Welcome, Comrade Patient

By Kim Bellard, December 14, 2017 Capitalism is in big trouble, even in the U.S. and especially among millennials.  So reports Fast Company and The New York Times.  Even capitalism-friendly publications like The Wall Street Journaland Bloomberg warn about it.  The oft-cited reasons include problems like increasing income/wealthy inequity and dimmer outlook for good jobs, but I have to wonder how much of a role our health care system plays in these kinds of attitudes. The WSJ also showed a 2016 Gallop poll in which capitalism and socialism were rated equally favorably (both just over 50%) by respondents ages 18 - 29, which was a stark contrast to every other age group (support for capitalism goes up by age, while support for socialism declines).  Similarly, a 2017 WSJ/NBC News survey found that the 18-29 age group was much more likely to say the government should do more to help people, again in contrast to other age groups.  In some ways, the U.S. health care system is a model of capitalism.  Lots of people are making lots of money, whether they be stockholders in health companies, doctors and health care executives, or even supposedly non-profit parts of the system.  The problem is, though, unless you are one of the lucky ones doing well with our current system -- and maybe even then -- you're probably not too happy with it.  Last year, Senator Bernie Sanders made unexpected headway in his race to be the Democratic candidate for President despite -- or perhaps because of -- his socialist leanings.  One of his key planks was for Medicare for all, an idea that has seen a strong resurgence generally.  Even more popular is the (admittedly vague) push for single payor. A Harvard-Harris poll found that 52% of Americans supported a single payor system, with even 35% of Republicans supporting.  Young people were most supportive.   Perhaps most astonishing is that a Merritt-Hawkins survey found that 56% of physicians now support single payor, a sharp reversal from prior surveys.  42% voiced strong support. Right now, millennials are not as engaged in health care as older age groups because they tend to need it less.  They don't have as many health problems and don't see health professionals as often.  That's why getting them to buy health insurance is a constant struggle, even when they have the lowest premiums.    But as this radicalized generation, who are already frustrated with economic inequity and the prospects for their future, realize how much they will have to pay for older Americans' health needs as well as for their own, push will eventually come to shove.  We have some hard thinking to do about how we finance health care, and for whom.  We have some hard thinking about what the role of profit, competition, and capitalism should be in our health care system.  We have some hard thinking to do about why our health care system is not serving more of us better. It may not be socialized medicine.  It may not be single payor.  It may not even be Medicare-for-all.  But it for sure will not be what we have now.  This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting

Patients Are a Design Problem

by Kim Bellard, November 15, 2017 When I say "patients are a design problem," I don't mean that the people who happen to be patients are a design problem.  They may well be, but that's an issue you'll have to take up with Darwin or your favorite deity (or, all-too-soon, perhaps a CRISPR editor...).  No, I mean that making people into patients is a design problem.  And it's a big one. Consider the following: 1.  Physician Respect: We treat physicians as something special. That white coat is no longer needed and may, in fact, be counterproductive, but serves to remind of us the deference the health care system believes physicians are due.  2.  Patient experience: It's hard to get appointments.  The appointment time is often just a vague indicator of when we'll actually see our doctor.  We may have services done to us that we don't really understand and which not uncommonly are unpleasant, to say the least.   We may be asked to fast unnecessarily for hours before blood work or procedures.  We often are unsure about what is going to happen next, or when. It is not a patient-centered system. 3.  Medicalization:  We talk about the health care system, but we really mean the medical care system.  We almost never include, or pay for, the other things that impact our health, like diet, exercise, and environment.  4.  Better, Soon: We've seen remarkable strides in what medical care can achieve.  We have become a nation of pill-poppers.  When something is wrong with us, we expect to be able to get it fixed, and we expect that to happen quickly.  5.  Confusion reigns: Nothing about health care seems easy.  It's hard to pick a physician, or a health plan.  The terminology makes no pretense at being understandable to anyone not a health care professional.  The bills are practically indecipherable.  If you need multiple doctors, tests, or procedures -- which you almost certainly will -- you'll have to navigate the maze around getting them.  No one, lay or professional, claims to understand the "system." 6.  Responsibility: We've delegated responsibility for our health to our health care professionals, especially our doctors.  It is more established than ever that regular exercise, moderate eating, and a balanced life would do more to improve our health than any regime of medical treatments.  Yet we continue to expect that the results of our increasingly poor habits will be "fixed."  These are why we are "patients."  These are why we are expected to be patient. We will always need physicians (although not always human ones!), and many other health care professionals.  That's a good thing.  They have knowledge and skills that can help us.  They deserve our respect.  But we should design our health care system around us, not them.  Make the "system" simpler.  Focus it around our health, not our care.  Expect us to have responsibility for our own health -- but ensure we have the tools we need to manage it.  Spend money to prevent health issues, not address them once they've happened. If patients are a design problem, then maybe people can come up with a design solution.   This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting

Elon, Do We Have a Disaster for You!

By Kim Bellard, October 18, 2017

One of the most interesting twists resulting from Hurricane Maria striking Puerto Rico was Elon Musk's offer that Tesla could help Puerto Rico solve its energy crisis, with a long-term, 21st century fix. 
It is telling that we don't have similar offers to rebuild the Puerto Rico's health care system, which is similarly devastated.  Or, for that matter, our system, which is its own kind of disaster.

Mr. Musk was asked on Twitter if Tesla could help Puerto Rico using solar and battery power, and he responded in the affirmative, saying it had done so on smaller islands but faced no scalablity issues.  Next thing we knew the Governor of Puerto Rico and he were talking.  Now Tesla is starting to deliver their battery systems to the island, so we'll see.

Maybe it is a marketing stunt on Mr. Musk's part -- if so, you have to give him credit for it -- but the idea has merit.  A disaster like Maria is a once-in-a-lifetime opportunity to try bold new ideas instead of blithely rebuilding what was there before.

Still, even Elon Musk isn't bold enough to offer to rebuild their health care system, much less ours.

Sometimes disasters do make us rethink our health care system.  Katrina, for example, has often been credited with creating the impetus for electronic health records (EHRs), since it destroyed countless paper records, wrecking havoc on care for thousands of patients.

But we didn't pay enough attention to even that very visible crisis.  We do have a lot more EHRs now, but less than 30% of hospitals self-report being interoperable.

The records themselves remain largely physician-centered and exclusively medical, although Epic, the nation's largest EHR vendor, is finally saying they will move to a "comprehensive health record" (CHR). . 

I'm glad that in 2017 EHRs vendors are finally realizing there is health outside a medical facility.

It shouldn't take a hurricane -- or an earthquake, or a bickering Congress -- to realize that we have an in-progress disaster with our health care system. 

