The Future of Aging and Technology

By SUSANNAH FOX

You might be wondering why a Chief Technology Officer would be talking about aging. Isn’t tech a young person’s game?

First of all, I love Alan Kay’s definition: Technology is anything invented after you were born.

Second, my grandmother, who used a CB radio in the 1970s and bought one of the first Apple computers in the 1980s, inspires a different point of view. When I showed her the internet in 1995, she said, “I was born too soon.” Then she proved herself wrong by living another 11 years, a daily internet user. I learned to never assume that someone’s age determines his or her interest in or affinity for technology.

I also believe we can learn from older adults and their use of technology. Studies show that if a website is optimized for older users, younger users benefit too. When I was building online tools, I would bring my laptop over to my grandmother’s house in Baltimore. She was my best beta tester. If it didn’t make sense to her, I would change the navigation.

What does the future hold?

One possibility is that technology will start to disappear and become like electricity, something we don’t notice on a daily basis. For example, instead of all the gadgets we use today to track and measure our health, sensors might be sewn into our clothes.

Another possibility is that technology becomes ever more present and intrusive, asking more of our attention and requiring even better eyesight and dexterity than the current smartphones require.

I am hoping for the first version of the future. The one that helps us get back to the point of technology – to assist us, not to resist us. To connect us, not to divide us.

I see three ways that technology can have a positive effect on the lives of older adults: through data, connection, and invention.

Data: At HHS, we want to empower citizens with their own health data. Medicare recipients can, for example, download a simple text file that contains all their claims data, which includes, for example, a complete medications list and the date of someone’s last flu shot. Once someone has that data file, they can bring it with you when you travel or give it to a new clinician. It’s called the Blue Button program because it is literally as simple as clicking on a blue button on Medicare.gov to get access to your data.

Connection: There is a cultural shift happening at the intersection of health and technology. The internet connects us not only to information, but also to each other. That’s a wonderful opportunity for all of us to learn from older adults, recreating the multigenerational household and village that we used to have – now the learning happens online on sites like Facebook, but also on specialty sites for caregivers, like Careticker, and on disease-specific sites, like PatientsLikeMe.

Invention: We are a nation of makers. I believe the U.S. can lead the world in inventing ways for older adults to age in place, with dignity. And the government can play a role in fostering this innovation.

For example, people living with Parkinson’s disease and other neurological disorders often develop a hand tremor, which makes it difficult to keep food on a spoon or fork. Liftware, a company in California, has created a set of utensils that counteract a tremor and allows someone to feed themselves. The research that drives this technology was supported by a grant from the National Institutes of Health.

In addition to providing research grants, the federal government can convene and encourage communities of practice, such as the Health Datapalooza and the White House Maker Faire. And we can look for ways to lift barriers to innovation, which is what my team in the HHS IDEA Lab does, finding ways to hack red tape and help create programs like the NIH 3D Print Exchange, a platform for people to share templates, like the patterns you would use to sew a dress, but in this case it might be a template for printing a prosthetic hand or a model for a heart.

Let’s continue the conversation about the future of aging and technology. Please share your ideas for how we might use data, connection, and invention to help all Americans live longer, healthier lives.

This is a cross-post from the White House Conference on Aging blog.

Susannah Fox is the CTO of the Department of Health and Human Services

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Rise of the Machines

By SHIRIE LENG, MD

“We are convinced the machine can do better than human anesthesiologists.”

This statement was made by a doctor. Not only a doctor but an anesthesiologist. Not just an anesthesiologist but a pediatric anesthesiologist. Not just any old pediatric anesthesiologist but one in charge of pediatric anesthesia research at the University of British Columbia medical school in Vancouver.

One can only assume that this guy has a pretty low estimation of what his colleagues can do. Must make for great break room conversation.

The doctor making this statement, one JM Ansermino, is co-creator of a new automated anesthesia system called, cutely, iControl-RP. This machine uses vital sign readings along with oxygen saturation levels and EEG monitoring to give anesthesia to patients undergoing surgery, without any human input. Thanks to my fellow blogger Karen Siebert for pointing this one out here and here.

iControl-RP is what the creators call “A scheme-based closed-loop anesthesia system”. Here’s what their paper says about it:

The system software in its entirety consists of approximately 22K lines of Scheme code and features a client-server implementation interfacing medical devices with portable graphical user interface. The strengths of the Scheme functional language have been leveraged to build a robust maintainable modular system with extensive testing facilities to mitigate the inherent safety hazards associated with the application.

Blah, blah, blah… wait. “Inherent safety hazards?” You think?

