A New Therapy That is Difficile to Swallow

Imagine the following. A tube is placed down a nostril, snaked into and through your stomach, right to the start of your intestines. Then someone else’s stool is pumped in to the tube and down your throat.

And if you’re suffering from a “C-diff” infection, trust me, the day has come when you’ll be begging for it. You can ask someone who has experienced it, or just ask an experienced nurse, about what it is like to suffer through the severe diarrhea that comes from an infection by the bacteria Clostridium difficile. It is severe, non-stop, and often life-threatening. It generally only happens when the gut has been robbed of its normal flora, the bacteria that is supposed to be there to compete with bad guys like C-diff (and a good reason to run whenever you hear anyone talk about a “colon cleanse,” a clean colon is an unhealthy colon!).

A C-diff infection is notoriously hard to treat, sometimes requiring months of a potentially toxic IV antibiotic (Vancomycin). But a new study seems to verify an old treatment. We can treat the infection by doing a fecal transplant, essentially replacing the normal flora that should be there. I have to say, when I first read about this treatment, my immediate response was “No Shit!” It makes sense though.

Donor stool  is screened for parasites and other serious infections, diluted and strained, and is then introduced in to the patient. (Now, to be fair, in Europe studies have been performed with the nasogastric tube as described above, but in the US, studies have been done via colonscopy.) The study linked to above was stopped early because it was so successful as to mean it would be unethical to continue the control arm. The treatment was 94% effective. Of 16 transplant patients, 13 were cured on their first infusion, and two more on a repeat round. In the two drug arms, the rates were 31 percent in the vancomycin-only group (4 of 13) and 23 percent (3 of 13) in the group receiving vancomycin plus lavage. That’s amazing.

In science, everything always needs to be repeated, and every endorsement is always hedged — but really, this was a rousing success. As an accompanying editorial says:

The study is an important confirmation of the efficacy of (fecal microbiota transplantation) for recurrent C. difficile infection… The results … represent a clear precedent in which planned therapeutic manipulation of the human intestinal microbiota can lead to demonstrable, clinically important benefits, thereby bringing FMT to the mainstream of modern, evidence-based medical practice. (It) will encourage and facilitate the design of similar trials of intestinal microbiota therapy for other indications, such as inflammatory bowel disease, irritable bowel syndrome, prevention of colorectal carcinoma, and metabolic disorders, to name just a few.

Given the Yuck factor, once we can meet the demand for the procedure as is, the next goal will be to create a synthetic stool, grow in cultures the bacteria needed and suspend them in some sort of benign slushy. NPR’s Shots health blog has a great interview with the Canadian team who came up with the synthetic substitute, amusingly dubbed “RePOOPulate.”

Kodak, Instagram and Healthcare

Dr. Rob Lamberts is a new friend of mine. (I’ve never actually met him, but with Facebook and Twitter and the like, you no longer to know someone to know someone, right?)

He is a Med-Peds physician in Augusta, GA, who is also rebounding from burn out (my diagnosis, not his).

Looking through his blog, I found an entry from last fall that, I think, speaks a lot of truth about the impending implosion of our health care system. At a time when costs are escalating, and quality is falling, and more and more people are going to make use of the health care system given the well-meaning, but ultimately misguided policies of the Affordable Care Act (I’ll go in to that more at a later date), something has to change. This industry has to evolve, or it risks becoming the Kodak of the first part of this century.

He writes:

Kodak was, at one point, the consummate American success story, dominating its market like few others. In 1976, it had a 90% market share of film, as well as 80% of cameras sold in the US.  Kodak Park, the property at the center of manufacturing once employed 29,000 employees, with its own fire company, rail system, water treatment plant, and continuously staffed medical facility.

Fast-forward to 2012, and the picture changes dramatically.  In a single year, Kodak declared chapter 11 bankruptcy, received a warning from the New York Stock Exchange that its stock was below $1/share for long enough that it was at risk of being delisted, announced it is no longer making digital cameras so as to focus on its core business: printing, and then a few weeks ago announced it was no longer making inkjet printers.  The job force in Rochester alone has gone down by nearly 90%, to an estimated 7200 employees.