Let's say we were starting from scratch.  Let's reset what our health care system could be.  Let's say we didn't have all these hospitals, hadn't trained any physicians, hadn't deployed any medical devices or used any prescription drugs, although we could start with the knowledge of what each of those could accomplish.

Would we remake the system as it is, or would we design something new?

In a previous post I enumerated several things about our health care system I was dying to redesign, and in another I gave some specifics about how a re-engineered system might work.  Even those, though, didn't start from entirely scratch, still focusing more on the medical than on the broader health perspective.

We should be spending more on our health needs -- broadly defined -- than on our medical care.  We should be more worried about if people are going to the park than if they are going to the doctor's office.  And when we do get medical care, we should make sure it is care that has solid evidence of working, rather than too often accepting care that might work.

Elon Musk has his hands full saving humanity, not to mention helping Puerto Rico, so we probably can't count on him to offer to reinvent our health care system too.  So who will it be?

This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting

Health Care's Juicero Problem

by Kim Bellard, September 8, 2017 Bad news: if you were still hoping to get one of the $400 juicers from Juicero, you may be out of luck. Juicero announced that they were suspending sales while they seek an acquirer. They'd already dropped the juicer's price from its initial $700 earlier this year and had hoped to find ways to drop it further, but ran out of time.  Juicero once was the darling of investors. They weren't a juice company, or even an appliance company. They were a technology company! They had an Internet-of-Things product! They had an ongoing base of customers! The ridicule started almost as soon as the hype. $700 -- even $400 -- for a juicer? The negative publicity probably reached its nadir in April, when Bloomberg reported people could produce almost as much juice almost as fast just by squeezing the Produce Packs directly. Moral of the story: if you want to introduce products that have minimal incremental value but at substantially higher prices, you're better off sticking to health care. Take everyone's favorite target, prescription drugs. As Donald W. Light charged in Health Affairs, "Flooding the market with hundreds of minor variations on existing drugs and technically innovative but clinically inconsequential new drugs, appears to be the de facto hidden business model of drug companies." As with prescription drugs, we regulate medical devices looking for effectiveness but not cost effectiveness -- and we don't even do a very good job evaluating effectiveness in many cases, according to a recent JAMA study.  Take robotic surgery, hailed as a technological breakthrough that was the future of surgery. A robotic surgical system, such as da Vinci, can cost as much as $2 million, but, so far, evidence that they produce better outcomes is woefully scarce.  Proton beam therapy? It's one of the latest things in cancer treatment, an alternative to more traditional forms of radiation therapy, and is predicted to be a $3b market within ten years. The units can easily cost over $100 million to buy and install, cost patients significantly much more than other alternatives, yet -- guess what? -- not produce measurably better results.  Last year Vox used 11 charts to illustrate how much more we pay for drugs, imaging, hospital days, child birth, and surgeries than other countries. Their conclusion, which echoes conclusions reached by numerous other analyses: "Americans spend more for health care largely because of the prices." We not only don't get a nifty new juicer from all of our health care spending, we don't even get better health outcomes from it.    Health care's "best" Juicero example, though, may be electronic health records (EHRs). Most agree on their theoretical value to improve care, increase efficiency, and even reduce costs. But after tens of billions of federal spending and probably at least an equal amount of private spending, we have products that, for the most part, frustrate users, add time to documentation, and don't "talk" to each other or easily lend themselves to the hoped-for Big Data analyses.  Many physicians might, on a bad day, be willing to trade their EHR for a Juicero.  Jonathon S. Skinner, a professor of economics at Dartmouth, pointed out the problem several years ago: "In every industry but one, technology makes things better and cheaper. Why is it that innovation increases the cost of health care?"  So we can make fun of Juicero all we want, but when it comes to overpriced, under-performing services and devices: health care system, heal thyself first. This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting

Health Care's Kodak Moment

by Kim Bellard, July 26, 2017

For those of us of a certain age, a "Kodak moment" connotes a special event that should be captured by a photo.  For younger generations, the term probably doesn't mean anything, because they don't know what Kodak is.  That's why, for some, "Kodak moment" has come to suggest a turning point when big companies and even entire industries can become obsolete. 

Health care could soon be at such a point.

Anthony Jenkins, a former CEO of Barclay's, recently warned that banks could face a Kodak moment soon.  He said they're already seeing a "Uber-moment," where smartphones and contractless cards are transforming the industry.  "The Kodak moment is completely different," Mr. Jenkins explained.  "That’s where customers realize there’s a totally better and different way of doing what they want to do, and the incumbent becomes obsolete."

In a separate speech, Mr. Jenkins elaborated that, due to new technologies, "we can imagine total transformation of the banking system."  He predicted banks have 5 to 15 years to face these challenges, or become irrelevant to their customers.

The "good" news, he added, is that: "Banks can avoid that, but they have to act now, and what they really need to do is think about innovation, but also transformation, doing something radically different."

For "bank" or "banking system" feel free to substitute "doctor/hospital" or "health care system"

Incumbents all-too-often grow protective and/or fail to take advantage of new opportunities.  The irony of disruption, Mr. Jenkins noted, is that it is "actually a great growth opportunity," and that "incumbents are best positioned to seize disruptive opportunities."  

Health care has a number of legacy problems that make it ripe for disruption.  Innovators look at these problems and see opportunities.

The opportunities -- or, threats, depending on one's point-of-view -- on health care's horizon are numerous.  They include:

• Digital health makes real-time information and communication feasible, such as with wearables and telehealth.
• Big Data will help us finally understand what is happening with patients and predict with better accuracy how we can manage our health.
• Robots will take over health care tasks/jobs that humans either don't want to do or lack the required precision to do.
• Artificial intelligence (AI) will be able to make sense of all that Big Data and all the various research studies, and can serve to either augment or, at least in some cases, replace physicians.
• 3D printing will allow us to replace an ever-increasing number of body parts, even systems, and do so with unprecedented speed and affordable cost.
• Nanotechnology will allow us to monitor and maintain us down to a cellular level.

Meanwhile, traditional health care companies -- from providers to middlemen to manufacturers to insurers -- are waiting with some trepidation to see what 21st century behemoths like Amazon or Apple are going to do in their space.  

Disruption might come from innovators within the health care industry, but it might also come from unexpected sources -- and in unexpected ways.  Kodak didn't take digital photography seriously enough, and it certainly wasn't expecting smartphones as the new camera.  

Health should have a number of the old-fashioned Kodak moments -- the birth of a child, a miraculous recovery, achievement of a health goal, and so on.  Whether health care organizations or even the entire health care system suffer the other kind of Kodak moment depends on how (and when) they respond to the disruptive opportunities now available to them.  