Look. Here is the “problem” that the folks in Vancouver are hoping to “solve”. Intravenous anesthetics like Propofol have dosage and administration guidelines that are, in practice, mere suggestions. People have a very wide range of responses to sedatives and the effects can not always be predicted. Which is why you have a human, an anesthesiologist or CRNA, up at the head of the bed controlling the dosing. This type of sedation, using intravenous agents only, is not usually called “General Anesthesia (GA)”. You can do a GA with just IV drugs but is not very common. Usually Propofol infusions are used in what we call a MAC or “Monitored Anesthetic Care” which is a really stupid name that basically implies that someone is giving sedation and monitoring how it works, but in reality means that the patient is sedated but retains the ability to maintain independent respiration, and someone is adjusting things so that both sedation and spontaneous breathing occur. In other words, you’re in la la land but don’t need to be put on a ventilator. We use it for procedures in which local anesthetic effectively numbs the surgical area so that all that is needed is to make the patient comfortable.

There are a number of cases in which doing a procedure under MAC becomes difficult to impossible. For example, if the local anesthetic is not adequate to block the pain at the surgical site MAC is tricky because the level of sedation needed to eliminate the experience of pain usually also causes people to stop breathing. Obese patients are at risk of airway obstruction at even fairly low levels of sedation. A young teenager might still be reactive at very high levels of sedation. People with involuntary movements, tics, restless legs, etc. often do not lose these movements when sedated. Some people get more agitated the less aware they are of their surroundings. People who take drugs or chronic pain medications respond very differently and may prove impossible to sedate adequately under MAC conditions.

In some cases the anesthesiologist might decide “switch from a MAC to a GA”, at which time the anesthesiologist takes over breathing for the patient and thus is able to provide an higher level of sedation. This decision is not made easily or lightly. It requires considerations about patient size and state of health, how effective the surgeon is at numbing the surgical area, how fast the surgeon is, what the anesthesiologists threshold is for switching, what operation is being performed, what the duration of action of the local anesthetic is, unexpected surgical findings or complications, and ultimately, the safety of the patient. If the decision is made an actual person, i.e, the anesthesiologist, has to secure the airway and then set the ventilator and gas parameters appropriately. Consider this from the iControl-RP paper:

A closed-loop automated drug delivery system that administers drug based on feedback from measurement of a physiological end point can potentially improve the outcomes for patients by addressing the inter-patient variability, providing greater hemodynamic and respiratory stability, more stable depth of anesthesia, and reducing the total dose of drug delivered.

Where in that sentence is there mention of any of the variables I just listed? Is there an algorithm for deciding a different approach is needed? Are there different settings for different surgeons? Do you dial in a different number for the super-anxious patient or the one with the Methadone habit? Inter-patient variability is what makes anesthesia part art, part science. Inter-patient variability is the very reason we need actual humans at the head of the bed. Patients are not Scheme code. Which is why…

The “operating room scenario” depicted in figure 1 of the creators’ Researchgate article features an attending anesthesiologist. To monitor the iControl.

Shirie Leng, MD is an anesthesiologist by training.

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Xerox is extending to consumers & communities

By MATTHEW HOLT

I’m steadily getting all those interviews I did 3+ months ago at HIMSS up onto THCB. (For those of you not paying attention we had a bunch of tech issues at THCB needing a big change and had to forswear videos for a while. But we’re baaack…)

This interview is with Xerox’s Tamara StClaire (Chief Innovation Officer, Commercial Healthcare) and Gail Croall, Chief Medical Officer, Healthspot.

Xerox has a big business in inpatient analytics–I interviewed Justin Lanning who runs their Midas+ Division back in 2012, and does lots of government based claims-processing (especially for Medicaid) and customer service centers. It even was one of the many companies building health exchanges (and struggled like many others!). In May this year (after this interview was shot) Xerox bought a community based visualization company called the Healthy Communities Institute which sells dashboards about public health issues to towns and counties–and has been a big player both at Health 2.0’s Healthy Communities Data Summit but also winning a couple of our challenges.

In late 2014 Xerox invested in Healthspot a telehealth company that builds kiosks. That partnership is the main focus of this interview. Below the fold there’s another video which is a tour of the Healthspot hub that you can expect to see cropping up in RiteAid pharmacies across Ohio and later the nation.

Demo from Lisa Maughan, VP, Marketing at HealthSpot

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Advertising The Future Health Care Marketplace

By MITCH ROTHSCHILD

Looking out the train window at a NJ Transit Coastline stop, I saw the future of shopping in health care. On the platform were side-by-side advertisements for health plans.