Adding pain for former Kodak fans was the announcement in April of this year that Facebook was buying the photo sharing company Instagram (which employed 13 people at the time) for an estimated $1 Billion.

I remember reading that at the time of their bankruptcy hearings, a judge placed a value of $525 million on the assets (primarily patents) of the company. And here the app, whose sole purpose is to take a photo that pales in comparison with the quality of a photo taken on kodak film, then to apply a filter to it, making it look like a photo taken on old, outdated film, was purchased for almost twice that amount!

…the success of Instagram at the expense of the wonderful folks up in Rochester happened because Kodak had too much at stake to embrace a disruptive technology that spelled doom to its business model.  Even if Kodak had embraced digital technology, wouldn’t they have still had to lay off tens of thousands of people in the process?  Wouldn’t they have had to stop making film, printing paper, and doing all of those tasks on which they had built a 90% market share?  The Kodak of my childhood, the one that paid for my college education, gave a canvas for Hollywood’s imagination, and inspired Paul Simon to write one of my favorite songs, that Kodak had to disappear because something better came along.

It used to be that photography was a mysterious process to most consumers.  They bought film from Kodak without understanding how it worked.  Kodak succeeded by making the process easy enough for the average person to do.  People used the camera without knowing how their pictures would turn out, sent the film off to get it magically transformed into photographs that they could show others.  Ironically, the company that literally made black boxes made billions by keeping the process a black box for most people.  Then came digital photography, cameras on phones, and eventually social media.  Now there was no need for film, no need for cameras, no place to send the photos to get developed, and even no need to be on the same continent to share pictures with people.  Technology eviscerated Kodak’s business model by removing the black box.  It wasn’t just digital cameras that doomed Kodak, making it easy to carry cameras everywhere and to share with people instantly was also needed…

Dr. Rob proceeds to apply this lesson to the idea of health care reform:

Health care has previously been a black box to most consumers – a mysterious process by which the high priests (doctors) would perform healing through the use of their special knowledge and the wondrous healing of medications.  But unlike Kodak, health care was able to keep raising prices instead of becoming more efficient.  Now the health care industry has an economy larger than nearly all countries on this planet.  The number of people employed by this economy is staggering, and the number of businesses built off of this model of inefficiency is huge.  Imagine the damage an “Instagram of health care” could cause.

That is why I no longer feel that the solution to our problem will come from within the system: the system itself must be eviscerated for it to survive, and most systems (like Kodak) don’t see evisceration as a good business strategy.  Legislators may pretend to pursue meaningful reform, but far too many of their constituents stand to lose their jobs if they succeeded, and far too much of their campaign funds come from companies built on the old economy of waste.  Having hospitals oversee ACO’s [Accountable Care Organizations] is like putting Kodak executives in charge of laws concerning digital image sharing.

So what would the “Instagram of health care” look like?  I think it would:

  1. Rely on technology to simplify things greatly.
  2. Use social technology to cut out black boxes.
  3. Put the control of care in the hands of the people who use it.

In a tiny, little way, this is what my informal Facebook Focus Group experiment is pointing me towards. Why not try to step out of the system (before it is eviscerated anyway) and at least try to do things  in a new way.

(photo:  Kodak No. 2A Brownie (Model C) by flickr user John Kratz)

The Doctor will E you now…

In my Facebook Focus Group experiment, one of the leading concerns was decreasing wait times in the office. Many people expressed dissatisfaction with taking an hour off from work, waiting an hour in the waiting room, and 30 minutes in the exam room (missing more work than planned), and then spending only 7 minutes in front of the physician for a simple problem. And who can blame them?

Another (single) response suggested e-visits. What’s an e-visit, you say? An e-visit is an encounter with a doctor or a nurse that doesn’t involve a trip to the office. It might be by phone or by teleconference. Sometimes it involves a pre-visit questionnaire. You don’t hear a lot about e-visits because, like so many things we do, it all depends on what the insurance companies think about it. If the health insurance companies in an an area pay for e-visits (and they do in some places, typically at discounted rates), then patients usually are excited to take advantage of them. Typically for simple problems or follow up for ongoing management of stable, uncomplicated chronic disease states.

