Dear readers –
You have the chance to amplify the conversation that we have been having (well, OK, so I have been having) on this blog. Please consider supporting a proposal for a panel on the “digital disruption” of health care at the 2019 South by Southwest Conference. I am proud to be a part of this, along with colleagues from Kaiser Permanente, GE Ventures, and USA Today. As you may know, SXSW is way more than a world famous music festival. It is also an ideas festival – a place to learn and teach and collaborate. Here’s a brief description of what we hope to address:
Peer into any medical bag and you may see a stethoscope, which came into use 150 years ago, and a blood pressure cuff – a 135-year-old technology. While these tools advanced the practice of medicine, today’s technologies hold enormous promise for improving the health and well-being of countless lives. But what about the patient-physician relationship? A computer in the exam room may provide the physician with integrated and actionable information, yet interfere with the patient-physician interaction. So how do we optimize innovations to sort hope from hype? This panel explores bridging the digital divide to improve the quality of health care, lower costs and make health care more human. Technologies we’ll discuss include:
– Predictive analytics
– Machine learning
– Precision medicine
The program is developed, in part, through online voting for the presentations that people want to see and hear. Please consider supporting our proposal by going to the “SXSW PanelPicker” at: http://panelpicker.sxsw.com/vote/86636 and “vote up.” If you don’t have a SXSW account, it only takes a minute to create one and vote.
Thanks, and see you in Austin!
In one of my earliest blog posts, I told the story of a patient of mine who asked if she could use an app on her smartphone to monitor her heart rate, and wrote: “Patients monitoring themselves! Cell phones transformed into medical devices! How cool is that?”
Since then, I have become more committed to the principle that patients should be the owners of their medical data and empowered to collect and manage it, and the technology to facilitate their ability to do so has improved remarkably. I recently purchased some of that new technology myself, and it goes well beyond what I was thinking was possible when I got excited 5 years ago at the prospect of self-monitoring heart rate.
This is a picture of my wrist with my new Apple watch, equipped with the Kardia band and yes, that is my ECG.
Continue reading Do It Yourself
I am a terrible coder. I think I am a pretty good doctor, but when it comes to coding, the process of figuring out which billing code to pick to assign to a bill for an office visit, I am hopeless. No matter how many times I have had the rules explained to me, or how much feedback I have been given about specific visits, or which “pocket guide” to coding I have been handed over the years, I can’t seem to get it right. Even my errors are non-systematic. Sometimes I “over-code” (picking a visit level insufficiently supported by my note) and other times “under-code.” And the things I get wrong are all over the map – sometimes my history lacks some “elements,” sometimes my review of systems covers the wrong number of systems, sometimes my exam is shy an organ or two…you get the idea. It is very hard to get better if you keep doing different things wrong. Of course, this begs the question why doctors should be coding as well as doctoring, but that is an issue for another day.
For now, my deficiency explains why I was intrigued to learn that CMS recently proposed changing the rules governing the coding and reimbursement for physician office visits. Currently, we are bound to rules for so called “evaluation and management” (E&M) visits that date back to the mid-1990s. The rules align the 5 levels of visit intensity (each coded with a different billing, or CPT code) with required documentation. There are parallel sets of codes (and documentation requirements) for new patient visits and established patient visits. Did I mention that this guidance is 90 pages long? Each code carries a different level of reimbursement, and commercial insurers use the same codes (at different price points) to pay for care of their subscribers.
The new proposal pretty much scraps all of that. CMS is floating the idea of “collapsing” levels 2 through 5, and creating a single payment level for established patients and a single payment level for new patients, each of which is somewhere in-between what is currently paid for a simple (level 2) or complex (level 5) visit. The stated rationale is that physicians would be able to spend more time with patients and less time stressing over what to code (or typing clinically irrelevant stuff in the medical record to justify higher levels of billing). In the words of CMS, it will favor “patients over paperwork.” You can read all 1472 pages of the proposed changes to the Medicare physician fee schedule here.
Continue reading More Changes to Medicare
Physician well-being is getting a lot of well-deserved attention these days. Its antithesis, physician burnout, saps physicians of their spirit, humanity, and effectiveness as healers. I have previously asserted that the best protection against burnout is for physicians to collectively shape how care is delivered, assuring that it is both effective (works for patients) and consistent with professional standards (works for doctors). I still think that is true, but I also want to put in a plug for unplugging.
I recently had the pleasure of “going off the grid” for a bit while enjoying a fabulous vacation in Alaska. Absent a brief period of connectivity in the middle of the trip, I was without cell service or Wi-Fi for the better part of two weeks. It was wonderful!
Continue reading Restoration and Well-being
Our most recent water bill was about 5 times higher than the one for the preceding quarter, so I called the local water authority to see if there had been a mistake. With a few keystrokes, the woman with whom I spoke was able to tell me exactly which days over the previous months appeared to have high usage, and asked if we had a leaky faucet or a running toilet. Well, yes, I explained, we did have a toilet that had been running (which I have since fixed), but I was surprised that it could lead to such an outsized bill. The response was more or less, “oh yeah, that can do it” and the more medically resonant “we see this.”
I was disappointed that the bill was real, but also sort of impressed that the water-works was able to pinpoint my usage, so I asked her about the metering. She explained that we have a smart-meter that transmits our usage on a daily basis to the central office. When I heard that, I asked why, if they could tell we had a problem, that they didn’t notify us or provide us with access to the data. Turns out they intend to make that information available to users in the near future. Cool.