Typically the domain of Broadway shows, mobile carriers and whiskey makers, seeing not one, but two insurance companies vie for mind space among New York commuters was heartening (even astounding) to a digital health executive like me.

Let me explain. For years, the industry has talked about the promise shopping holds to reduce costs and improve quality. But the speed of most things in health care comes at a snail’s pace.

It makes sense that consumers’ first glimpse of an emerging health care economy is through insurance plan shopping. At 18-months old, health exchanges are nearing the end of their infancy. Individual health plans make up 40 percent of the insurance market – a major increase from the 10 percent they represented before the Affordable Care Act.

The problem with shopping for health insurance is that one plan doesn’t look much different from the next. On the exchange, the concocted metal distinctions – bronze, silver, gold, and platinum – delineate cost, but not unique selling propositions. That said the insurance exchanges have served in an important starter role towards coupling healthcare and shopping in the minds of consumers.

And so, as it has always been, advertising is the quickest means to creating company and product differentiation and accelerating that shopping curve.

Other products, more alike than different –think dish soap, car insurance and beer – have established their own brand promises and attributes through marketing dollars. Palmolive softens hands as you do dishes. Fifteen minutes could save you 15 percent with Geico. Coors is coldest beer in the world. So, too, will taglines and characters come to differentiate health plans, complete with geckos and Clydesdales, even a Super Bowl ad.

But as insurers get hip to courting customers and customers hip to being courted, additional developments will usher in shopping around doctor selection and medical procedures: The rise of high deductible plans has made consumers more sensitive to medical care costs; The emergence of alternative care settings like specialty centers, retail health clinics and telemedicine offer choice and convenience; Moreover, the ability to shop virtually every other aspect of our daily lives.

Not too long ago, critics dismissed the idea that a hip replacement could be purchased like a car. Today, that assertion might be met with ‘How soon?’’ Young companies are working hard on solutions that lend transparency to the process of making informed healthcare choices. Smart, progressive health providers have also embraced transparency, not just for the good of customers, but their bottom-line, as well.

It won’t be tomorrow, but the path has decidedly accelerated. We are now fumbling towards the direction of health insurers and providers becoming true consumer brands, as savvy as Apple or Nike.

How will the wave of mergers currently engulfing the health insurance industry impact this development? It won’t, meaningfully. Whether five or three mega-insurers, insurance is local and competition will remain. At the same time, we are all of a sudden on a fast(er)-track relative to courting and charming, and expect by the time these unions reach operationally actionable space, we will have all grown accustomed to being wooed. And what’s not to like about that.

After all, $3 trillion dollar industry demands a number of strategies for growing membership. Given that, it wouldn’t be surprising to see health ads take up not just two spaces, but the whole platform.

Mitch Rothschild is Executive Chairman and Founder of Vitals.com

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At 50, Medicare and Medicaid Face the Challenge of a New Generation of Super Pricey Drugs

By STEVEN FINDLAY

Happy birthday Medicare and Medicaid!   Fifty years old today.   Middle age.  Congratulations.  You’ve survived a lot—and 76 million baby boomers and 60 million low-income Americans are mighty glad you’re still around, covering one in three Americans, with solvency until 2030 at last accounting.

Unfortunately, the challenges are not going to let up.  In fact, they’re likely to get worse.  Those challenges are discussed at length in several places that celebrate this milestone—most notably here, here, here,  in the current issue of the Journal of the American Medical Association   (subscription required for access to full articles); and in an Oxford Press book of 16 essays.

This piece focuses on one of the biggest challenges facing both programs: the increasing number of very expensive specialty drugs.

These are medicines made primary through bioengineering.  They are often referred to as biologics.  THCB readers will no doubt have heard of the hepatitis C drug Sovaldi, the current poster child of expensive drugs at $84,000 for a 12-week course of treatment.  More generally, specialty drug prices range from $2,000 to $10,000 a month.  One source pegs the average price at around $36,000 a year.

When there were just a few biologics, it was not a big problem.  But now there are a couple dozen.  Some treat rare diseases that afflict a small number of people, but an increasing number target cancer, multiple sclerosis, rheumatoid arthritis, immune system disorders, and even heart disease.

Specialty drugs accounted for 30% ($112 billion) of the $374 billion spent on prescription drugs in 2014, and they drove the bulk of the 13% increase in drug spending that year over 2013, according to IMS Institute for Healthcare Informatics.  That leap in drug spending contrasted with low single digit increases for the previous few years.

