winners of the globalization against the losers."  It is a cry for liberty by workers suffering from economic stagnation and a rebuke of the political elite establishment.
The American Counterpart
Sovereignty is important in America as well. It is the will of the people, as  they  revolt against the establishment in Washington, D.C.,  and against being “globalized” as a forgotten  subsidiary  of the world’s global economy.    Global climate warming agreements,   international trading pacts, secretive foreign treaties with adversaries, and withdrawal of American power from the world scene, may be the ways to go, but the opposition do  not agree.  As in Britain,  middle class and worker anger is growing as is reaction against immigration,  globalization,  free trade,   unemployment,  capital flight, and the technology elite, rich people, and the well-educated.
Sovereignty in Health Care
In American health care,  sovereignty manifests itself  as a reaction against  ObamaCare.  The basic thrust of the health law is having Washington “govern” the patient-doctor relationship. This is done in the names of enhanced efficiency, quality, and outcome, as seen through the eyes of governing elites.
Gains and Losses
Among patients and physicians,   this  gain in government power is perceived  as loss of personal sovereignty. It  comes at a price – higher taxes,  more regulations,   loss of privacy, and increased  intervention into the lives of patients and  disruption of physician work patterns.
Patients and doctors resent having their life styles and practices measured,  monitored,  and transformed and being told what to do.
That is why as many of one-third to one-half of patients  withhold  or distort information or even lie  when they see doctors using electronic health record systems to record their personal information.  
That is why physicians complain about government-induced hassles, leading to losses of productivity,  overhead expenses, and time spent away from patients – all to please the whims and misconceptions  of government  bureaucrats and policy elites.
It may be, of course, that each mindset – that of the government  elite and that  the governed -  are partly right and partly wrong.    
Culture-Changing Events
Whatever point of view prevails , keep in mind that cultural changing events -  interconnected information-globalization produced by computerization,   universal access to this information by IPhone and other devices,    mass migration facilitated by open-border mentalities,   declines  in the  personal and physician sovereignties ,   and noble bureaucratic intentions to improve population-health  through use of data -  come at a high price,  will generate controversies about loss of  personal “liberties and freedoms, “ and  will  take time to implement and cultural attitudes to overcome.

Thursday, June 23, 2016

House Republicans Unveil Plan to Replace ObamaCare  Met with Mixed Reviews
House Republicans  just released a 37 page  health plan ofnhow they propose to replace ObamaCare.
The document contains these key points.
It would:
·         Repeal ObamaCare but retain 3 of its provisions – 1) coverage of young adults under their parents’ plans, 2) those with pre-existing conditions, and 3, not allow  cancellation of policies because of disease.
·         Expand Health Savings Accounts allowing people to use tax-free money to pay for care.
·         Offer refundable  tax credits to subsidize purchase of private health insurance.
·         Decrease dependence on employer-sponsored health plans, by placing a cap on employer provided insurance.
·         Allow people to buy insurance across state lines.
·         Provide $25 billion over 10 years to help small businesses negotiate better contracts with insurers.
·         Let states regulate and pay for Medicaid, either through block grants to “per-capita” allotments.
·         Partially privatize Medicare beginning in 2024 through  a “premium support” optio
  • Reform medical liability.
As expected, the plan was met with mixed review.   Republicans insisted the plan was “patient-centric” and "market-based"  and would lower premiums,  decrease costs,  and expand access and choice.   Democrats said it was vague, non-specific , would tax  workers’  benefits,   consisted of recycled ,  stale  GOP ideas of the past,  and said nothing of how to covered the 20 million newly insured and subsidized  by ObamaCare.
Here, briefly, is what  the media said about  the plan.
·          The New York Times  said it was full of vague unsubstantiated chatter.
·         The Associated Press noted it relied too much on tax credits, malpractice reform,  and health savings accounts.
·         Kaiser Health News stressed its emphasis on “high risk pools,  reliance on state-controlled funding of Medicaid,  and that it left a  lot of questions unanswered.
·         The Atlantic  commented it showed a recommitment by the GOP to repeal Obamacare and to reform Medicaid and Medicare.
·         Investor’s Business Daily  hailed it as step towards a market-based system that would remove the “heavy hand” of government.
·         The Wall Street Journal  said it left too many details to be filled in,  and depended on Trump’s election, but as least it gave the GOP an agenda to run on.
·         The Los Angeles Times  ridiculed  it as “Ryan’s plan” and reinforced the notion that the GOP was not really serious in tackling complex health reform issues.
·         Politico said it “was short on details” on how the GOP proposed to reduce premiums by double digits. bend the cost curve downward, cover those recently subsidized by ObamaCare
·         Bloomberg summed it up by saying it would  end ObamaCare while keeping  its most popular parts.
One leading Republican said the 37 page plan was simply a “framework for debate” and depended on which political party emerged “triumphant”, perhaps “Trumphant”is a better word,  in the 2016 general election.    The ultimate question, of course, is :  Who shall control the rules and expenditures for health care,  centralized  government  or diverse markets, and in what proportion?