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Monday, April 25, 2016

Digital Health IT = "Better Care at Lower Cost." Right?

That was the promise, recall?

Below, I shot this off a slide deck screen at the HIMSS Conference in 2012.

Last Friday while on my way home from my weekly volunteer day in San Francisco, I heard an interesting NPR "Intelligence Squared" debate on the question "should corporate subsidies be eliminated?"
The auto industry, agriculture, the energy sector. What do they have in common? These industries benefit from government subsidies in the form of loans, tax breaks, regulation, and other preferences. Critics from the left and right say that not only do these subsidies transfer wealth from taxpayers to corporations, they distort the markets and our economy. Proponents say that government has an important role to play in launching innovation via strategic investment, and its support helps American companies thrive. Do we need subsidies, or is this corporate welfare?
From the transcript:

And that motion is Eliminate Corporate Subsidies and here to make his closing statement against the motion, Michael Lind, policy director of the economic growth program at New America and author of "Land of Promise."

Michael Lind:
Medical errors are the third leading cause of death in the United States. Up to 440,000 Americans die each year from preventable medical errors. A lot of it because the lag with doctor's offices using paper records. As part of the stimulus act in 2009, the federal government has spent to date more than $35 billion in incentives to individual doctors, hospitals, and other health care providers. What's the result? In 2009, those using -- the physicians using electronic health records were only 21.8 percent. Today, a few years later, they are 78 percent. The subsidy worked. In 2009, only 12.2 percent of non-federal acute care hospitals were using a basic computer electronic health record system. By 2014, after this $30 billion had been spent, more than 76 percent were. This is a tremendous unsung success of federal policy. Now, there are problems with the next stage.

There are problems with interoperability, with monopolistic corporations engaged in so- called data blocking. So there are problems with it. But, you know, this sort of really brings it home. As a result of this particular highly successful federal subsidy, your loved ones or your own life may be saved and as long as there are a few programs like this that are successes, you need to vote against the motion.

John Donvan:
Thank you, Michael Lind.

Well, myriad critics would dispute the assertion that the HITECH "Meaningful Use" initiative has turned out to be a "highly successful federal subsidy." Mr. Lind's citing of post-MU accelerated HIT uptake does nothing to answer the "better care at lower cost" question. Many critics argue that MU has in fact stifled innovation, and has largely served to line the pockets the large incumbent EHR vendors, while perhaps even having an adverse effect on care delivery, via clinically irrelevant "productivity treadmill" compliance imperatives.

Beyond issues of uniform, appropriate operational definitions of "better" and "lower cost," I continue to regard it as premature to declare either "failure" or "victory" in this area. As I observed a year ago in my March 2015 HITECH Interoperababble Update post:

I have noted before what I call "Health IT Policy ADHD." Major legislation gets passed and funded, and when we don't get immediate, dazzling results, we go sour on it, lamenting its "failure," and calling for its demise. HITECH is not that old. There have really only been four years of full-bore boots-on-the-ground operation. REC contracts were let in 2010, and the RECs spent most of their first year getting their sea legs under them and scurrying about hustling skeptical clinical participants...

We never tire of citing the "information superhighway" analogy. Fine. The U.S. Interstate Highway system took more than 35 years to complete. Significantly and sustainably transforming the incredibly complex, heterogeneous U.S. healthcare delivery and information infrastructure easily rivals it in scale and exceeds it in complexity by orders of magnitude. Moreover, this $35 billion outlay comes to about $22 per capita per year since the deployment of the HITECH program five years ago. The latest NHE per capita expenditure is about $10k. $22 is about 0.2% of that (0.0022). Close to being a rounding error...
Some other vexingly inhibitory factors go to the byzantine, dysfunctional economic imperatives of organizational structures and cultures in the health care space. See my accruing rant The U.S. healthcare "system" in one word: "shards."