Health Care Goes to the Mall

by Kim Bellard, June 29, 2017 It's either auspicious or ironic: decades after other retail industries, health care is coming to the mall. These are not, generally, good days for the malls.  We've all seen strip malls that were never finished or that have simply fallen on hard times, but in recent years those stalwarts of American shopping -- enclosed malls -- are sharing that fate.  Credit Suisse says that 20-25% of the 1,100 U.S. malls will close over the next five years. The Wall Street Journal predicts that "the mall of the future will have no stores."   They cite malls filling empty spaces with churches, schools, even offices or apartments.  E.g., Ford is leasing 240,000 square feet at a suburban Detroit mall for new offices. The New York Times had a similar report on the changes to malls.  As one developer told them, "Dining and entertainment is the new anchor — not Sears, not Macy’s."   One thing that many agree upon: malls of the future will include: health care. Another Wall Street Journal article focused specifically on health care moving to malls, and included several examples: ·         Dana-Farber Cancer Institute has leased 140,000 square feet of a 286,000 square foot Boston-area mall, which also has several other health and wellness tenants. ·         The Maury Regional Cancer Center has been in the Columbia Mall (Columbia, TN) since 2012. ·         The Biggs Part Mall in Lumberton NC has Southeastern Regional Medical Center as a key tenant. ·         UCLA Health operates primary care centers in the Village at Westfield Topanga. ·         Vanderbilt Health has been part of the One Hundred Oaks mall in Nashville TN since 2009. Other examples include Cedar Sinai (The Runway at Playa Vista -- LA) and Prime Healthcare (Plymouth Meeting -- Philadelphia), according to Bloomberg.   Johns Hopkins Medical President Gill Wylie told Bisnow that he watches retail vacancies for opportunities: "We do urgent care and primary care.  So I'm sitting there thinking, 'Gee if all these Staples end up closing, there might be space out there.'"  They've already snapped up four former Blockbuster locations for urgent care facilities.   Mr. Wylie said he also pays attention to big department stores and malls, citing their infrastructure, parking, and ADA compliance as givens.   Fady Barmada, of Array Advisors, led the conversion of New York City McDonald's to an urgent care center, and noted that: "Health systems know that, by co-locating themselves with well-used and well-attended retail facilities, they can increase the visibility of their facilities and become platforms for the creation of unique and interesting programs." But moving to retail locations won't, in itself, make health care organizations more patient-centered.  To do that, they'll have to make the patient experience easier (if not always enjoyable), give them clear choices, and truly treat them like valued customers. Moving is easy.  Changing is hard.   This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting

Rise of the Drones

By Kim Bellard, May 24, 2017

For those of us of a certain age, we expected to be living in a Jetsons-type world, complete with flying cars.  That hasn't happened, but it is starting to appear as though the skies may, indeed, soon be full of flying vehicles.  It's just that they may not have people in them. 

Welcome to the brave new world of drones.

Many people may have viewed drones as a toy akin to radio-controlled airplanes. We're beyond that now.  Last summer PwC asked "Are commercial drones ready for take-off?"  They thought so, estimating the total available market for drone-enabled services at $127b

This is not going to all be about getting your books, or your socks, or even your new HD television faster.  It is going to impact many industries -- including health care.

And that impact has already started to happen.

Zipline International, for example, is already delivering medical supplies by drone in Rwanda.  They deliver directly to isolated clinics despite any intervening "challenging terrain and gaps in infrastructure."  They plan to limit themselves to medical supplies, but not only in developing countries; they see rural areas in the U.S. as potential opportunities as well.  Last fall they raised $25 million in Series B funding.  

Drones are also being considered for medical supply delivery in Guyana, Haiti, and the Philippines.   

And drone delivery is already being tested in more urban areas.  The Verge reported that Swiss Post, its national postal service, is working with two hospitals in Lugano to ferry lab samples between them. 

Similarly, Johns Hopkins has been testing drone transport of blood supplies, concluding that it is "an effective, safe, and timely way to get blood products to remote accident or natural catastrophe sites, or other time-sensitive destinations."

Airbus is developing the A-180 drone specifically to deliver medical supplies, especially for emergencies.  Its cargo capsule is "capable of transporting everything from medicine and antivenin to supplemental blood and even organs." A company called Otherlab is going a different direction.  Wired reports that their drone will deliver its package -- then decompose, making it ideal for deliveries to humanitarian crises (or to battle sites, since Darpa helped fund them).  

Lest we focus too narrowly on the concept of drones delivering medical supplies, argodesign has proposed a flying ambulance, which could be operated as a drone or by a pilot.  If you've ever seen ambulances stuck in traffic and felt sorry for the patients relying on them, such ambulances could be the solution -- arriving faster and to locations regular ambulances could not reach.  

But for real impact, let's go back to Amazon.  CNBC's Christina Farr broke the news last week that Amazon was considering getting into the pharmacy business. Put rapid delivery -- especially with drones -- together with lower and more transparent prices, and it is no wonder that the stocks of CVS and Walgreens took a hit when the news broke about Amazon's new interest.

Health care has been all-too-much a story of waiting.  That's quickly changing, with telemedicine, WebMD, retail clinics, and -- soon -- 3D printing and health care robots.  We can add health care drones to the list, allowing 30-minutes-or-less kinds of promises that we haven't even begun to tease out yet.

Bring on the drones!

