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Friday, August 21, 2015

Medical Progress: Looking back, looking ahead.

As I have noted before, this blog began in 2010 principally to serve as as a chronicle of my involvement with the then- just-deployed federal Meaningful Use program. But, given my ineradicable contextual big-picture interests, the posts have ranged far and wide topically, spanning the breadth of more or less overlapping subjects surrounding "mere" Health IT (itself inclusive of a number of areas such as "usability" and the vexing misnomer "interoperability"): ePHI security and privacy (including the dense requirements of HIPAA), intellectual property, the Byzantium of our healthcare economics (including the durably-contentious PPACA and the recent hot area of venture capital-fueled health apps "innovation"), clinical pedagogy, medical science, the so-called "Art of Medicine," organizational culture (most notably, though not exclusively, as it impacts patient safety), process QI initiatives such as Lean, Six Sigma, and Agile, and the confounding multifaceted "Upstream."

I thought it a good time to reflect on some history, particularly in light of my recent post on the incipient, ostensibly "transformative" boom in applied "Omics" science.

Fifty years ago this month, when I was an exuberant living-the-dream 19 yr old guitar player performing with the veteran "Hollywood Argyles" at The Beachcomber nightclub on the boardwalk in Seaside Heights, NJ, this opinion piece appeared in JAMA.

August 16, 1965

Of Science, Humanism, and Medicine

The school of Hippocrates established the course of modern medicine when it discarded the magic of previous centuries to base its teaching on observation of the patient at the bedside. Essential unit of medical practice was what later became known as the consultation, described by English clinician Sir James Calvert Spence as “...the occasion when, in the intimacy of the sick room, a person who is ill, or believes himself to be ill, seeks the advice of a doctor whom he trusts. This is a consultation and all else in the practice of medicine derives from it.”

After  many intervening changes, a further revolution developed in the 19th century when science and technology effectively invaded clinical medicine. In the 20th century, the Flexner report revolutionized medical education and stimulated the establishment of full-time clinical departments. Medical thinking became permeated by new, rapidly developing technology, and medicine moved into the Age of Science. Today, the laboratory test in the clinical experiment have too a large degree supplanted the consultation is the essential unit of medical practice. Family–doctoring and even consulting practice have come to be regarded as comparatively inferior pursuits in which the truths of science have not yet come to full bloom.

The scientific explosion of the century has brought incalculable benefit to the progress of medicine. Research institutions under full-time staffs give promise of being the instruments of even greater scientific discovery in the future. Yet, there is cause for concern in this new climate of opinion  (as authoritative as it is naïve) that has risen from the astonishing success of science in our lifetime; there is danger in the optimistic view that science holds the answers  to all of the problems of medicine, if we can but find them. Other values are made to seem less important. Obscured is the realization that sickness and death are inevitable sequelae of life, that science can never bring to an end human suffering.

Essentially, medicine is at least as close to humanism as it is to science, it is concerned with all that touches on human life and feeling. Medicine must employ science; his horizons are too broad to be in compost by any division of knowledge. The practice of medicine — although it must be buttressed by hospitals and laboratories — is basically an affair between highly educated, highly trained human beings and those who seek their counsel in the privacy of the consultation room. The quality of medical practice depends on the  intensity with which physicians, motivated by humane feelings toward their patients, apply their knowledge and experience to the particular problem at hand. The proper concern of medicine’s people, not things; human life and values, not an anatomy and physiology. Practitioners must be guided by the cold light of science; and if they are to do their best, they must feel warmth and fulfillment in applying their knowledge to the problems of individuals.

It is unfortunate that a schism exists between academic medicine and medical practice at a time in history when social and economic forces portend a further medical revolution which, although primarily concerned with the distribution of medical services, has serious implications for medical progress. “The Obsolescence of the Practitioner–Teacher”… Attempts to stimulate every unification of the ranks of physicians. The profession must guide its way into a future that will not have sacrificed the best of its heritage.
JAMA. 1965; 193 (7):610
Interesting, no? In some ways, the more things change, the more they remain the same. See my December 2014 The art of medicine consists of amusing the patient while nature cures the disease.

