A couple of recent articles got me thinking some more about the anticipated impact of “consumer health devices.” The first was in the Wall Street Journal and reported on the annual consumer electronic show (CES) in Las Vegas. The other was a review in Nature Medicine by Eric Topol on the current state of artificial intelligence in medicine.
The Journal piece made the point that CES had more health-related offerings than ever before. Sure, the show still featured the latest home entertainment offerings (how about an 98” 8K OLED TV?), but now also showcased everything from a watch that can check your blood pressure (see below), to a sensor and associated app for assessing the quality of sperm in a specimen collected in the comfort of one’s own home (use your imagination). You can get a rundown on “all the new cool gadgets” here.
Topol’s piece was a comprehensive (216 references!) look at the capabilities and applications of artificial intelligence in medicine. In particular, he assessed the impact of “deep neural networks” on clinicians, on health care delivery systems and on patients. These networks are a particular kind of machine learning that generate sophisticated pattern recognition algorithms based on an annotated set of images. The review is worth the read, but I would say the punch line is that there is incredible potential, but not (yet) much evidence, of the transformative power of artificial intelligence in medicine. That said, the inexorable growth and availability of large bodies of data in digital format (necessary to train algorithms), ever more rapid and less expensive computing power, and nearly unlimited data storage capacity in “the cloud” portend a much more extensive role for this technology.
Continue reading Where is this Going?
I got a heads up the other day that our organization had been dissed by a CNN reporter who was frustrated by her inability to get tested for Zika. You can read her original piece and the follow-up here. Short version is that she was upset that it was difficult for her to get tested after returning from a vacation to Costa Rica where she encountered “a good amount of mosquitoes” and later developed a mild febrile illness.
I won’t defend that she was made to feel like she was getting the run around, and it seems like – at the very least – we could have done a better job of communicating with her. But what she seems to dismiss, even though it goes to the core of her encounters with all of the medical providers she contacted, is whether she should have been tested at all. Continue reading Test Responsibly
Readers of this blog know that I am a fan of public reporting of performance data. I believe that data transparency helps fulfill an obligation to our patients to be honest about the care we provide, and is also a potent stimulus for improvement. There are obvious conditions that ought to be met before any sort of data – about quality, patient experience, finances or anything else – is shared in this way. The data should be meaningful (pertaining to something that patients are likely to care about), valid (the data actually measure what we say it measures), reliable (vary consistently with performance) and presented in a way that patients can easily make sense of it.
Our own efforts to report the patient satisfaction scores of Northwell Health Physician Partners physicians has been well received by our members and the press because it meets all of these criteria.
Some of the other public reporting efforts, such as recent reporting of surgical complications by Pro Publica, have been criticized for failing to meet the standards of validity and reliability, although I and others have been supportive of their efforts.
Continue reading More Public Reporting
Drug pricing has become a hot topic. Maybe I have become sensitized to it, but it seems like there is something about the cost of pharmaceuticals everywhere I turn – in medical journals, online discussion groups and mainstream news outlets. Just this past week, the front page story in the business section of the New York Times ran a long profile of a pharmaceutical executive that centered on his company’s controversial pricing practices. The article mentioned that pricing is now generating lawsuits and potential Congressional action.
Why all the attention? I am guessing (really – just guessing) that there are a few reasons.
Continue reading Drug Prices and Costs
All good physicians want to do the right thing. They want to recommend effective therapies to their patients that will improve outcomes or alleviate symptoms. It is widely accepted that the best way to discover new effective therapies is through the use of clinical trials. Among clinical trials, the reference standard is the randomized, double-blinded, placebo-controlled trial, which is designed to minimize bias in the selection of therapies or the interpretation of results.
I have written before about the limitations of clinical research in advancing medical practice. As I have said, it is literally impossible to study every clinically relevant question, and it is also impossible even in theory to use randomized controlled trials as the methodology for many of the questions that can be studied.
A recent article in the New York Times highlighted another challenge to the paradigm of clinical trials as the engine for improving medical practice. The piece was about a change in policy at the National Institutes of Health, being implemented by Michael Lauer, the “newly appointed deputy director for extramural research.” In the interest of full disclosure, I have known Mike for many years (we were cardiology fellows in the same program at Boston’s Beth Israel Hospital in the late 1980’s) and you would be hard-pressed to find a nicer, smarter or more upstanding guy.