This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting

Clicks-and-Mortar: Health Care's Future

By Kim Bellard, April 27, 2017 The woes of the retail industry are well known, and are usually blamed on the impact of the Internet.  Credit Suisse projects that 8,600 brick-and-mortar stores will close in 2017, which would beat the record set in 2008, at the height of the last recession.   And then there's health care, where the retail business is booming. In a recent Wall Street Journal article, Christopher Mims set forth Three Hard Lessons the Internet is Teaching Traditional Stores.  The lessons are: 1.             Data is King 2.             Personalization + Automation = Profits 3.             Legacy Tech Won't Cut It It's easy to see how all those also apply to health care. But health care is different, right?  Patients want to see their physician.  That physical touch, that personal interaction, is a key part of the process.  It's not something that can be replicated over a computer screen.   Yeah, well, the retail industry has been through all that.  Retail once primarily meant local mom-and-pop stores.  They knew their customers and made choices on their behalf.  But it was all very personal. Still, though, when Amazon came along, booksellers were adamant: no one wants to buy books sight unseen!  When that truism was proven false, other sectors of retail had their turn in the Internet spotlight, and the last twenty years of results haven't been pretty for them.   It turns out that the personal touch isn't quite as important as retailers liked to think. So why hasn't health care been more disrupted by the Internet?  Well, for one thing, when you buy a book online, your state doesn't require that you buy it from a bookstore that is licensed by its not-so-friendly licensing board, as is true with seeing doctors over the internet.   Strike one for disruption. For another thing, we (usually) trust our doctors.  Then again, we used to trust recommendations from bookstore staff too.  That is, when they had time for us, if they seemed knowledgeable, and if they were making recommendations that fit us rather than just their own preferences. Think the same thing won't happen when AI gets better at diagnoses?  Let's go back to Mr. Mims three lessons and see how they apply to health care: ·         Data is King: Health care collects a lot of data, and will get even more with all the new sensors.  The big tech companies know their customers very well and tailor interactions accordingly; health care must as well. ·         Personalization + Automation = Profits:, We're stuck in waiting rooms, filling out forms we've already filled out elsewhere. That is not a personal experience that can survive in the 21st century.  It has to be smoother, faster, and friction-less.   ·         Legacy Tech Won't Cut It: EHRs that no one likes.  Claims systems that take weeks to process a claim.  Billing processes that produce bills no one can understand.   The list could go on almost indefinitely.  All too often, health care's tech is not ready for prime time.   The question is, are health care's leaders learning these lessons? The future of retail appears to be in "clicks-and-mortar" (or "bricks-and-clicks").   Health care can act like B Dalton or Borders, assuming until it is too late that their consumers will visit them in person, because they always had.  Or it can act now to jump to the data-driven "clicks-and-mortar" approach that other retail businesses are moving to.   Health care organizations which get that right will be the one to survive.   This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting

Disobey, Please

By Kim Bellard, March 29, 2017 The M.I.T. Media Lab is taking nominations for its Disobedience Award, which was first announced last year.  As the award's site proudly quotes Joi Ito, the Director of the Lab and who came up with the idea: "You don't change the world by doing what you are told." I love it.  The site, and the award's proponents, make clear that they are not talking about disobedience for the sake of disobedience.  It's not about breaking laws.  They're promoting "responsible disobedience," rule-breaking that is for the sake of the greater good.  The site specifies: This award will go to a person or group engaged in what we believe is an extraordinary example of disobedience for the benefit of society."    In Mr. Ito's original announcement, he elaborated: The disobedience that we would like to call out is the kind that seeks to change society in a positive way, and is consistent with a key set of principles. The principles include non-violence, creativity, courage, and taking responsibility for one's actions."  The creators of the award are probably not thinking much about health care -- despite disavowing it is about civil disobedience, many examples they've given revolve around people resisting what they think are improper government actions -- but they should be.  If there's a field where lots of stupid, or even bad, things happen to people , through design, indifference, or inaction, health care has to be it. The list of disobedient acts in health care that would serve society is longer than my imagination can produce, but here are some examples: ·         The nurse who says, no, I'm not going to wake up our patients in the middle of the night for readings no one is going to look at. ·         The doctor (or nurse) who knows a doctor that they believe is incompetent and decides, I'm going to speak up about it.  I'll make sure patients know. ·         The billing expert who decides, no, I'm not going to keep up the charge master, with this set of charges that aren't based on actual costs and which almost never actually get used (except by those unfortunate people without insurance).  Instead, we'll have a set of real prices, and, if we give anyone any discounts, they will be based on ability to pay, not on type of insurance. ·         The EHR developer who realizes that, it's silly that this institution's EHR can't communicate with that institution's EHR, even though they use the same platform and/or use the same data fields.  . ·         The insurance executive who vows, I'm tired of selling products that are full of jargon, loopholes, and legalese, so that no one understands them or knows what is or isn't covered.  We're going to sell a product that can be clearly described on one page using simple language. ·         The practice administrator who understands that patients' time is valuable too, and orders that the practice will limit overbooking and will not charge patients if they have to wait longer than 15 minutes.  ·         The medical specialty that commits to being for patients, not its physician members, by developing measures, specific to patient outcomes, in order to validate ongoing competence. Going back to the award's principles of non-violence, creativity, courage, and taking responsibility for one's actions -- well, the above would all seem to fit.  They're all achievable.  It only takes someone to stand up and decide to do them. This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting

The Good, the Bad, and the Ugly in Health Care

By Kim Bellard, February 22, 2017

I hate being a patient.

My exposure to the health care system has mostly been through my professional life or through the experiences of friends and family.  The last few days, though, I unexpectedly had an up-close-and-personal experience as a hospital inpatient.

I offer what I consider the Good, the Bad, and the Ugly of the experience.

The Good:  The People
The various people involved in my care, from the most highly trained physician to the person who delivered meals, were great. I loved my nurses.  I liked my doctors a lot.  The aides, the lab techs, the imaging tech, the transportation specialists -- all of them doing jobs that I wouldn't be able to do -- were each friendly and helpful, taking pride in what they did and how it helped my care. 

The Bad: The Processes
On the other hand, on the lists of criticisms about our health care system, many of its rules and processes truly do deserve a place.  They're like part of an arcane game no one really understands. 

I'll offer three examples:

• ·         Check-in
• ·         NPO
• ·         Discharge

The Ugly: The Technology

Oh, health care technology.  It is equally capable of delighting as it is of frustrating.  It is truly remarkable that the doctor could go up my arm to perform a procedure in my chest, just as the detail an MRI provides is simply astonishing.  

Let's start with the perennial whipping boy, EHRs.  On many occasions, EHRs did not mean that people did not still often have to drag in other electronic equipment or even paper in order for them to do their job.

MRIs are a wonderful technology, but as I was laying in that claustrophobic tube getting imaged, I kept thinking: what the heck are all those clanging noises?  

I was on various forms of monitoring devices, the smallest of which was the size of a 1980's cell phone and still required countless wires attached to numerous leads.  I kept wondering, hmm, have these people heard of Bluetooth?  Do they know about wearables?

My favorite example of ugly technology, though, came when I had to fill out a form, so that it could be faxed to the appropriate department.  

No health care system is perfect.  Every system has its own version of the Good, the Bad, and the Ugly. Our system can do better.  Let's give all those great people working in health care a better chance to help us.

This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting

Living in a Retro Health Care System

by Kim Bellard, January 26, 2017

Living in the 21st century is cool, right?  We've got smartphones, ultra-thin tablets, the Internet, wearables, Uber, self-driving cars, virtual/augmented reality, drones, digital currency, and all the TV/movies/music you could want available for streaming anytime, anywhere.  It makes Back to the Future II's 2015 look drab by comparison (except maybe for the hoverboards!).   

So why does it seem like so many people are entranced with the 1980's?

Take, for example, the resurgence of vinyl. Vinyl is back, set to become a billion dollar industry (again).  