On healthcare workforce cultural dysfunction specifically, recall my post The "Talking Stick" and the three-legged stool of sustained, transformative healthcare QI.

Socioeconomic issues: “When it comes to health, your zip code matters more than your genetic code.”

Relatedly, The future of health care, continued. Where will economics come in?

Then, there are more fundamental concerns, going to the effects of digitization on clinical cognition per se. See Are structured data now the enemy of health care quality?

I've also set forth my concerns regarding "personalized medicine," which necessarily include the various "omics" scientific disciplines. See, e.g., Omics update: National Human Genome Research Institute Health IT news.

So many contending, frequently mutually-negating moving parts, so little time.

Now comes a very big new wrinkle.

This book has been an utter delight to read, at once scholarly, scientific, accessible, and conversationally genial. The implications for health and health care delivery could not be more important, IMO. Seems like I spent half of the weekend reading parts of it aloud to my wife. I bought the Kindle edition, and have also just ordered a hardcopy for her and my daughter.
...I have made the human body the focus of my career. In fact, I am extremely lucky to be a professor at Harvard University, where I teach and study how and why the human body is the way it is ... I study fossils, I travel to interesting corners of the earth to see how people use their bodies, and I do experiments in the lab on how human and animal bodies work...

...of all the questions I am commonly asked, the one I used to dread the most was “What will human beings look like in the future?” ... My reflexive answer was always something along the lines of: “Human beings aren’t evolving very much because of culture.” This response is a variant of the standard answer that many of my colleagues give when asked the same question.

I have since changed my mind about this question and now consider the human body’s future to be one of the most important issues we can think about. We live in paradoxical times for our bodies. On the one hand, this era is probably the healthiest in human history. If you live in a developed country, you can reasonably expect all your offspring to survive childhood, to live to their dotage, and to become parents and grandparents. We have conquered or quelled many diseases that used to kill people in droves: smallpox, measles, polio, and the plague. People are taller, and formerly life-threatening conditions like appendicitis, dysentery, a broken leg, or anemia are easily remedied. To be sure, there is still too much malnutrition and disease in some countries, but these evils are often the result of bad government and social inequality, not a lack of food or medical know-how.

On the other hand, we could be doing better, much better. A wave of obesity and chronic, preventable illnesses and disabilities is sweeping across the globe. These preventable diseases include certain cancers, type 2 On the other hand, we could be doing better, much better. A wave of obesity and chronic, preventable illnesses and disabilities is sweeping across the globe. These preventable diseases include certain cancers, type 2 diabetes, osteoporosis, heart disease, strokes, kidney disease, some allergies, dementia, depression, anxiety, insomnia, and other illnesses. Billions of people are also suffering from ailments like lower back pain, fallen arches, plantar fasciitis, myopia, arthritis, constipation, acid reflux, and irritable bowel syndrome. Some of these troubles are ancient, but many are novel or have recently exploded in prevalence and intensity. To some extent, these diseases are on the rise because people are living longer, but most of them are showing up in middle-aged people. This epidemiological transition is causing not just misery but also economic woe. As baby boomers retire, their chronic illnesses are straining health-care systems and stifling economies. Moreover, the image in the crystal ball looks bad because these diseases are also growing in prevalence as development spreads across the planet.

The health challenges we face are causing an intense worldwide conversation among parents, doctors, patients, politicians, journalists, researchers, and others. Much of the focus has been on obesity. Why are people getting fatter? How do we lose weight and change our diets? How do we prevent our children from becoming overweight? How can we encourage them to exercise? Because of the urgent necessity to help people who are sick, there is also an intense focus on devising new cures for increasingly common noninfectious diseases. How do we treat and cure cancer, heart disease, diabetes, osteoporosis, and the other illnesses most likely to kill us and the people we love?

As doctors, patients, researchers, and parents debate and investigate these questions, I suspect that few of them cast their thoughts back to the ancient forests of Africa, where our ancestors diverged from the apes and stood upright. They rarely think about Lucy or Neanderthals, and if they do consider evolution it is usually to acknowledge the obvious fact that we used to be cavemen (whatever that means), which perhaps implies that our bodies are not well adapted to modern lifestyles. A patient with a heart attack needs immediate medical care, not a lesson in human evolution.

If I ever suffer a heart attack, I too want my doctor to focus on the exigencies of my care rather than on human evolution. This book, however, argues that our society’s general failure to think about human evolution is a major reason we fail to prevent preventable diseases. Our bodies have a story— an evolutionary story— that matters intensely. For one, evolution explains why our bodies are the way they are, and thus yields clues on how to avoid getting sick. Why are we so liable to become fat? Why do we sometimes choke on our food? Why do we have arches in our feet that flatten? Why do we have backs that ache? A related reason to consider the human body’s evolutionary story is to help understand what our bodies are and are not adapted for. The answers to this question are tricky and unintuitive but have profound implications for making sense of what promotes health and disease and for comprehending why our bodies sometimes naturally make us sick. Finally, I think the most pressing reason to study the human body’s story is that it isn’t over. We are still evolving. Right now, however, the most potent form of evolution is not biological evolution of the sort described by Darwin, but cultural evolution, in which we develop and pass on new ideas and behaviors to our children, friends, and others. Some of these novel behaviors, especially the foods we eat and the activities we do (or don’t do), make us sick...

The core subjects of this book— human evolution, health, and disease— are enormous and complex. I have done my best to try to keep the facts, explanations, and arguments simple and clear without dumbing them down or avoiding essential issues, especially for serious diseases such as breast cancer and diabetes...

...I have rashly concluded the book with my thoughts about how to apply the lessons of the human body’s past story to its future. I’ll spill the beans right now and summarize the core of my argument. We didn’t evolve to be healthy, but instead we were selected to have as many offspring as possible under diverse, challenging conditions. As a consequence, we never evolved to make rational choices about what to eat or how to exercise in conditions of abundance and comfort. What’s more, interactions between the bodies we inherited, the environments we create, and the decisions we sometimes make have set in motion an insidious feedback loop. We get sick from chronic diseases by doing what we evolved to do but under conditions for which our bodies are poorly adapted, and we then pass on those same conditions to our children, who also then get sick. If we wish to halt this vicious circle then we need to figure out how to respectfully and sensibly nudge, push, and sometimes oblige ourselves to eat foods that promote health and to be more physically active. That, too, is what we evolved to do.

Lieberman, Daniel (2013-10-01). The Story of the Human Body: Evolution, Health, and Disease. Knopf Doubleday Publishing Group. Kindle Edition, locations 41-99.
Boy, does he ever deliver across the full span of the book. A must-read, in my view.

Some triangulation.

I came to this book by way of, one of my requisite daily stops.
Human life has changed immensely over the millennia, but never so much or so quickly as in the past century. For almost the entire 200,000-year existence of our species, Homo sapiens, biology controlled us. We gathered fruits, nuts, and plants; hunted and fished for the animals that were available; and like the wildebeest or zebra, we moved on when resources ran low. Even after the advent of farming and civilization, and the development of cities, we were still very vulnerable to the whims of the weather, and to famine and epidemics. 

But in just the past hundred years or so, we have turned the tables and taken control of biology. Smallpox, a virus that killed as many as 300 million people in the first part of the twentieth century (far more than in all wars combined) has not merely been tamed but has been eradicated from the planet. Tuberculosis, caused by a bacterium that infected 70– 90 percent of all urban residents in the nineteenth century and killed perhaps one in seven Americans, has nearly vanished from the developed world. More than two dozen other vaccines now prevent diseases that once infected, crippled, or killed millions, including polio, measles, and pertussis. Deadly diseases that did not exist in the nineteenth century, such as HIV/ AIDS, have been stopped in their tracks by designer drugs. 

Food production has been as radically transformed as medicine. While a Roman farmer would have recognized the implements on an American farm in 1900— the plow, hoe, harrow, and rake— he would not be able to fathom the revolution that subsequently transpired. In the course of just one hundred years, an average yield of corn more than quadrupled from about 32 to 145 bushels per acre. Similar gains occurred for wheat, rice, peanuts, potatoes, and other crops. Driven by biology, with the advent of new crop varieties, new livestock breeds, insecticides, herbicides, antibiotics, hormones, fertilizers, and mechanization, the same amount of farmland now feeds a population that is four times larger, but that is accomplished by less than 2 percent of the national labor force compared to more than 40 percent a century ago. 

The combined effects of the past century’s advances in medicine and agriculture on human biology are enormous: the human population exploded from fewer than 2 billion to more than 7 billion people today. While it took 200,000 years for the human population to reach 1 billion (in 1804), we are now adding another billion people every twelve to fourteen years. And, whereas American men and women born in 1900 had a life expectancy of about forty-six and forty-eight years, respectively, those born in 2000 have expectancies of about seventy-four and eighty years. Compared to rates of change in nature, those greater than 50 percent increases in such a short timespan are astounding...

Diseases, it turns out, are mostly abnormalities of regulation, where too little or too much of something is made. For example, when the pancreas produces too little insulin, the result is diabetes, or when the bloodstream contains too much “bad” cholesterol, the result can be atherosclerosis and heart attacks. And when cells escape the controls that normally limit their multiplication and number, cancer may form. 
To intervene in a disease, we need to know the “rules” of regulation...

Carroll, Sean B. (2016-02-16). The Serengeti Rules: The Quest to Discover How Life Works and Why It Matters (Kindle Locations 96-130). Princeton University Press. Kindle Edition.
"To intervene in a disease, we need to know the “rules” of regulation."

Yeah, and Dr. Lieberman would say that we need to look more closely at the implications of the broad span of human evolution in order to effectively manage, mitigate, and/or cure what he calls today's "diseases of evolutionary mismatch." Absent that contextual grounding, we may well do everything else (including HIT deployment and process QI) as efficaciously as possible and still come up short.

BTW, tangentially, a bit more "evolution" triangulation.

Michael Tomasello sets forth a pretty compelling case for the evolutionary adaptive utility of prosocial, empathic, and altruistic inclinations and behaviors. My summary excerpts here.

Ayn Randians will have a cow.

Dr. Lieberman:
...For millions of years, our ancestors relied on innovation and cooperation to get enough food, to help care for one another’s children, and to survive in hostile environments, such as deserts, tundras, and jungles. Today we need to innovate and cooperate in new ways to avoid eating too much food, especially excess sugar and processed industrial foods, and to survive in cities, suburbs, and other unnatural environments. We therefore need government and other social institutions on our side, because we never evolved to choose healthy lifestyles. Most people don’t get sick through any fault of their own, but instead they acquire chronic illnesses as they age because they grew up in an environment that encourages, entices, and sometimes even forces them to become sick. For many of these diseases, we can then only treat the symptoms. Unless we want to end up as a species ever more dependent on medicines and expensive technologies to cope with the symptoms of preventable diseases, we need to change our environments. In fact, it is questionable whether we can continue to afford the cost of our current trajectory of increased longevity and population sizes combined with increased chronic morbidity. 

I think it is reasonable to conclude that cultural evolutionary processes today are gradually replacing one form of coercion with another. For millions of years, our ancestors were required to consume a naturally healthy diet and to be physically active. Cultural evolution, especially since humans began farming, has transformed how our bodies interact with the environment. Many people today still live in poverty and suffer from diseases caused by poor sanitation, contagion, and malnutrition that were much less common in the Paleolithic. Those of us fortunate enough to live in the developed world have escaped those miseries, and we can now choose to be inactive as much as we want and eat whatever we crave. In fact, for some, such habits are the default setting. Those choices or urges, however, often make us sick in other ways, which then compel us to treat our symptoms. Right now, we are generally satisfied with the system we have created, thanks to long life spans and overall decent health. But we could do better. And as the mismatch environments we have created and pass on to our children through the pernicious feedback loop of dysevolution intensify, we increase our risk of suffering from needless, preventable diseases. [Lieberman, op cit, pp. 364-365].
I would make Daniel Lieberman's book required reading in Med School. Buy it and study it ASAP.

BTW, I came to the book here, at The Daily Beast.


Count me a fan of Gould's "Drunkard's Walk" theory of evolution.
Before the advent of rapid, accurate, and inexpensive DNA sequencing technology in the early 2000s, biologists guessed that genes would provide more evidence for increasing complexity in evolution. Simple, early organisms would have fewer genes than complex ones, they predicted, just as a blueprint of Dorothy’s cottage in Kansas would be less complicated than one for the Emerald City. Instead, their assumptions of increasing complexity began to fall apart. First to go was an easy definition of how complexity manifested itself. After all, amoebas had huge genomes. Now, DNA analyses are rearranging evolutionary trees, suggesting that the arrow scientists envisioned between simplicity and complexity actually spins like a weather vane caught in a tornado...

With comb jellies at the base of the tree, evolution suddenly seems less like a march towards complexity and more like a meandering stroll. This isn’t a new idea. Back in 1996, evolutionary biologist Stephen Jay Gould posited that evolution progresses like a drunkard’s walk. Organisms, he said, stand an equal chance of becoming simpler or more complex over millions of years—although sometimes there’s a lower limit on how simple they can possibly be, just as a drunk may fall into a gutter at the far left side of the road. An Internet meme even celebrates oddities that result from evolution’s stumble: “ Go Home Evolution, You’re Drunk,” features organisms with sub-optimal traits that have managed to survive just fine...

Perhaps the fact that people are stunned whenever organisms become simpler says more about how the human mind organizes the world than about evolutionary processes. People are more comfortable envisioning increasing complexity through time instead of reversals or stasis. Physicist Sean Carroll calls humans “ terrible temporal chauvinists” for this reason, because they desperately want the street from the past to the future to run in one direction. The textbook scenarios on early animal evolution might be correct, but they should be treated as hypotheses built by temporal chauvinists. When new data suggests a rearrangement, it must be considered no matter how perplexing the conclusion seems.

Casey Dunn, an evolutionary biologist at Brown University in Providence, R.I. who took part in the still-contentious comb jelly project, now doubts all notions of increasing complexity. Instead, he says the environment selects whatever form handles the challenges at hand, be it simple, complex, or plain ugly.  Mother Nature, with her 4 billion years of experience, does not work like Steve Jobs, continuously designing sleeker versions. When asked whether de-evolution, a reversal from the complex to the simple, happens frequently, Dunn replies, sure. “But,” he adds, “I wouldn’t call that de-evolution, I’d call it evolution.”
The "bush of life" rather than "the tree of life" metaphor. I just like the "Occam's Razor" simplicity as it applies to evolution. You need assume only three things, all of which exist: [1] simple carbon-based organisms capable of reproducing, [2] a relatively stable environment with a reliable source of energy input, and [3] a lot of time. You need not anthropomorphically assume "purpose," "intentionality," an evolutionary "drive toward complexity."

Pop the clutch, and 4.7 billion years later you might end up with us (along with the enormous volume of single-celled microbial life that still accounts for the bulk of planetary biota). Re-run the experiment and you probably get something unrecognizably different (Dr. Lieberman even generally alludes to this likelihood).

All the more reason to treat life with reverence.


Put up a short post, one pointing back here, over at the new publishing platform. See The underappreciated evolutionary factors that bear on human health and impede effective modern health care

Just trying out the platform. It's OK. I have my doubts as to their business model.

More to come...

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