Assuming reimbursement is not an issue, are they okay? Can a doctor do as good a job without seeing a patient face-to-face? A new study was just published that looked at simple problems like UTI’s and sinus infections found e-visits to be more cost effective and similarly effective. The one difference they found was that those receiving care in an e-visit were more likely to receive antibiotics then those seen in person. But there was no ultimate difference in outcomes.

My opinion is that, when your doctor knows you well, a lot of what typically happens in the office could safely happen over the phone (or via teleconference), and certainly be more convenient for the patient, compared to taking time off work and suffering long waits in the office. I’m interested to know how you feel…

Shoot for the Moon. And Bacon.

I posted the following status update on Facebook today and had an overwhelming 180-plus responses, and dozens of “likes” endorsing individual answers. It was amazing. Although not very scientific, the exercise turned out to be a good marketing survey!

Facebook Focus Group time–Other than a doctor that knows what he or she is doing, what do you want in a doctor’s office? Shoot for the moon. Do you want free lollipops? Evening hours? Humans answering the phones? Reply with one or three things you think you would want from your doctor?

(Please comment here whether or not you have been a patient of mine in the past, or whether you want to be in the future. This is for anyone who has ever been a patient. Forget what is conventionally available. Ask for anything you want!)

My purpose is obvious. I am hoping to start a new practice on Nantucket, and need to decide on what I want that practice to look like. What better way to plan it than to ask the people it might matter to the most?

In asking everyone to “shoot for the moon,” I wanted honest opinions about how an office should run, about what would make a new practice stand out, and be the best one out there.

Here are the results. I grouped the responses into categories and summed their mentions and “likes.” In order:

40       Online access to medical records
35       Decreased wait times
31       Dual waiting rooms—sick and well
31       Undivided attention/good listening
27       Evening hours
27       Weekend hours
25       Attention to diet/nutrition/exercise, overall wellness
24       Email access
21       Help to avoid unnecessary ER visits
18       Questions to prompt for reasons for visit (during visit or before)
18       Courtesy call if running late
18       Courtesy from receptionist
18       Avoid triage or gatekeeper role of receptionist
17       Alternative/integrative treatment options
16       Online self-scheduling tool
15       Waiting room comfort (seating, temperature, good magazines, privacy)
15       Decreased wait for appointments
12       No automated answering machines
10       Bacon
10       Followup with test results
9          Comfortable exam room environment (seating, lighting, good magazines)
9          Seeing doctor, not NP or PA
8          Walk-in slots
8          Enhanced check-in technologies
8          Respect my opinions on illness
7          Donuts
7          Alerts/reminders from doctor
6          Telephone access for after-hours emergencies
5          Coffee
4          Teleconference (Skypelike) or other alternative visit options
4          Nutella
4          Wifi
3          No lollipops
2          Lollipops
2          Home-cooked meals
1          Same day appointments
1          Cookies
1          Snacks
1          Drinks
1          “Fancy” chocolates
1          Massages

Pretty interesting results, don’t you think? First of all, it would seem that it is more important for me to provide complimentary bacon to my patients than a comfortable exam room environment or walk-in slots for appointments. Why didn’t I think of that? Bacon is always the key to excellent customer service!

You can tell the thread had a little humor in it, and that is always a good thing. But, ignoring the requests for Nutella and home-cooked meals, I was happy to see that online access to medical records was the most “liked” topic. This shouldn’t be a surprise. Today’s patients, raised on WebMD and the University of Google want to be involved in their care, or at least feel well-informed about their visits.

In October, a study was published in the Annals of Internal Medicine that looked at the interaction between clinician and patients (as well as the satisfaction each party feels and its affect on healthcare) when visit notes were made available after every doctor’s visit. It was summarized as follows in an article on the study in Forbes magazine:

“Patients accessed visit notes frequently, a large majority reported clinically relevant benefits and minimal concerns, and virtually all (99%) patients wanted the practice to continue.  With doctors experiencing no more than a modest effect on their work lives, open notes seem worthy of widespread adoption.”