UPDATE: I've just finally had my Calypso Beacon prostate implants done (after several weeks' delay), for my upcoming IMRT tx. That did not go particularly well. The urologist had difficulty getting a clear view prostate image with the rectal ultrasound probe, and the px took a long time to complete. I don't think he does a lot of these. He even alluded to not having "done this lately." Maybe that's my Bad; I probably should have asked. I had been told by his MA that "it won't be as bad as the biopsy."

Wrong. the biopsy px was a piece of cake compared to this transient bit of torture. I was wishing I'd brought a change of shirts. I soaked the one I was wearing.

I joke that "I feel like I have Toby Keith's boot up my ass."

Whatever. It should be relatively easy from here on.
Side note: Monday I called the urology clinic to verify my Tuesday Calypso implants px appointment and their Oakland address. "No, we don't show any upcoming appointments for you ... wait, let me check ... OK, we're changing our computer system, and your appointment is still in the old one."
They're migrating from NextGen to Epic. 30 minutes later I got an email notifying me of a new message in my Muir portal inbox. I logged in. It was advising my of my next day's urology clinic appointment.

On the continuing BCBSRI EoB follies. This latest is a real head-scratcher.

Click to enlarge. So, ZERO dollars billed to the insuror by anyone, yet BCBSRI nonetheless paid $10.64 to someone, for something, and my coinsurance amount for this phantom remittance is $1.17? The EoB page 2 detail tabulation lists a bunch of my November 2014 orthopedic PT encounters at the Brentwood facility (long since settled, and regarding which I apparently overpaid back many months ago by $123.16). None of the subtotals and totals add up. Not even close.

Another EoB dated the next day (07/23/15) also showed up in the mail along with this one, stating that my OOP met (Out Of Pocket) for 2015 is in fact not zero, but I have a max OOP balance of $986.92 (which, no doubt, my IMRT tx will zero out).

In the words of President-elect Donald Trump®, "these people are stupid!"

This is one reason why we in the U.S. pay double. This kind of stuff is pure Steve Brill.


Sometimes I get to thinking that the folks at BCBSRI should be designated a Protected Class under the ADA. I just got a bill from "John Muir Magnetic Imaging." $2,925.00 for my July 9th endo-rectal coil MRI. Full retail balance. "Due upon receipt."

I logged into the BCBSRI subscriber portal.

At least this time it shows up.

That's it. No additional information detailing the justification rationale for the claim denial. No idea what "UM" refers to. "Utilization Management"?

I responded in their "secure messaging system."

Click to enlarge if necessary for reading clarity.

Let's recap: first, they denied my post-biopsy sepsis hospitalization claim, on the negligently erroneous grounds that I was "no longer insured" (they'd used my expired 2014 subscriber ID, still floating around somewhere in Muir's database -- notwithstanding that I'd handed over my active 2015 card at the hospital when I went in for the sepsis tx. Then they flubbed the ER doc group's separate "independent contractor" claim for $623. It finally got processed and paid some 90 days out, after a bunch of emails and phone calls. I was on the hook for about $45 of that in the end. The reason for that bumbling has really never fully clarified. In part some, stupid, dissembling beg-off crap about a mismatch between my wife's Walnut Creek P.O. box (where her BCBS mail goes) and our Antioch street address.

Look; you have my full name, my DoB, my Social, and my BCBSRI Subscriber ID, don't try to play me with this "no-match" baloney. I've been around IT too long.

With respect to this latest CusterFluck, recall, if you've followed my "shards" posts, that BCBSRI, via their "EviCore" auth review vendor, initially denied pre-auth for the endo-rectal coil pelvic/prostate MRI, which was subsequently overturned on appeal. Muir refused to even schedule me absent an auth. It was eventually approved, and the px was performed.

But, now, they refuse to pay for any of it.

It almost smacks of fraud. More charitably, though, chalk it up to bureaucratic incompetence? 'eh?

Shards. Sand in the gears.