Continue reading Improving the Evidence
I was stunned when I saw this headline in the New York Times last week: “Court sides against FDA in ‘off-label’ drug promotion case.” In case you missed it, here is the lede:
The maker of a prescription fish-oil pill won an early victory Friday against the Food and Drug Administration over its right to publicize unapproved uses of its drug.
The gist of the story is that the pharmaceutical company successfully claimed that restricting its ability to promote off-label use with (in the words of the court) “truthful and non-misleading information” violated its First Amendment right to free speech.
Let me be clear here. I am all for maintaining the longstanding prerogative that physicians and other licensed prescribers have to prescribe approved medications for unapproved indications. That’s not what this is about.
Continue reading This is a Very Bad Idea
There were several news stories last week that reported that Pfizer had abandoned its efforts to have its Lipitor brand of atorvastatin made available over the counter, without a prescription. I was never a big fan of OTC statins (more on that later) but I was struck by the reason that Pfizer put out:
The study did not meet its primary objectives of demonstrating patient compliance with the direction to check their low-density lipoprotein cholesterol (LDL-C) level and, after checking their LDL-C level, take appropriate action based on their test results.
Left unstated (and unclear) in this is exactly what the appropriate action was supposed to be. I guess they were implying that patients were supposed to check how they responded to the drug and then figure out if they should keep taking it, change the dose or seek professional advice about next steps.
Continue reading Right Call; Wrong Reason
I was driving to work the other day, and there was a story on the radio about the Congressional reaction to the latest recommendations for breast cancer screening from the United States Preventive Services Task Force (USPSTF).
Here’s the background. USPSTF published recommendations in late 2009 for the use of screening mammography in different age groups. For women between 40 and 50 years old, the panel concluded “that the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination (CBE) beyond screening mammography in women 40 years or older.” In other words, they did not recommend biennial mammograms – which they did for women between 50 and 74 years old – for the younger cohort. That led to a firestorm of criticism that younger women would be “denied” mammography, and Congress wrote into the Affordable Care Act that “exchange” (Obamacare) insurance plans cover regular mammography for women over 40.
Fast forward to now.
Continue reading Congress and Dr. Bayes
I was disturbed by a recent article in the New York Times about the Texas Medical Board. The piece described the decision by the Board to sharply curtail the use of telemedicine in the state. Specifically, the Board mandated that telemedicine services could only be provided in the context of a pre-existing patient/physician relationship, and that such a relationship must be established face-to-face, and not via electronic means. According to the Times, the restrictions were strongly supported by the Texas Medical Association.
This seems to me to be a wrongheaded, backward looking and overall pretty lame attempt to stem the inexorable tide of patients and physicians connecting in new ways. I really wish I could believe the Board member who said he voted for the new restriction because he was “terribly, terribly worried about the absence of responsibility and accountability” in electronic encounters. It sounded to me, instead, that he was “terribly, terribly worried” about a new business model for medical care that provides greater convenience and lower cost to patients than traditional office visits.
Continue reading Patient Advocates? Really?
When the Affordable Care Act (ACA) was passed in 2010, the most contentious provisions – which are still the subject of challenges in federal courts – were the establishment of state-wide insurance exchanges, the “individual mandate” that compels eligible citizens to buy insurance, and the expansion of state Medicaid programs. Less well appreciated, but arguably more important, were a wide range of reforms to the Medicare program. Summarized here, they touch on almost all aspects of the program, but I want to concentrate on just one.
The law directed CMS to move Medicare from a strictly fee-for-service (FFS) payment model (“paying for volume”) to one in which the quality of care was factored into the payment received by hospitals and physicians (“paying for value”). As I have written previously I believe this is the right move. There are just too many challenges to improving care and lowering costs that derive from “straight” FFS that is disconnected from any assessment of quality. And while you may not have known that they grew out of the ACA, the payment reforms themselves have gotten a lot of attention. Penalties for readmissions, requirements for physician quality reporting, pilot programs for bundled payments and accountable care organizations are just of few of the Medicare reforms. Even though they currently influence a small percentage of overall Medicare spending, these changes may already be having a big impact on how care is delivered.
Continue reading Not Your Father’s Medicare