So now, in my own little study, my Facebook friends have put online access to medical records as their number one request in an “ideal medical practice.” In the study, this meant actually delivering copies of the notes. But there are different ways to interpret this informal request from Facebook, especially since I did not specify what this would entail. Other than in the study environment described above, not many electronic medical records are programmed to share visit notes online, as this is something that, prior to this study, is so foreign to ambulatory medicine that it has likely never been requested of the health IT companies. Today, online access to medical records is more likely to be represented in a patient portal, written by the software companies, to which a patient can securely log in and see some portion of their records. This should, in the least, include appointment requests, problem lists, allergies, medicine list, visit summaries, lab results, and secure messaging.

“Decreased wait times” is not a surprise at number two, given our severe doctor shortage and the pressures from our third-party payer system that makes a doctor see more and more patients each day to maintain a steady income. If I were to recreate the practice that I left, the mill that grinded me up and spit me out in a bag of grits, I would have the same situation all over again. In opening a new practice, I will need to find a way to limit the overall patient load to better match the advanced level of service I am talking about trying to provide, which includes minimal wait times. I think at least part of the solution, in addition to limiting patient load, is found farther down the list. If I try to mostly stick to same day scheduling, allowing patients to schedule their own appointments online, and offer alternative visit options like Skype or telephone visits, then I should be able to limit the time spent waiting for me to see you.

Coincidentally, this will also help me take care of the issue that surprised me by coming in third, having a dual waiting room, separating the sick from the well. Going forward, I do not want a practice with more than one person waiting!

So what is next? I need to take this list, as grandiose as it may seem, and see if I can come up with a practice model that can make it happen. I am going to try!

Aisle 20, AR-15s, ammo; Aisle 21, Cheetos, Slim Jims; Aisle 22. Primary Care…

Walmart announced Friday that it plans to provide “full primary care services” to consumers nationwide within five to seven years.

The retail giant made headlines in 2011 when it sent 14-page letters to health providers and companies requesting information to help it establish “the largest provider of primary health care services in the nation.” However, the company quickly clarified that it was “not building a national, integrated, low-cost primary health care platform.”

Speaking at the Foundation of Associated Industries of Florida’s 2013 Health Care Affordability Summit, Marcus Osborne—Walmart’s vice president of health and wellness payer relations—was asked whether the retailer plans to pursue retail clinics in rural areas.

He said, “That’s where we’re going now: full primary care services in five to seven years.”

Osborne added that Walmart’s clinics will be in underserved, urban areas because the chain has many stores in those areas. “One of the areas we’re highlighting is where there isn’t access to care,” he said. (So, if we were to get a Walmart in the old Grand Union space? Hmmm.)

Can Walmart provide us with primary care as efficiently as it provides us with unnecessary plastic objects and junk food? I think the answer is probably yes. It might not be the same kind of one-on-one doctor-patient relationship we long for, and it might involve more urgent care from midlevel providers and less preventive care or chronic disease management from physicians, but I think that a business like Walmart, that runs an efficient, national corporation, could find a way to disrupt things and deliver some level of care in a more efficient manner. For that matter, I bet the Cheesecake Factory could as well.

But here’s the catch. It can do so only if it does what other retail medical outlets are already doing: ignore the third-party payers. Almost everything that’s wrong with our health care system is the direct result of third-party payment. In response, there are a lot of people reinventing healthcare, in small corners around the country, and showing great improvements in efficiency, quality and patient satisfaction, by opting out of the third-party payer status quo. If Walmart were to negotiate directly with businesses and customers to provide care on its own terms, and not have to bow to health insurance companies like the rest of us do, I think they could indeed make a big impact. I just hope they do not skimp on quality. I don’t mind buying a plastic onion chopper that is going to break in 9 months, when I know I am getting it for ¢50, but I do not want discounted services when my child is sick and seeing their doctor.

I am not saying that our problems are being created by health insurance. There is nothing in principle wrong with insurance. The source of our problems is using insurance companies to pay medical bills. It’s insurance companies acting pro emptore — in place of the buyer. When this happens, a number of things begin to change, all of them bad:

  • The provider becomes the agent of the insurance companies, rather than of the patient — and this changes the practice of medicine to the third-party’s view of how it should be practiced.
  • The provider no longer has to compete for patients based on price.
  • Absent price competition, the provider no longer competes for patients based on quality.
  • Overall, the provider’s incentive is to maximize against reimbursement formulas rather than provide low-cost, high-quality care.
  • The third-party payer further maximizes profits by adding levels of regulatory smokescreen, making it harder for providers to be reimbursed for what they’re owed in the first place.
  • Causing the providers to work harder, see more, and further sacrifice quality.

Walmart has clearly been testing the waters for a couple of years, even prior to their bombshell announcement in November, 2011. A National Center for Policy Analysis Health Policy blog summed up their efforts almost two years ago:

This past weekend, Wal-Mart was offering health care screenings to male customers at no charge. Sam’s Clubs across the country gave any customer willing to take the time:

  • BMI Index measurements,
  • Blood pressure tests,
  • Cholesterol readings,
  • PSA (prostate cancer) tests, and
  • TSH (thyroid stimulating hormone) tests.
  • And that’s not all. Sam’s Clubs have more free screenings planned for the future. Here’s the schedule:

  • July: Kids Health Screenings
  • August: Vision Health Screenings
  • September: Diabetes Screenings
  • October: Women’s Health Screenings
  • November: Digestive Health Screenings
  • Further, at the store I visited there was no waiting. And if there happened to be a wait, I suspect it would be handled the way Wal-Mart handles prescription drugs. In order to reduce both the time cost and the money cost of care, Sam’s Club Pharmacy promises:

  • Hundreds of generic prescriptions for just $4,
  • Prescriptions filled in just 20 minutes, and
  • Text alerts to tell you when your prescription is ready, so you can shop while you wait.
  • So, is this a good thing or a bad thing? I don’t know. Instinct says that replacing a traditional doctor with a Walmart branded one is a bad thing. But on the other hand, the system is so broken that before long, the traditional doctors will be offering laser hair removal, weight loss clinics, Botox injections and Lasik eye surgery instead. We might need the Waltons to come along and bust things up a bit.

    A 21 State Salute

    Today’s Globe has a front-page above-the-fold article about Nantucket Cottage Hospital: “21 States Take Aim at Mass. Hospital’s Medicare Windfall-Nantucket’s Tiny Hospital that funnels hundreds of millions to other institutions.”

    The article makes it sound like we’re a money laundering operation cleaning up dirty wads of cash as they come in to the state from Medicare.

    “…the 19-bed hospital on the tony island…has become a national symbol of inequity and political machinations in the way the federal government reimburses hospitals for treating Medicare patients.”

    The reporter tells the story as if Massachusetts hospitals teamed up with Senator Kerry in 2011 and found a way to game the complicated Medicare reimbursement system. And now, after an Institute of Medicine report from last summer, which named the shift in reimbursement (from other states to Massachusetts) the “Nantucket Effect,” 21 other state’s hospital associations finally figured out the game, and the game is up.

    “…a coalition of 21 states is seeking to reverse the windfall, calling it the “Bay State boondoggle,” the product of “Yankee ingenuity” — the artful manipulation of obscure payment formulas.”

    I cannot remember exactly when, but before our affiliation with Partners Healthcare in 2008, NCH had already declared as a Critical Access Hospital. This reform was put in to place to help save rural hospitals that are suffering across the country. If you met the criteria (which centered around hospital size and proximity to other hospitals), Medicare agreed to reimburse you based on your costs alone, rather than on the complex formulas this article discusses. For NCH, this was a big benefit, given our high costs of doing business.

    But even back then, there was a formula that determined the reimbursement rates for a state’s hospitals, and it included the “Rural Wage Index,” a calculation of how expensive it is to do business at the most rural hospitals in the state. When a hospital opts for Critical Access designation, it is no longer used in the calculations of the Rural Wage Index.

