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
I think that almost everyone would agree that making good choices requires access to good information. That may be especially true with regard to choices about one’s health, where the stakes are high, the issues are often complicated, and there is a lot of uncertainty. That is why I feel so strongly that promoting patient access to clinical data is the right thing to do, that it drives better care, and that patients will increasingly demand it.
Here is another, more personal, reason why I feel strongly about it.
Best wishes for a happy and healthy New Year.
The phrase “only in America” was one I heard frequently as a child. It was often said in a light-hearted manner, sometimes with a faux Eastern European accent, but always with a deep reverence for what my parents believed to be it’s central truth: that the United States was a special place. Its unique blend of opportunity, freedom and compassion had allowed our family to go from poor immigrants to prosperous professionals in 2 generations. What a country!
I thought of that phrase this morning in a darker, ironic sense, as I read about a middle-aged couple in Tennessee who were struggling to figure out how to afford health insurance. The husband is retired, and the wife makes a solid salary at a small company. Yet they found that they were trapped by their circumstances: they were too young for Medicare, earning too much for Medicaid, not offered health insurance by the wife’s employer, and not able to afford the market rate for an individual policy on the ACA exchange. After considerable study they decided that they had two options – they could get a divorce, which would allow the husband to qualify on the basis of his lower income for an insurance subsidy, or the wife could take a substantial pay-cut, which would make them eligible for an exchange subsidy. They chose the latter, and actually appear to have come out ahead, since the subsidy was greater than the after-tax difference in her pay before and after.
What is wrong with this picture? Here are a few things that come to mind:
- The health insurance “system” is clearly broken if it creates incentives, no matter unintended, to dissolve marriages and earn less
- There is a huge “complexity tax” that we are all paying to prop up the Rube Goldberg arrangements of the current health insurance marketplace. How much time, effort and anxiety were spent by this couple to figure this out? For those of you fortunate enough to have employer-provided benefits, how much time did it take you to do your benefits enrollment? Did you get it right?
- All this is playing out while Congress cut taxes on the most fortunate in our society
Only in America.
It is no secret that there is a lot of waste in healthcare. Even if one leaves aside the most egregious examples such as duplication of tests and patient harm that necessitates more care, we still collectively do a lot of stuff that does not improve health. A recent report in Health Affairs changed my assumptions about what that stuff looks like.
The authors analyzed claims data from an all payer database in Virginia for services provided in 2014. They prospectively defined 44 services that were of “low value” defined as providing no net health benefit in specific clinical circumstances. Their assessments were based on nationally recognized standards, including the “Choose Wisely” campaign of the ABIM, the US Preventive Services Task Force, CMS criteria, and others. They then scoured the database to see how frequently these services were provided, and calculated the aggregate costs associated with them.
Continue reading Looking in the Wrong Place?
The headline in the New York Times summarized the initial reaction of the cardiology community – “unbelievable” – but still seemed to understate the ground-shaking implications of a recent study of coronary stenting.
The report of The Objective Randomised Blinded Investigation with Optimal Medical Therapy of Angioplasty in Stable Angina (ORBITA)Trial was published last week in the Lancet. In brief, investigators in the UK (hence “randomised”) enrolled about 200 patients with angina, objective evidence of inducible myocardial ischemia and angiographic and hemodynamic evidence of significant single vessel coronary artery disease. Half the group received a drug eluting stent, with excellent technical results. The other half got a sham angioplasty. Both groups were treated medically. The key finding: “real” stenting produced no measurable benefit in exercise time increment (the primary endpoint) compared with a “placebo procedure.” The study was well done, with true blinding of patients and evaluating physicians, careful selection of endpoints, and sufficient power to support the conclusion. Whoa.
Continue reading Holy (Sacred) Cow!