People are falling in love with cassette tapes again.  Their sales rose 74% in 2016. People are even inventing new ways to listen to old formats.  The Verge reports on Love, "the first intelligent turntable.”  

Retro isn't confined to music.  One of the hottest Christmas presents was the Nintendo NES Classic. Hey, we've got the Today show doing a 1970 retro show, the NFL going crazy with throwback uniforms, and the predicted reemergence of flip phones.  People even want retro computers.  

If any industry would keep its eye relentlessly on the future, you might expect it would be health care.  Few of us would want to go back to what health care was like in the 1980's, and none of us would accept the health care of the 1950's (except maybe those house calls).  

No, in health care we expect the kind of futuristic -- or, at least, modern -- experience that tech-based start-ups are promising.  If health care went retro, why, we'd usually make appointments to see our doctors in their offices instead of seeing them on-demand 24/7, wait long periods in their bland waiting rooms, fill out lots of paperwork, have our white-coated doctor listen to us with their stethoscope, have lots of unnecessary or even harmful tests and procedures, even have our information sent by fax.  No one would want to go back to all that.

Oh, wait -- that is our health care system, for the most part.  It hasn't gone retro because we haven't yet moved past retro.  

Get this: fax machines remain the predominant form of communication in health care, with fax volume hitting new records.  That's not retro, that is insanity.  

Get this: physicians hate their EHRs so much that they are cited as a leading reason for physician burnout, and in their frustration with them physicians are turning to medical scribes to do the inputting.  

Get this: after seeing a consumer revolt in the 1990's against managed care's capitation, small provider networks, and restrictive medical management, they're all back in vogue, in one form or another.

I get retro.  But I do not want to get care in a retro health care system.  

EHRs are a perfect example of how we took something that should revolutionize health care, and turned it into something that not only no one is happy with but that many feel often impedes care, to the point some want to go back to paper records.  We didn't do the wrong thing with EHRs, we just are doing it wrong.

We should be thinking big and bold about how we want our health care system to work in the 21st century.   We should be looking forward, not backward. We have all the technology we need to make our health care experience, well, if not like magic, then certainly more like a 21st century health care should seem.  Let's get there first -- then maybe we can think about how we can do some cute retro to it.  

This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting

Just Doing Our Jobs

by Kim Bellard, December 14, 2016

Health care fraud is bad.  Everyone agrees about that (except those who profit by it).  We'd similarly agree it is all too pervasive.   Some estimate that fraud could account for up to 10% of health care spending.  But that's chump change: estimates are that other kinds of wasteful spending, such as unnecessary care and excessive administrative costs, are easily double that. 

An op-ed in The Boston Globe may have it right:  we need an overdiagnosis awareness month.The op-ed was a tongue-in-cheek suggestion to highlight the various cancer awareness months, the most famous of which is October's Breast Cancer Awareness.  These campaigns promote the need for the associated screenings, but don't typically also mention how controversial many of them are.  

 
Overdiagnosis goes much further than screenings.  As Atul Gawande wrote last year, we're getting an "avalanche of unnecessary care," getting too many services of not just low value but of at best no value to patients -- and, at worse, actually harmful to them.  Not just pointless tests or unneeded prescriptions, but also too many questionable procedures, such as total knee replacements, heart stents, or spinal fusions. 

The real problem is that most people involved in the "epidemic" of overdiagnosis and over-treatment our health care system, well, they think they're just doing their jobs. 

They don't think they're trying to rip anyone off, they certainly don't think that they're harming anyone, and they most definitely don't think their role is superfluous.  This is all only possible because it is still too hazy about what is the right treatment for who, when, not to mention what a "fair" price might be for anything.  So, when in doubt, do more.

As a result, health care employment is booming.  Some project it will be largest job sector within three years.  Indeed, as the chart below shows, virtually all of the U.S. job growth this century has been in health care jobs.  That, quite simply, is astounding. 

Yet, despite all this growth, there continue to be urgent cries of shortages of key health care professionals.  We just cannot seem to get enough qualified health care workers.  If you're looking for a job, that's good news, but if you're paying the bill for all those jobs, it should be scary.

In health care, we just add more jobs.

Overtreatment works, at least if you're the one doing the treating.

And everyone in health care keeps doing their job.

Look, this fantasy isn't going to continue.  Health care isn't going to become 100% of GDP.  It's not going to get to 50%, or 40%.  At some point the revolt will happen, the revolution will occur, and health care spending will finally slow, stop, and eventually plunge. 

Then all those health care jobs are not safe.  People will lose their jobs.  A lot of people.  People who, until then, thought they were doing good.

So when the next health care innovator comes along, we should try to get past the hype and ask: OK, specifically, what jobs will this eliminate -- which ones, how many, when?  If they don't have answers, or only offer vague promises, well, smile politely and get out your wallet.

In health care, perhaps one way to do your job might just be to find a way to eliminate it.

This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting

No Thanks, I Already Have Number

By Kim Bellard, November 17, 2016

Health care has a problem.  Well, of course, it has many problems, but one of them is that the various parties involved in the health care system can't agree on who we are.   Twenty years ago HIPAA called for creation of unique patient identifiers to accomplish this task, but within two years Congress put this on hold until further notice, and we're still waiting.

Everyone used to use social security numbers for this purpose, until we finally figured out the folly of that (especially since that number was never intended to be used as a national identification number).

News flash; we already have a unique, non-government-issued identifier: it's called a cell phone number.

It's obvious why we want a universally accepted patient identifier.  Providers and insurers have to agree on who you are to exchange claims and payments.  Different providers have to agree on who you are if we're ever going to get to interoperability of health information.

We can't/shouldn't use social security numbers, and not everyone has a drivers license number.  Health insurance numbers change whenever you change insurers, or even stay with the same insurance company but change employers.  What to do?

Thus the cell phone number.

According to the Pew Research Center, in 2015 92% of U.S. adults had a cell phone. That's not everyone, but not everyone has a social security number either.  When you do business with almost any organization these days, you are likely to be asked to provide your email and cell number number.

The New York Times reported on how the cell phone numbers have already become a widespread identifier.  As a security consultant told them, it has become "kind of a key into the room of your life and information about you."

As The Times pointed out, there are no legal requirements for companies who have your cell phone number to keep it private, unlike protected health information (PHI).  To be fair, they also noted how poorly protected social security numbers have been as well, leading to billions of dollars in annual fraud losses.  With cell phones, though, hackers have shown that, once they have your number, not only can they link you to various databases, but they can also listen to your phone calls, read your texts, even track your location.

However, it's not all bad news.  You can lock your phone or change your number if you think your cell phone number has been breached.