So, come Monday morning I will surely again be at length on the phone in "please hold; your call is important to us" mode, wasting my (unpaid) time trying to rectify this so that the MRI provider gets paid, without my being backed up into the coercive threat of a "past due collections" action.

UPDATE: Monday morning I called the Muir Imaging payment center to apprise them of the issue, and also had some "secure messaging" interaction on the BCBSRI portal. The latest reply:
Dear Robert Gladd, Thank you for the additional information. I have spoken with Dr. Xxxxx's office, and I am waiting for a return call from them, as they needed to access some records that the person that I spoke with could not access. They have promised me a return call by the end of day on Wednesday. I will reply via secure message after I have spoken with them. Thank you for your patience.
Dr. Xxxxx is the Radiation Oncologist at Stanford who ordered the pelvic/prostate endo-rectal coil MRI, sent electronically to Muir. Precisely why BCBSRI needs to contact him again escapes me. His px order is on record. The initial denial by their px/tx review subcontractor EviCore is on record. The appeal and subsequent denial reversal by EviCore is on record. The pre-auth is on record. The MRI was scheduled and performed. All a matter of record. A record that should be right there in the BCBSRI data.

I don't get it. there's no un-ringing this bell. What are we gonna have now? A "post-authorization" denial?

Refrain: This is why we pay double.


My query is on the bottom. The CS Rep response is atop that.

So, Muir Imaging used the wrong code in their billing submission. And, the data processing amnesiacs at BCBSRI looked no further -- which, I guess, plays to their advantage. Work the float for at least another billing cycle.

Next up for me? A CT imaging "targeting / tx planning" encounter at Rad Onco on Tuesday, after which I will commence 9 weeks of Calypso M-F IMRT, probably 2 weeks following that session. Should BCBSRI remain true to form thus far, I expect there will be more bozo stuff to report.


Recall my recent citing of this book?

It will be released on Tuesday August 25th. Can't wait to get it and study it. It was just the topic of a NPR "Fresh Air" segment.


While I await tomorrow's release of "Machines of Loving Grace," yet another book on the topic has hit my radar. Just downloaded it.

Have yet to read it, but here's a snip from a quick keyword search:
The days of the “country doc” are long gone, but information technology is also transforming the character of medical practitioners in surprising ways.

The main shift is a growing recognition that the medical arts are not arts at all but a science that is better driven by statistics and data than intuition and judgment. In bygone eras, it was at least plausible that someone could absorb a reasonable proportion of the world’s medical knowledge and apply it to cases as they are presented. But over the past half century or so, as it became clear that the avalanche of research, clinical trials, and increased understanding of how our bodies (and minds) work was beyond the comprehension of a single individual, the field fractured into a myriad of specialties and practices. Today, your “primary care physician” is more of a travel agent to the land of specialists than a caregiver, except for the simplest of ailments.

But the hidden costs of this divide-and-conquer approach to medical care are about to become painstakingly clear. Coordinating the activities of multiple practitioners into a coherent plan of action is becoming increasingly difficult, for two reasons. First, no one has the complete picture, and, even if they do, they often lack the detailed knowledge required to formulate the best plan of action. Second, specialists tend to treat the specific conditions or body parts that they are trained for, with inadequate regard for the side effects or interactions with other treatments the patient may be receiving. For me, the practice of medicine today conjures the image of a Hieronymus Bosch painting, with tiny, pitchfork-wielding devils inflicting their own unique forms of pain.

As a patient, you would ideally prefer to be treated by a superdoc who is expert in all the specialties and is up to date on all of the latest medical information and best practices. But of course no such human exists.

Enter IBM’s Watson program. Fresh off its Jeopardy! victory over champions Brad Rutter and Ken Jennings, Watson was immediately redeployed to tackle this new challenge. In 2011, IBM and WellPoint, the nation’s largest healthcare benefits manager, entered into a collaboration to apply Watson technology to help improve patient care. The announcement says, “Watson can sift through an equivalent of about one million books or roughly 200 million pages of data, and analyze this information and provide precise responses in less than three seconds. Using this extraordinary capability WellPoint is expected to enable Watson to allow physicians to easily coordinate medical data programmed into Watson with specified patient factors, to help identify the most likely diagnosis and treatment options in complex cases. Watson is expected to serve as a powerful tool in the physician’s decision making process.” As with its original foray into AI fifty years ago, IBM is still cautious not to ruffle the feathers of the people whose rice bowls they are breaking, but one person’s decision process support tool is another’s ticket to the unemployment line.