    Partners did not come to Nantucket Cottage Hospital in 2008 wanting to acquire the hospital simply because they needed a small hospital on a tony island to fill out their portfolio. They didn’t ask NCH to give up their Critical Access designation, with the promise to make whole any losses they might incur as a result, just to be nice. This was their promise even back then, recapturing the hundreds of millions of dollars that had been diverted from state hospitals when that designation kicked in.

    There was no attempt to game the system. Massachusetts Hospitals Association, along with the big hospital systems in the state, all noticed the checks from the government were getting smaller, researched it and realized why (our change to Critical Access designation) and found a quick and easy fix. Acquire NCH and drop the designation. Nothing wrong there.

    To the 21 states crying foul now, I say, what took you so long? Don’t blame Massachusetts or Nantucket Cottage Hospital. Blame the Centers for Medicare and Medicaid Services that would even start with such an archaic formula to determine how much they should pay a hospital for taking care of sick, elderly people.

    Anyone unfamiliar with it will not believe the rules involved with Medicare reimbursement to hospitals. To summarize, a hospital is not paid according to the services a Medicare beneficiary needs. They are paid according to the diagnosis. If you have Medicare, and are admitted with pneumonia, Medicare has already determined that a pneumonia ought to be good for 1.8 days of hospital stay (as long as you also have an IV in place and are receiving IV antibiotics). If your pneumonia is complicated, and you end up needing to stay an extra few days, there is no change in how much they pay. If you are 78 and otherwise healthy and independent, but too weak from the pneumonia to go home just yet, that is tough. Medicare will not pay more than the amount needed to cover the 1.8 days. The hospital has to decide whether to eat the added costs of your stay, or push you off to a nursing home.

    Hospitals have to know that they’re going to get paid the 1.8 days, and have to bill Medicare accordingly. Some hospitals have as many Utilization Managers as they have nurses, in order to do this right. Reason is, if a hospital does it wrong, if they assume that since a patient has a comorbid diagnosis like a urinary tract infection means that they get 2.4 days of stay, instead of 1.8, and they’re in a gray area of the rules, then a private auditor, a Medicare-endorsed bounty hunter, can come to a hospital 3 or 4 years later, audit the books, interpret the rule in a way that best benefits it (while working on a commission), declare fraud, and insist on a refund with penalties! Seriously. The mafia is jealous of this arrangement!

    And, finally, to make matters worse, the amount that Medicare will pay for the 1.8 days varies by locale, according to formulas like the one discussed in this article. A formula so complex that it took these 21 states 4 years to realize why they were losing money!

    So, don’t come pointing fingers at Nantucket! These days you hear a lot about “entitlement reform” and reporters and pundits are usually talking about how the Republicans want the Democrats to agree to spend less on healthcare for the elderly. To cut spending. But this article shows that we truly do need to reform this entitlement. Not at the expense of the beneficiaries. But to the advantage of hospitals across the country trying to survive on Medicare payments. If the rules could be reformed, made simpler, hospitals could cut costs dramatically and do better, even, with lower reimbursements (by replacing administrators with lower-cost healthcare providers), and we could use the money saved to pay down the debt, to mint $1 Trillion coins, to improve access to mental health and preventive services, or even to cover the pending costs of Alex Jones’ therapy!

    (photo from Flickr user Images_of_Money)

    UPDATE: The states have delivered a letter to President Obama asking that Nantucket Cottage Hospital be placed on a floating barge, so as to not be considered a Massachusetts hospital. Read about it here.

    An Rx for IT

    Many of you know that, since this past summer, I have been working in a consulting role with a medical software company in Westborough, MA called eClinicalworks. I have learned a great deal about the role of technology in the delivery of healthcare.

    Having 5 months of experience in the industry now certainly qualifies me to tell you exactly what is wrong with it and where the industry needs to go from here. Right?

    Logic has always dictated that the most important reason to use computers is to lower costs and increase efficiency. A new study by the RAND Corporation shows this is simply not true. From the NYTimes yesterday:

    “The conversion to electronic health records has failed so far to produce the hoped-for savings in health care costs and has had mixed results, at best, in improving efficiency and patient care, according to a new analysis by the influential RAND Corporation.”