Like it or not, our cell phones are becoming our lifelines to the world, including but in no way limited to health.  Health care might as well acknowledge that fact, the way that most other industries are already starting to.  You can send money to someone using just their cell phone number; why not file a claim or link electronic records?

Don't want to use your cell phone number as your identifier?  OK, get a free Google Voice number, or use an app like Sideline to add a free second number to your existing mobile phone.

Meanwhile, most systems even in health care already can and probably do store our cell phone numbers.  It'd be just like health care to develop an expensive new solution to a problem.  For once, could we go the obvious route?

This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting

Will Anyone Notice?

By Kim Bellard October 13, 2016

There's an interesting verbal battle going on between two prominent tech venture capitalists over the future of AI in health care. Marc Andreessen asserted that Vinod Khosla "has written all these stories about how doctors are going to go away...And I think he is completely wrong."  Mr. Khosla was quick to respond:  "Maybe Mr. Andreessen should read what I think before assuming what I said about doctors going away."

It turns out that Mr. Khosla believes that AI will take away 80% of physicians' work, but not necessarily 80% of their jobs, leaving them more time to focus on the "human aspects of medical practice such as empathy and ethical choices."  That is not necessarily much different than Mr. Andreessen's prediction that "the job of a doctor shifts and becomes a higher-level, more important job that pays better as the doctor becomes augmented by smarter computers."

When AIs start replacing physicians, will we notice -- or care?

Personally, I think it is naive to expect that only 20% of physicians' jobs are at risk from AI, or that AI will lead to physicians being paid even more.  The future may be closer than we realize, and "virtual visits" -- telehealth -- may illustrate why.

Recently, Fortune reported that over half of Kaiser Permanente's patient visits were done virtually, via smartphones, videoconferencing, kiosks, etc.  That's over 50 million such visits annually.  

Sherpaa, a health start-up that is trying to replace fee-for-service, in-person doctor visits with virtual visits.  Available with a $40 monthly membership fee, the visits are delivered via their app, tests or emails.  Their physicians can order lab work, prescribe, and make referrals if needed.

How many people would notice if virtual visits were with an AI, not an actual physician?  

Companies in every industry are racing to create chatbots, using AI to provide human-like interactions without humans.  And health care bots are on the way.

Not everyone is convinced we're there yet.  A new study did a direct comparison of human physicians versus 23 commonly used symptom checkers to test diagnostic accuracy, and found that the latter's performance was "clearly inferior."  The symptom checkers listed the correct diagnosis in their top 3 possibilities 51% of the time, versus 84% for humans.  

However, consider the symptom-checkers may be the most commonly used, but may not have been the most state-of-the-art.  And the real test is how the best of those trackers did against the average human physician. Humans still got the diagnosis wrong is at least 16% of the cases.  They're not likely to get much better (at least, not without AI assistance).  AIs, on the other hand, are only going to get better.  

It used to be that physicians were sure that their patients would always rather wait in order to see them in their offices, until retail clinics proved them wrong.  It used to be that physicians were sure patients would always rather see them in person rather than use a virtual visit (possibly with another physician), until telehealth proved them wrong.  And it still is true that most physicians are sure that patients prefer them to AI, but they may soon be proved wrong about that too.

AI is going to play a major role in health care.  Rather using physicians to focus more on empathy and ethical issues, as Mr.  Khosla suggested (or paying them more for it, as Mr. Andreessen suggested), we might be better off using nurses and ethicists, respectively, for those purposes.  So what will physicians do?

The hardest part of using AI in health care may not be developing the AI, but in figuring out what the uniquely human role in providing health care is.

This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting

I Really Wish You Wouldn't Do That

By Kim Bellard, September 22, 2016

Digital rectal exams (DREs) typify much of what's wrong with our health care system.  Men dread going to go get them, and -- oh, by the way – they apparently don't actually provide much value. By the same token, routine pelvic exams for healthy women also don't have any proven value either.

The recent conclusions about DREs come from a new study.  One of the researchers, Dr. Ryan Terlecki, declared: "The evidence suggests that in most cases, it is time to abandon the digital rectal exam (DRE).  Our findings will likely be welcomed by patients and doctors alike."

The study actually questioned doing DREs when PSA tests were available, but it's not as if PSA tests themselves have unquestioned value.  Even the American Urological Association came out a few years ago against routine PSA tests, citing the number of false positives and resulting unnecessary treatments.

Indeed, the value of even treating the cancer that DREs and PSAs are trying to detect -- prostate cancer -- has come under new scrutiny.  A new study tracked prostate cancer patients for ten years, and found "no significant difference" in mortality between those getting surgery, radiation, or simple active monitoring.

The surgery and radiation, on the other hand, had some unwelcome side effects.  Forty-six percent of men who had their prostate removed were wearing adult diapers six months later, and impotence was reported in 88% of surgical patients and 78% of radiation patients.

As for the pelvic exam, about three-fourths of preventive visits to OB-GYNs include them, over 60 million visits annually.  They're not very good at either identifying or ruling out ovarian cancer, and the asymptomatic conditions they can detect don't have much data to indicate that treating them early offers any advantage to simply waiting for symptoms.

Or take mammograms.  Mammograms are uncomfortable, have significant false positive/over-diagnosis rates, and costs us something like $4b annually in unnecessary costs, yet remain the "gold standard."

Then there is everyone's favorite test -- colonoscopies.  Only about two-thirds of us are getting them as often as recommended, and over a quarter of us have never had one.  There are other alternatives, including a "virtual" colonoscopy and now even a pill version of it, but neither has done much to displace the traditional colonoscopy.  And all of those options still require what many regard as the worst part of the procedure, the prep cleansing.

The final example is what researchers recently called an "epidemic" of thyroid cancer, which they attributed to overdiagnosis. In fact, according to the researchers: "The majority of the overdiagnosed thyroid cancer cases undergo total thyroidectomy and frequently other harmful treatments, without proven benefits in terms of improved survival."  Not only that, once they've had the surgery, most patients will have to take thyroid hormones the rest of their lives.

All of these examples happen to relate to cancer, although there certainly are similar examples with other diseases/conditions (e.g., appendectomy versus antibiotics for uncomplicated appendicitis).

Two conclusions:

1.  If we're going to have unpleasant things done to us, they better be based on facts

2.  We should do everything we can to make unpleasant things, well, less unpleasant:

Let's get right on those.

This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting

Out With the Old...Wait, Not in Health Care

By Kim Bellard, August 16, 2016

The last company still manufacturing VCRs announced it has ceased their production.  VCRs had a good run, most households had one, but their time has passed.  Meanwhile, the stethoscope is celebrating its 200th birthday, and is still virtually the universal symbol for health care professionals.  