No one likes the idea that his or her field is simply too big and fast moving to master. And doctors in particular aren’t likely to graciously concede control of their patients’ treatment to synthetic intellects. But eventually, when outcomes demonstrate that this is the better option, patients will demand to see the attentive robot, not the overworked doctor, for a fraction of the fee, just as many people would now rather have an ATM than a human teller count out their cash.

Kaplan, Jerry (2015-08-04). Humans Need Not Apply: A Guide to Wealth and Work in the Age of Artificial Intelligence (Kindle Locations 1738-1764). Yale University Press. Kindle Edition.
See my July 20th post "AI vs IA: At the cutting edge of IT R&D."

Also apropos, Margalit Gur-Arie has a fine new post up.
Measuring the Doctor-Patient Relationship
...Although there is ample rhetoric about the doctor-patient relationship and patient-centered everything, much of what we do in health care today is in stark contradiction ... Patient choice is being curtailed by a bewildering array of narrow network health plans and wholesale clinical decisions made by corporate CEOs. Competence is being redefined to include care provided by non-physicians, non-clinicians, and algorithmic software. Continuity of care is being discouraged in favor of cheapness, convenience and continuity of medical records, while conflict of interest is inherent in all so called value-based arrangements. Compassion has been scripted by marketers, and communication, precisely codified for the eclectic, self-managing, highly educated, financially secure, and largely healthy, patient segment, has become the second most important factor defining the interaction between patients and the health system. The premier factor is of course, access to all of the above...
And then there's this, from NEJM:
The Paternalism Preference — Choosing Unshared Decision Making
Lisa Rosenbaum, M.D.

...Clearly, patients should have access to all available information, from their medical records to anticipated costs of care. But that it's wrong to deny anyone information doesn't make it right to always provide as much as possible. Might there, in fact, be such a thing in medicine as Too Much Information?...

Last March, my friend Paul Kalanithi, a 37-year-old neurosurgeon, died of lung cancer. Writing after his diagnosis, he contrasted his newfound obsession with cancer survival statistics with his struggle to communicate such information to his own patients without destroying their hope. As he struggled to extract from his oncologist precise information about his life expectancy, he realized, “What patients seek is not scientific knowledge doctors hide, but existential authenticity each must find on her own.”

Perhaps we can't provide existential meaning, but the way we share information may exacerbate patients' sense of vulnerability and alienation. When we rattle off a litany of possible risks, say “Please sign here,” and check our watches when the patient says, “Hold on, I need to put on my glasses to read this,” we have neither succeeded in the spirit of patient engagement nor honored anyone's values. But is more information the answer?

In an essay entitled “Arrogance,” published posthumously in 1980, former Journal editor Franz Ingelfinger describes his experience as a patient with adenocarcinoma of the gastroesophageal junction — the area he'd studied for much of his career. As he considered the trade-offs of chemotherapy and radiation, receiving contradictory expert opinions, he and his physician family members became “increasingly confused and emotionally distraught.” Finally, one physician friend told him, “`What you need is a doctor.'” Ingelfinger notes, “He was telling me to forget the information . . . and to seek instead a person who would . . . in a paternalistic manner assume responsibility for my care. When that excellent advice was followed, my family and I sensed immediate and immense relief.”

The doctors I admire most are characterized not by how much they know but by a sophisticated intuition about how best to share it. Sometimes they tell their patients what to do; sometimes they give them a choice. Sometimes, when discussing treatment options, they cover all seven tenets of informed consent. Sometimes, instead, seeing the terror of uncertainty in a patient's face, they make their best recommendation and say, “I don't know how things are going to turn out, but I promise I'll be there with you the whole way.”

More to come...

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