Medicare (via Part D, Part B and Medicare Advantage) pays 25% to 30% of the nation’s prescription drug tab each year.  And somewhere around 16% of Medicare’s budget is spent on prescription medicines—about $90 billion in 2014.  Consistent with IMS’s finding for drug expenditure overall, Medicare Rx drug spending leapt 12.6% from 2013 to 2014, the fastest rise in years and up from a 2.5% increase in 2013 over 2012, according to a CMS report out this week.

Solvaldi alone cost Medicare some $4.5 billion in 2014—becoming the single most expensive drug Medicare enrollees received.

While Medicaid spends less proportionately on Rx drugs, the specialty drugs are having an impact.   In 2012, they accounted for 28% of Medicaid drug spending even as they represented just 2% of prescriptions.  Preliminary data from ProPublica indicates that Solvaldi and one other hepatitis C drug were on track to cost states an aggregate $2 billion or more this year.

Express Scripts, the huge pharmacy benefit management firm, sliced its 2014 data to calculate drug cost growth nationally.  Due almost solely to specialty drugs, the estimated number of Americans with drug costs exceeding $50,000 increased 63% in 2014, from 352,000 to 576,000, the company estimated.

That the trend to more pricey drugs will continue is not in question.  More biologics are being approved every year, and according to a 2013 industry report some 900 are in the pipeline, with many nearing submission to FDA for approval.    By some estimates, specialty drugs could comprise over 50 percent of all drug spending by 2020.  Beyond that is anyone’s guess.   At this week’s release of the CMS report on health spending between now and 2024, Sean Keehan, a CMS economist, said drug spending was now the “largest area of uncertainty” in CMS’s projections.

The big question, of course, is: are these pricey medicines worth the cost?  Do they yield good value?  Are they fairly priced? Or are drug companies profiteering?   And, if specialty drugs are going to remain very expensive, how are we possibly going to afford them?  A simple back of the envelope calculation suggests that just 10 more Sovaldis over the next 6 to 8 years could run up a tab in excess of $50 billion a year by the eighth year (if each drug is priced around $50,000 and taken by 100,000 people).

Let me anticipate comments from drug companies.  Yes, there’s emerging evidence that Sovaldi may indeed be worth the cost when prescribed to the right people.  It is more or less a cure (for about 90% who get it), and far better than previous hepatitis C drugs.   It thus prevents liver failure and other dire consequences of hepatitis C, and many hospitalizations.  And patients have much better quality of life.  In short, it looks every bit like a wonder drug, so far—the kind we ought to be applauding when it comes to market.

Unfortunately the same can’t be said of many other specialty drugs, and especially those to treat cancer.  There’s not the space here to get into this at length, and it’s a complex discussion that involves tough ethical issues, clinical judgments, patient preferences, and contradictory evidence.  Suffice it to say that evidence grows steadily that too many new cancer drugs priced at $50,000 to $150,000 a year are buying most patients only a few extra months of life, on average, and those may not be months with good quality of life.

Concern and even outrage is growing.  That emanated most pointedly this month from a group of 118 cancer doctors.  In a brief commentary in the journal Mayo Clinic Proceedings, the physicians call for immediate steps to lower the price of cancer drugs, the average price of which they say has increased five-fold or more over the past 15 years to over $100,000 a year in 2012. The physicians avoid directly offending drug companies, but state the following:

“Drug companies keep challenging the market with even higher prices. This raises the question of whether current pricing of cancer drugs is based on reasonable expectation of return on investment or whether it is based on what prices the market can bear.”

They also note that the structure of both private insurance benefits and Medicare mean some cancer patients needing a $120,000 drug can be saddled with out-of-pocket costs as high as $30,000.  While that level of expense is relatively rare, it’s common for people needing expensive drugs to bust through both their deductible ($1,000 to $3,000) and hit their health plan’s out-of-pocket maximum (as much as $6,000 for family coverage).  For middle-income families, that’s untenable.

Employers, insurers, and states share the cancer doctors’ concern.  Employers and insurers are re-evaluating their drug coverage, with pressure from unions, consumer groups and others to separately cap out-of-pocket costs for specialty drugs.  Some of the ACA healthcare exchanges are also taking a close look at the problem.  One, in California, has already set an out-of-pocket cap of $250 per prescription per month.

State lawmakers are taking action, too, or are poised to.  Seven states (Delaware, Louisiana, Maine, Maryland, Montana, New York, and Vermont) now limit out-of-pocket payments for people in private health plans under state jurisdiction (which does not apply to large employer plans)—generally to between $100 to $250 a month.  In other states (California, Massachusetts, and North Carolina, Oregon, and Pennsylvania) lawmakers are debating whether to require drug companies to justify their prices with detailed filings.