There has got to be a moral in there somewhere. VCRs are a classic example of how technology (usually) moves on.  Except in health care.

Like stethoscopes.  Digital advocate Dr. Eric Topol recently tweeted: "The stethoscope's 200th birthday should be its funeral. That's all well and good, but -- to paraphrase Mark Twain -- reports of its death are greatly exaggerated.

It's not like stethoscopes do all that good a job, or, perhaps, that physicians use them all that well.  A 2014 study found that participants only detected all tested sounds 69% of the time.  As the authors diplomatically concluded, "a clear opportunity for improving basic auscultations skills in our health care professionals continues to exist."   

Oh, and stethoscopes also help carry germs.

And it's not like there aren't alternatives.  As one might expect in the 21st century, there are electronic/digital stethoscopes.  There are also handheld ultrasounds that provide another strong alternative.

And now, of course, there are smartphone apps for stethoscopes.  Apple was claiming 3 million doctors had downloaded its $0.99 stethoscope app as long ago as 2010, with Android versions also available.  

And yet stethoscopes hang in there.  

We might like to think that physicians continue to use traditional stethoscopes because they are simply being thrifty, since electronic stethoscopes and handheld ultrasounds are much more expensive, but that seems a reach.  They've certainly not been reluctant to adapt other types of newer, more expensive technology -- at least, not as long as they can charge more for it.  

It is a conundrum that has bedeviled economists: why in health care does new technology almost always increase costs, unlike most other industries?  E.g., DVRs were much better than VCRs, but quickly became comparably priced.  Professor Kentaro Toyama cites what he calls technology's Law of Amplification: "Technology’s primary effect is to amplify, not necessarily to improve upon, underlying human inclinations."

And in health care, those underlying inclinations don't drive towards greater value.

When it comes to stethoscopes, it's not about the money.  Many physicians believe that the stethoscope helps foster the patient-physician relationship.  In a recent article in The Atlantic, Andrew Bomback admitted that, "Indeed, for many doctors (myself included), the stethoscope exam has become more ceremony than utility."  

Physician/engineer Elazer Edelman argues that a stethoscope exam can help to create a bond between patients and physicians.  He worries that technology may be fraying the "tether" between doctors and patients. Still, if the relationship depends on which device a physician uses to listen to our chest, that relationship is in bigger trouble than we think.

So, R.I.P. VCRs, and thanks for the memories.  As for stethoscopes, and for health care more generally, though, maybe the moral is that we should focus less on status symbols and more on what is best for patients.

This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting

What Pokémon Go Means for Health Care

By Kim Bellard, July 21, 2016

In recent days there have been a flood of stories trying to explain the Pokémon Go craze.  
Many -- e.g., The New York Times and Fast Company -- believe that Pokémon Go is finally going to make augmented reality mainstream, as well as showing AR's advantages over virtual reality, since the latter typically requires at least a headset plus a high powered PC.  It makes AR quick, easy, and free, teaching players how AR can seamlessly fit into the real world.

The game has players wandering around their neighborhoods, their eyes torn between their phones and the real world, visiting places they never stopped at before and meeting people they might never have talked to before.  People are already talking up the game's health benefits.  The New York Timesreports that it "has kids on the move."  More importantly, when people are playing the game they are not sitting passively behind a screen in their house.

Pokémon Go is not, by itself, going to lead to dramatic improvements in the nation's health.  Nor was it intended to.  It is, however, yet another example about we can use games, or at least gamification, can help us with our health.

However promising gamification in health care may be, it is the AR that may well hold the most promise for health care.  Google was not wrong to pursueGoogle Glass, just premature.  Pokémon Go may be signaling that we're now finally ready for AR, and that it will be consumers as well as professionals who can benefit from it.

The potential uses in health care are virtually endless, but here are a few examples:

• Ever been lost in a hospital, meandering haphazardly despite various signs and color-coded arrows?  How much better would an AR map be?  
•  Ever feel like your doctor spends too much time staring at your chart or a screen?  Instead of looking there for information about you, how much better would it be if he/she was looking at you, with AR notations for key information about you?  
•  Ever not understand what your doctor is telling you about your diagnosis or treatment?  It is well documented how few patients leave their doctors office/ER/hospital understanding what they were told.  How much better it would be if your phone could listen to the conversation, and provide AR "translations" into layman's terms of what is being said?  
• Ever been told you needed a prescription, a test, or other treatment, and wondered how much it might cost?  You might have even asked your doctor, who most likely doesn't know either.  How much more powerful transparency efforts would be if those prices showed up as AR in the place of service at the time of the discussion about them, again with both the patient and the doctor seeing them?
• Ever make "bad" food choices, despite calorie and nutritional information more omnipresent on labels and menus?  How much better would an interactive AR display of the information be?

Health care has no shortage of information.  Its problem is more making that information accessible to the right people, at the right time.  This is the real potential of AR, and figuring out how to do so in as impactful yet unobtrusive way will be the challenge for developers.

Pokémon Go is not the model for the future of health care, but it offers a model for it we should be paying attention to.

This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting

Millennials Are (Not) So Different

By Kim Bellard, June 24, 2016

If we believe conventional wisdom about them, they like to live with their parents, at least until they can move into their urban-center condo.  They hate to drive.  They're maddening in the workplace, demanding lots of frills and constant praise yet returning little loyalty.  They're hyperconnected through their various digital devices.  And, when they deign to think about health care, which isn't often, they want all digital, all the time. 

There's some truth to the conventional wisdom, but not as much as you'd think.  A new study from Credit Karma flatly asserts that "everything you thought you knew about Millennials may be wrong," finding that they still have aspirations to much of the same "American Dream" as previous generations.   

The hyperconnected part is certainly true.  Millennials are much more likely to have a smartphone,  and -- jawdroppingly -- on an average day they interact with it much more than with anyone else, even their parents or significant other.  

Things get really interesting when it comes to health.  Millennials are often viewed as not very interested in health care, but it is the second most important social issue for them, right after education and ahead of the economy. 

A deep dive on millennials and health care by the Transamerica Center for Health Studies had some results that also don't necessarily fit the stereotypes. Taking care of their health was tied with getting/keeping a job as their top priority. 70% have been to a doctor's office within the last year, although for minor issues they're more likely to head to urgent care/a retail clinic. When it comes to getting health information, this supremely digital generation still relies most heavily on health care professionals and friends/family (especially their mothers!).

There has been a dramatic drop in being uninsured -- 11% versus 23% as recently as 2013 -- but millennials don't like much about health insurance.  They feel much more informed about their health and how to improve it than they do about how to find health care services or their health insurance options.  