Continue reading Heart Monitors and Running Toilets
When I was a cardiology fellow back in the 1980s, I learned about a variety of early tools for evaluating heart health that had been displaced by the modern standards of electrocardiography (ECG, or EKG for the Deutschephiles) and echocardiography. One such technique – ballistocardiography – stuck with me, and may be making a comeback.
Ballistocardiography is based on the observation that the mechanical action of the heart leads to subtle but reproducible movement of the whole body. It is the old “every action has an equal and opposite reaction” maxim in, well, action. We literally shudder a little bit each time the heart ejects blood. Back in the day, researchers compared patterns of that shudder to detect and quantify disorders of cardiac output. As someone who had studied biomedical engineering in college, I thought it was pretty cool that you could non-invasively estimate cardiac output by measuring how much somebody bounced up and down with each heartbeat, even though it had been eclipsed by more accurate and easier to use technology.
By the way, you can easily measure the effect yourself, if you have an analog bathroom scale. Just stand on it as still as you can, and you will notice the needle deflects slightly with each heart beat – as the blood goes “up” out of your heart, your body goes “down” and your weight appears to increase momentarily. More elaborate ways to measure and quantify the effect are, of course, available on YouTube.
Continue reading What Goes Around Comes Around
I believe strongly that “data about patients should be patients’ data.” That is why I support the OpenNotes movement and the push to provide patients with access to data from their cardiac implantable electronic devices. Last week, I had the opportunity to spend the day among an eclectic group of pioneers who are taking the principle of patient empowerment through data to its next logical step – patients generating their own data in order to understand their own state of health, and expand the understanding of health and illness in general.
The occasion was a symposium on cardiovascular health, sponsored by the Quantified Self. Quantified Self (QS) is described on its website as a “company” but it is also a movement. A slightly dated but useful description of the movement is available here. Its members are people who are using new tools in new ways to learn more about themselves. Most of these tools are electronic, often wearable, sensors that can easily and continuously track parameters such as heart rate, blood pressure, temperature, activity, etc., but some go way beyond that, to track things like the composition of the gut microbiome. Other participants were creating new technologies to make tracking and data sharing and analysis easier.
Continue reading Quantified Self
All of the “players” in health care are getting bigger. Consolidation is the name of the game as hospital systems hire more physicians, multi-hospital systems merge, insurers develop their own “captive” provider networks and new hybrid organizations, like CVS/Aetna (and maybe Walmart/Humana) are coming with dizzying frequency. Some of this feels to me like an arms race, with size (and its attendant market power) itself the goal, rather than growth as a means to assemble the right combination of resources at the right scale to improve care.
Even so, I believe scale can improve care. Given where I sit, I don’t suppose that is much of a surprise, but I would go further to say that organizational heft is now necessary to provide high quality care through enhanced and better coordinated access to the right technology, the right providers and the right services, when and where patients need them.
It is in that context that I found a recent opinion piece in JAMA an important read. In it, the authors present a thoughtful theoretical framework for considering the potential downside of the growth of provider organizations. Titled “The Risks to Patient Safety from Health System Expansions” it includes new threats to patient safety and suggests potential strategies for mitigating them, summarized in this table:
(Click image to enlarge)
It is important to note that the authors do not advocate limiting the size of provider organizations or retreating from the prevalent plans for growth to avoid these risks. Rather, they conclude: “Institutions must actively plan for, monitor, and manage the resulting risks as part of a comprehensive strategy, including sharing data on quality and safety, and sharing oversight of care for the joint patient population.”
Makes sense to me. What do you think?
A colleague recently sent me a link to the “American College of Cathopathic Physicians” a new organization whose mission “is to protect the professional autonomy and advocate for a full, broad scope of practice for DNPs as a ‘cathopathic physician’ completely equal in every way to our MD and DO counterparts.”
I was, I admit, so stunned by the statement (and confused by its grammatical errors) that I thought the whole thing might be an elaborate joke. It was only after spending some time exploring the site that I realized that it was for real, and a really bad idea.
Lets start with the absurd circular “reasoning” that the group uses to justify labeling DNPs as “physicians.” According to the site (their quotations are unattributed):
A physician is commonly defined as a “doctor who practices medicine” which is “the art of healing” or “promoting, maintaining, or restoring health through the study, diagnosis, and treatment of disease”. Other organizations, such as the federal government, define a physician as a healthcare professional with “the authority to make independent judgments in the examination, diagnosis, treatment, prevention, and care of the human body”.
It then goes on to advocate for DNPs to have such authority, which in turn it believes would justify calling DNPs physicians. And of course, once you get to call yourself a physician, why wouldn’t you have full independent authority? After all, that’s what it means to be a physician, right? So, basically, if you call yourself a physician, then you are one.
Continue reading Not All Doctors Are Physicians
For each of the last several years, we have held a retreat for the leadership of our medical group. In the early years, we used the meeting to address basic questions about who we were and what we were trying to accomplish. In 2014 we established a series of priorities for our group, which we summarized in what we affectionately called “the flower”:
This road map served us well in the years since, but we decided it was time for a refresh, so at our most recent retreat we revisited our priorities, and came up with this:
Continue reading Strategic Priorities