    Actually, the most important reason to use electronic medical records is to improve the health of our patients, to guard against errors, and to improve the overall experience for patients. Like Facebook, technologies can (in an ideal world) help us, as doctors, better communicate with our patients and to access their medical history (their “Timeline” as it were), and make the experience better and more streamlined for doctors and patients alike.

    But, up to now, medical software hasn’t been designed to engage patients, it has been designed to improve physician billing. More attention has been paid to maximizing communication with payers and to making it easier to document an encounter to support the complexity needed for higher billing codes. Most EMRs will flawlessly communicate a charge electronically to any one of hundreds of health insurance companies, but still are unable to import your medical history and put the data in the right place in your chart!

    People typically spend less than one hour a year with their doctors (and 8,759 hours per year checking their Facebook newsfeed and looking for cute pics of kittens on the Internet). Some people even skip that one-hour of visits all together. Combine this with studies that have shown that patients forget around 85% of what a doctor says during visits, ant that means, at best, my patients remember about nine minutes of everything I say per year.

    What if that information had a chance to sink in? What would that do for our country’s health? What if instructions and education made it past the checkout window? What if we could remind our patients to take their pills or exercise? Send contextual health information in between visits? Prompt for important preventive procedures and tests? Of course, there’s all kinds of technology that exists to help us communicate with one another, e.g., Facebook, Skype, or text messaging. But you see very little of that designed to safely and securely facilitate communication between doctors and patients. That’s what our industry needs to be working on, tools to safely and securely mimic these types of technologies to improve the communication. (Part of the problem is, of course, health insurance doesn’t reimburse for such disruptive technologies and there is, therefore, less incentive for doctors to try, and little incentive for IT companies to work on this.)

    Yet, this is what I am working on with eClinicalworks, new software to try and maximize the experience, and to make such communication easy and efficient for the doctors, and more accessible for the patients. I find it to be very rewarding work and I cannot wait to start using the fruits of our labor!

    What about Nantucket? Could technology help to improve the healthcare delivery on Nantucket?

    I think the answer is Yes and No or, better yet, “ought to” and “it ain’t going to happen!”

    Right now, Nantucket is just another good example of the disease that is affecting Health IT nationally, the inability to exchange data between different systems. It is such a shame that this industry is so far behind other industries, such as the financial or shipping sectors. When I use my Stop & Shop card to purchase a box of Kraft Mac & Cheese, Kraft knows this, somehow, and automatically sends $0.03 as a refund to an organization called UPromise, which then deposits it into a 529 College Savings Fund I have with Fidelity (because I registered my S&S card with UPromise) and it shows up in my monthly emailed statement. And yet, if Dr. Lepore is out of town one day, and Dr. Butterworth sees one of his patients for an emergency, he is unable to see the record of that patient’s medicine allergies. This is unforgiveable (of our industry).

    Nantucket’s health technology woes, like the nation’s as a whole, and are due to having multiple systems in place that do not talk to each other, causing a continued reliance on paper, making errors and oversights more likely to happen, and leading to inefficiencies in workflow.

    The MGPO practices currently uses a record system called the LMR, which was written years ago for the physician practices at Mass General. Recognizing it’s difficulties in scaling to cover MGH’s expansion into new areas and hospital systems, as well as the trouble it has in integrating with other systems in place in their system as a whole, such as, the different systems for billing, and scheduling, and lab information, Mass General has recently signed a contract with Epic Systems to replace it with their software, and will spend over $600 million and 10 years to implement it! (And you wonder why your knee MRI is $3,000.)

    My first concern about this is that if it is going to take 10 years to implement this, it’s hard for me to imagine the remote practices and smaller hospitals in the Partner’s system will be high on the list of priorities for installation. This will take a while.

    My second concern is that Epic is a closed, legacy system. Using it, data communication (i.e., patient information) within Partner’s institutions should be improved. One database. One record. But Epic, as a closed system, is a shut door for this same data when it comes to communicating with other systems, e.g., smaller hospital systems, other ambulatory practices, radiology and lab centers, and even other systems using Epic.

    Finally, if it takes 10 years for them to implement it, I question whether or not this system will still be relevant. Ironically, even though it is a private company worth billions, Epic’s software is based on a computer language called MUMPS, the Massachusetts General Hospital Utility Multi-programming System, which was written 44 years ago, by scientists in an animal lab at Mass General! Forty-four years in computer programming years is akin to this haven been written as an addendum to the Gutenberg Bible! Since it is extremely challenging and costly for any organization that is not using it to interface with it, and since one of the biggest pushes in federal health regulation is towards the interchange of data, I question how relevant this software will be in 10 years. Certainly, if your goal was speed and efficiency, free and easy interchange of information, there are more modern “Cloud” technologies out there to be taken advantage of. But the problem is scaling these newer technologies to work in large hospital systems like Partners, and Johns Hopkins, and the Cleveland Clinic. And this is the niche Epic has created for themselves. This tried and true, if outdated, software makes it easier to customize large installations.

    There was an interesting article in Forbes this past summer that discussed whether or not the hold Epic is developing on some of our larger hospital systems is a good thing or a bad thing for healthcare in general. My opinion is that closed systems are bad for healthcare as a whole.

    In an ideal world, Nantucket’s hospital and handful of physician practices would have a unified software system in place that would allow for ease of use at the point of care, for patient online access to their records, secure messaging and improved communication with providers in between visits, and a safe but reliable and electronic exchange of information from the ER to the hospital to the lab to the doctor’s offices and to the patient. This system would also need to be open to communication from America, as it were, sending and receiving data from non-Partner’s and Partners hospitals (e.g., South Shore, Cape Cod, BIDMC, Dana Farber, Quest Labs, as well as MGH) and physicians.

    Unfortunately, when it comes to Health Information Technology, there is no “ideal” world! Such a system does not exist. But as a small, contained health system, it would seem to me that if it were to be possible anywhere, it should be possible here! In the meantime, no good answers except to wait and see how long Epic takes to wash ashore.

    Google + CDC

    I love how Google technologies and traditional CDC surveillance can be used to quantify the severity of an outbreak like this year’s fle epidemic. Slate has an article, with frightening graphics, summarizing this.

    PS. It’s not too late to get the vaccine!

    An ER Physician’s take on guns

    ER Physician and Army vet Dr. David Newman discusses gun violence in this NY Time op-ed:

    I have sworn an oath to heal and to protect humans. Guns, invented to maim and destroy, are my natural enemy.

    A Trilllllllllllllion Dollars


    According to Matt Yglesias at Slate, one possible way to avert the upcoming financial Armageddon of the debt ceiling crisis would be to mint in platinum $1,000,000,000,000 dollar coins, and use them to finance the government:

    “…a ludicrous but perfectly legal solution is also available to him. Treasury Secretary Tim Geithner can order the United States Mint to create large-denomination platinum coins—a $1 trillion coin, say, or a bunch of $10 billion coins—and use them to finance the government.


    It all goes back to sub-section (k) of 31 USC § 5112 ‘Denominations, Specification, and Design of Coins.’ The opening subsections consists of boring specifications about the coins the United States issues. Subsection (k) says ‘The Secretary may mint and issue platinum bullion coins and proof platinum coins in accordance with such specifications, designs, varieties, quantities, denominations, and inscriptions as the Secretary, in the Secretary’s discretion, may prescribe from time to time.’

    So there it is in black and white. Geithner can have the Mint create a $1 trillion coin. Then he can walk it over to the Federal Reserve and deposit it in the Treasury’s account. Then the government can keep sending out the checks—to soldiers and military contractors, to Social Security recipients and doctors who treat Medicare patients, to poor families getting SNAP and to FBI agents—it’s required by law to send—and the checks will clear. It’s a simple, elegant solution.”

    © 2009 ackdoc - Greg Hinson, MD 508/325-9981 info@ackdoc.com Purchasing help RSS feed