Perhaps that is why two-thirds have never comparison shopped for health insurance.

Lastly, TCHS found that millennials rate affordability as the most important aspect of the health care system, but many don't find it affordable.  About 20% can't afford routine health expenses, even though millennials' median health expenses are under $100 per month.  Nearly half have skipped care to reduce their expenses. Similarly, most millennials view monthly premiums over $200 as unaffordable.

If there is a key difference with millennials' health care, it may be in their emphasis on technology.  A report from Salesforce.com found that 76% of millennials valued online reviews in choosing a doctor, and 73% want doctors to use mobile devices during appointments to share information. 60% are interested in telehealth options in lieu of office visits.

It is perhaps no wonder millennials are turning to technology when it comes to their health.  They highly value face time with their doctor, but they may not be getting it.  According to the Salesforce report, 40% of millennials don't think their primary care doctor would recognize them on the street. 

Many of us might suspect the same thing, and that should trouble us all.

When it comes to health care, as with many other aspects of life, it may be less that millennials are different in what they want as it is that they're quicker to adopt newer options for getting it.  The rest of us should learn from that, not shake our heads at it.

This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting

Practicing in an Age of Uncertainty

By Kim Bellard, May 27, 2016

If you've ever had a hard time trying to decide what's best for your health, perhaps you can take comfort in the fact that physicians often aren't so sure either. 

Or perhaps not.

A new study in Annals of Surgery, and nicely reported on by Julia Belluz inVox, focused on surgical uncertainty.  The researchers sent four detailed clinical vignettes to a national sample of surgeons, seeking to get their assessment on the risks/benefits of operative and non-operative treatment, as well as their recommendations. You'd like to think there was good consensus on what to do, but that was not the case.

In one of the vignettes, involving a 68 year-old patient with a small bowel blockage, there was fairly universal agreement -- 85% -- that surgery was the best option.  In the other three vignettes, though, the surgeons were fairly evenly split about whether to operate or not, even on something as common as appendicitis. 

So, there may be a "right" answer but you might as well flip a coin in terms of getting it, or there may just not be a right answer.  Both options are troubling.

The authors believe that surgeons are less likely to want to operate as their perception of surgical risk increased and the benefits of non-operative treatment increased, and more likely to want to operate as their perception of surgical benefit increased and non-operative risk increased.  The problem is that surgeons vary dramatically -- literally from 0 to 100% -- on their perceptions of those risks.

Most surgeons based their estimates of risks/benefits on their experience, their training, and -- if you're lucky -- on whatever literature might be available, but it is doubtful that we can usually expect an objective, quantifiable assessment. 

The American College of Surgeons has developed a "surgical risk calculator" to help surgeons better gauge these risks, using data from a large dataset of patients.  However, an earlier related study from the same team of researchers found that it doesn't make much difference.  The calculator did narrow the variability of surgeons' assessment of risk, but: "Interestingly, it did not alter their reported likelihood of recommending an operation."

Oh, well.

It is not just surgeons who aren't always sure of the right course of action, of course.  A study in the American Journal of Managed Care found that 62% of physicians reported that they found the "uncertainty involved in providing patient care disconcerting."  The discomfort with uncertainty did not vary appreciably between type of specialty.

Then there is the example of PSA tests.  In 2008 the US Preventive Services Task Force recommended routine PSA tests not be given to men over 75, and in 2012 broadened that recommendation to all ages.  Yet data suggest that the group least likely to need the tests -- men over 75 -- had the smallest declines in rates of testing.  Almost 40% of this age group are still getting the test, which is not far from the previous rates. 

As one researcher told The New York Times,   "That’s just insanity...bad medicine, poor use of health care resources and poor decision-making.”

There's all too much of that in our health care system.

This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting

Getting on the Blockchain Bandwagon

By Kim Bellard, April 28, 2016

Face it: health care IT infrastructure is a mess.  After spending tens of billions of dollars to "incent" providers to move to EHRs, they're using them but are not very happy with them. We now have millions of electronic records that are still way too siloed, and all too often incomplete.

Enter blockchain.

To the extent most people think of blockchain at all, it is in relation to one of its most prominent users, Bitcoin.  Bitcoin, which has its passionate advocates and equally passionate skeptics, is not synonymous with blockchain.  Blockchain is the technology that allows Bitcoin to operate, but they are no more one and the same than Salesforce.com and Oracle are.

In layman's terms -- and, trust me, when it comes to this I definitely am a layman -- blockchain is a set of distributed records, or databases, that are shared by multiple parties and which can only be updated by a majority of those parties.  There is no central authority, no central database.  It reminds me of the Internet's distributed networks, which help assure its robustness. 

Equally important, in blockchain once a record is stored (or "transcribed"), it can't be tampered with.  For better or for worse, Bitcoin has demonstrated that blockchain does, in fact, assure anonymity, privacy and security. 

Blockchain is starting to become more visible even outside of Bitcoin.  Businesses are being told they need a "blockchain czar.  Wall Street is starting to embrace it.  Britain looking into using it for manage the distribution of public money
 
Some people think it is the greatest thing since sliced bread -- or, in modern terms, since the Internet.  IBM's Jerry Cuomo says: "Blockchain has the potential to become the technological foundation for all electronic transactions conducted over the Internet."

If they are even remotely right, blockchain is something that we better be paying attention to, and what industry needs its advantages more than health care?

We're already beginning to see blockchain show up more in health care.  For example, Gem just announced Gem Health, As they say: "We need a modern infrastructure that unlocks new channels for services to connect, while balancing the need for strong data privacy and security.  Blockchain technology is that infrastructure."

Philips is onboard, with the Philips Blockchain Lab joining the Gem Health network.

It's not going to be easy.  Health care has had a hard time agreeing to things like ICD-10 or HL7, much less interoperability standards.  In CIO, Peter B. Nichol points out the need for foundational protocols, such as the Linux Foundation's Hyperledger project is working on  If we thought getting providers to use EHRs was hard, picture trying to get the health care industry onto a entirely new technology platform like blockchain. 

True to form, the "HIT standards mandarins" are already showing resistance to blockchain.

However, Mr. Nichol also enumerates a number of companies already jumping on the blockchain bandwagon for healthcare uses, including not just Gem but also Tierion, Factom, HealthNautica, and Guardtime.  It is something that any organization involved in health care can ignore only at their own risk.

Look, I'm no technology seer.  I don't know if blockchain is going to totally revamp how we store and update data, as its proponents claim.  What I do know is that, when it comes to health care, our current approaches are not getting us to the interoperability that we need, or are doing so only at glacial speeds, and that they allow our electronic data to be increasingly vulnerable.   

If not blockchain, what?

This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting