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Tuesday, September 9, 2014

The late Joan Rivers, and some troubling health care system questions

Joan Rivers died while I was back in NJ attending my high school 50th reunion. Very sad. From THCB:
What Killed Joan Rivers? Piecing Together a Medical Mystery

There are minor operations and procedures, but there are no minor anesthetics.  This could turn out to be the one lesson learned from the ongoing investigation into the death of comedian Joan Rivers....
There is no way to know, without further information, whether the root cause was trouble with her heart, her breathing, a sudden stroke, or another type of catastrophic event. There is no way to know if problems were due to sedative drugs she might have received.
There is no way to know, without further information, if the extra equipment and personnel available in a full-service hospital as opposed to an outpatient clinic would have made any difference in Ms. Rivers’ resuscitation and outcome.

But this much is clear:  there is pressure today from the government and insurers for physicians to perform complex procedures even on high-risk patients in free-standing ambulatory centers. Why? To save money. The extra equipment and staff in full-service hospitals are expensive...
Read the entire post. How many non-celebrity octagenarians routinely expire in the wake of surgical anesthesia? Will the rate worsen as we push more patients to ASCs?

Hospital business model threatened, but retail outlook bright
High deductible insurance plans are causing some headaches for healthcare providers — keeping utilization depressed

The currents of health reform and consumerization are getting more treacherous for incumbent hospital businesses, according to a new report by Standard and Poor’s Rating Services.

With an influx of newly-insured populations and the growth of Medicare’s baby boomers, American healthcare continues to be a massive market for goods and services. The landscape, however, is shifting for better and worse, depending on the market segment.

The new norm of high deductible plans is “causing some headaches for healthcare providers — keeping utilization depressed,” write S&P analyst Mariola Borysiak and colleagues. Retail companies, meanwhile, “are realizing quickly that this consumerization trend is an opportunity, even beyond their existing pharmacy businesses.”

Traversing this new landscape with a dependence on traditional fee-for-service business models, hospitals largely face a negative credit outlook in S&P’s view: “top line revenue constraints,” “soft demand, in part because of high deductible plans,” and the transition to value-based payments from fee-for-service...

THCB has a bunch of great posts today. to wit:
Is Healthcare a Business?
Edmund Billings, MD

In the United States, the question has been asked time and again but never satisfactorily answered. By virtue of publically financed healthcare systems, the rest of the developed world has decided, to a greater or lesser extent, that medicine and healthcare are not pure businesses—that citizens have a right to care, even when they can’t pay all associated costs.

It’s starting to look like Americans won’t be able to duck the question for much longer.

In the last year, the profitability of U.S. hospitals eroded for the first time since the Great Recession, pushing some closer to and others over the solvency precipice. Revenues are down and costs are up.  And these issues appear systemic and entrenched, giving rise to a series of important and relevant questions: How can hospitals adapt?  If they do, will they still survive? And, do we as a nation think it’s important to make hospitals accessible, even if they lose money?...
Yeah. From an email correspondence I had a while back with my friend Joe Flower:
Another question not asked enough: How much should it rightfully cost to have that trauma-equipped hospital with its ER down the street (or the fire department station, etc)? We all talk about “staying out of the ER and the hospital,” but when YOU really need it, you want it to be there. Having that kind of standing capacity, effectively equipped and staffed, is gonna COST, period... 
Gladwell makes note of the distinction between “actuarial” and “social” insurance. We don’t see enough emphasis in public discussion. Moreover, an irony I always talk about is that health “insurance” on the actuarial/risk indemnity side is a ~60 year proposition (speaking just of adults here), yet we continue to sell it in one-year chunks, wasting a lot of resources in the process. PPACA does nothing to abate that...
See my May 2009 post "The U.S. health care policy morass" from back when I first started writing about these issues.


The scary Apple Watch future
You think your smartphone is a privacy-destroying tracking device? You ain't seen nothing yet

Andrew Leonard,

Watching the livestream of Apple’s iPhone and Apple Watch event Tuesday morning was an intriguing exercise in cognitive dissonance. On the one hand, the fanboy adulation that swamped Cupertino seems almost unseemly in its jubilation. When CEO Tim Cook uttered the legendary “One More Thing” mantra for the first time since the death of Steve Jobs, a good third of the assembled audience appeared ready for instant Rapturing. Yet at the same time, on Twitter, an endless parade of snark and carping threatened to overwhelm any attempt at actual analysis.

And that was too bad, because the company’s rhetoric about its new products exposed a fascinating contradiction at the heart of Apple’s evolution. Apple simultaneously made an explicit commitment to keep our personal information private, while at the same time demo-ing a device designed to capture an unprecedented degree of our most personal, intimate details...

But wait, not five minutes after stressing the importance of keeping information private, Apple introduced the Apple Watch, a device that connects directly to your skin and comes with multiple sensors that will be able to monitor a wide range of biometric data. During the Apple Watch rollout, I lost count of the number of times I saw critics complain that “millennials don’t wear watches” or “I don’t need a $349 device to tell me what time it is” or “why do I want to duplicate all the functionality of my phone on a smaller device while still having to carry my phone with me?” All these observations are true enough (though I’ll bet that somewhere down the line, the Apple Watch will be able to stand alone without an iPhone). But they miss completely the positive case for why people might seek out such a device. The fact that the Apple Watch tells the time is the least interesting thing about it. If you’re the kind of person who likes to keep track of your exercise metrics, the Apple Watch is an instantly seductive fitness tracker. As a cyclist with a bike computer that’s beginning to show its age, I can easily see replacing it with an Apple Watch. I know scores of people who track their steps every day with pedometers, who might enjoy a device that can also give them turn-by-turn directions while they walk. And I know diabetics who are desperate for simple user-friendly devices that can be used to track their blood glucose levels.

We’ll find out sometime in 2015 if the use-cases for the Apple Watch are compelling enough to make the product a success. But for now, the intriguing point is that the Apple Watch is well positioned to act as a device that continually monitors our physical and biological state — and it just doesn’t get any more personal than that.

So yeah, here’s hoping that Apple means it when it boasts about not being in the business of collecting our information.
Particularly if you're a celebrity taking nude "selfie" photos, 'eh? Dunno. I wear a Fitbit now. Pretty crude device, actually. I'd like to be able to continuously monitor more parameters.

Below, more from THCB.
Should Wearables Data Live In Your Electronic Medical Record?

The great promise of wearables for medicine includes the opportunity for health measurement to participate more naturally in the flow of our lives, and provide a richer and more nuanced assessment of phenotype than that offered by the traditional labs and blood pressure assessments now found in our medical record.  Health, as we appreciate, exists outside the four walls of a clinical or hospital, and wearables (as now championed by Apple, Google, and others) would seem to offer an obvious vehicle to mediate our increasingly expansive perspective.

The big data vision here, of course, would be to develop an integrated database that includes genomic data, traditional EMR/clinical data, and wearable data, with the idea that these should provide the basis for more precise understanding of patients and disease, and provide more granular insight into effective interventions.  This has been one of the ambitions of the MIT/MGH CATCH program, among others (disclosure: I’m a co-founder).

One of the challenges, however, is trying to understand the quality and value of the wearable data now captured...
Good post. And a great following comment:
Does wearable data belong in an EHR? Yes, eventually. Medicine is undergoing a major shift because of information technology. And by information technology, I am not referring to just EHR systems, but everything that enables the collection, searching, and analysis of data. Clinical care has always been an information intensive field, but for most of its modern history paper and brains have been the only to information management tools available.
Fast processors, sophisticated databases, high-capacity storage, and fast networks are relatively recent occurrences in the history of health care. We are still ironing out information and data exchange standards. Information technology has advanced faster than our ability to incorporate its capabilities into routine care. 

Dumping data from wearable devices onto already stressed providers is a bad idea because current EHR systems are not ready to manage what they would receive. Clinical decision support is still primitive. Data analytics is more often said than done.

Fortunately, there is a general acceptance that information technology is a part of clinical practice. With this acceptance, we can now turn our attention to making software that better supports clinical care. And by better I do not mean adding a few new features to systems designed to be patient data repositories (EHR systems) and declaring them to be the solution, but rather designing systems from the ground-up to intimately support clinical work (clinical care systems).
And, an equally fine, cautionary response:
William Hersh, MD says:
The answer to this question depends in part on, Whose EHR? Although there probably should be, there is not yet a single EHR for each person. When there is, we could possibly discuss where personal information like this might reside, how it might be summarized for quick overview viewing by clinicians, and so forth.

But in our current state of numerous EHRs, belonging to each and every clinician, hospital, etc., this question is too vague. Should personal fitness data go into the primary care EHR? Since that may be a physician with limited resources, should we expect his or her system to be able to accommodate such data? In our still predominantly sickness-based health care system, how much time and effort should we expect that physician to devote to it?

This is a complex question whose answer depends on the underlying context.
Transform: Health and technology need to bridge economic gaps
September 9, 2014 12:49 pm by Dan Verel

The intersections of health, culture, socioeconomic status and emerging technologies must be weaved together more seamlessly in order for the healthcare delivery system to truly improve health outcomes for those most in need. Meanwhile, consumer-focused care and the application of new data and analytics by payers and providers will only accelerate in the coming years.

With respect to so-called big data, even the most advanced provider organizations are struggling to cope with an onslaught of new information, and it can be overwhelming.

“We’re in the middle of an exponential data explosion like we’ve never seen before, and it’s getting faster and faster,” said Mike Rhodin, senior vice president of IBM Watson. “All of that information is starting to swell up.” Information is being culled from already-published data in medical journals and from drug clinical trials, to name just a few sources. On top of that, new information from EHRs and claims data is being added to the mix.

“All that information is creating an environment where we need new tools that can work with us, not in place of us,” Rhodin said, adding that it won’t slow down anytime soon.

“Information and IT is going to start being as important to medicine as the discovering of drugs to diseases and surgical practices,” he said.

But while technology and health IT will play a key role, significant barriers to health persist, including economic conditions that often portend poor health outcomes in both urban and rural environments.

“Economic parity would go a long way in overcoming health outcome gaps..."
"Upstream factors?" Recall also from my August 13th post?

Larry Keeley, of Doblin Innovation Consultants, said innovation has to take into account both technology and public health, and that disruption should be focused on social issues, not simply one industry or one company.

“What if community health is more about economic health and status and only a little about medicine?” he posited...
It is, in fact.


Just kidding, of course. The above is from Science Based Medicine's post "Autism Prevalence Unchanged in 20 Years."

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