As laudatory as such efforts are, a state-by-state approach is not a long-term solution.  And it does nothing for Medicare beneficiaries.  I end this piece with the cancer doctors’ recommendations (adapted and slightly elaborated).  I concur with them.

(1) Permit Medicare to negotiate prices directly with drug companies, now explicitly barred by the 2003 Medicare Prescription Drug, Improvement, and Modernization Act.   As Medicare moves swiftly to pay providers based on the quality and value of their care, the same should hold for prescription drugs.

(2) Authorize the Patient-Centered Outcomes Research Institute (PCORI) to evaluate the benefits and value of new drug treatments, and include price in their assessments.  That’s now blocked by a provision in the Affordable Care Act,  which gave birth to PCORI; industry insisted on the provision.  It’s time to repeal it.

(3) Allow people to import prescription drugs for personal use and give FDA the power to monitor the program and certify channels of purchase.  An unenforced federal law blocks importation now. (I’d make this a pilot program for five years to immediately give consumers the option.)

(4) Pass legislation to prevent brand-name drug companies from delaying access to generic drugs—so-called pay-for-delay practices that permit brand-name companies to pay generic manufacturers to delay the introduction of lower-cost generics.

(5) Reform the patent system to make it more difficult for drug companies to prolong market exclusivity unnecessarily (patent “evergreening”) by slightly modifying existing drugs.

(6) Encourage organizations that represent cancer specialists and patients (e.g., the American Society of Clinical Oncology, American Society of Hematology, American Association for Cancer Research, American Cancer Society, National Comprehensive Cancer Network) to consider the overall value of drugs and treatments in formulating treatment guidelines.

I’d add two:  (a) Enact legislation that would permit the FDA to speed the approval of biosimiliars, the copies of biologic drugs authorized by the Affordable Care Act; and (b) until Medicare is allowed to negotiate with companies, extend the mandated lower prices Medicaid pays (via rebates) to Medicare beneficiaries who get the low income subsidy.

The politics of all of the above is difficult to say the least.  I hope it emerges as an issue in the 2016 elections.  A Kaiser Family Foundation poll of 1,200 adults released last month found that three-quarters of Americans think prescription drugs costs are unreasonable, and they blame the drugs companies.

Steven Findlay is an independent journalist who covers medicine and healthcare policy and technology.  

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3 Great Exercises for Pregnancy and Pelvic Health: Video

Hi everyone, but especially mamas-to be!
I’ve been seeing Dr. Aliya as a patient for my prenatal care and it is REALLY helping me feel my best. She is a chiropractor, a total pre and post natal expert and a mama herself.

Outside of seeing her, I do these exercises in the video at home and kegels too all in an effort to strengthen my body and give my bambina as much room to grow as possible. I have also found that since entering my third trimester, walking and yoga are really the only two forms physical activity I feel good doing. If you are pregnant, the key is to really listen to your body. Some women can maintain a similar level of activity pre-pregnancy until 40 weeks, others (myself included) cannot.

Of course ultimately I’m hoping that these exercises on the the ball and my moderate physical activity will help me have an easier birthing experience by reducing tension in my body.

I really have no expectations of how my birthing experience will be. I’ve heard the horror stories as well as many wonderful birthing stories and everything in between. I’m going into it with open mind and preparing my body as best as I possibly can. This is what I recommend to you! Stay positive and also have an open mind.

In this video, Dr. Aliya will talk about the benefits of chiro treatments and we will show you the three exercises you can do at home.

Unfortunately we didn’t get into the benefits of “twerking” but I do that regularly too, around the house especially when listening to Queen B!

According to Dr. Aliya, seeing a chiropractor and doing these exercises regularly can:

1. Help to alleviate discomfort and pain due to pregnancy

2. Promote pelvic alignment and balance in the spine

3. Reduce tension in the muscles and ligaments connected to the uterus helping baby get into optimal head down position.  

4. Prepare your body for labour and delivery

Here’s the video, I hope you enjoy it and find these exercises useful:

You can find Dr. Aliya at Restore Health Integrative Clinic and Toronto Yoga Mamas. She’s on instagram and her website is: http://draliya.ca/

What are you doing to take care of your pregnant body, share below! I love hearing from you.

By the way, have you checked out my toxin-free natural beauty products yet, including my belly bump butta? While you are pregnant and beyond, it is of utmost importance that what you put on your body is free from junk chemicals. I’m fiercely committed to this and that’s why I’ve created a line of products that are safe for you and safe for baby.

Have a joyous day!

Joy

Joy McCarthy

Joy McCarthy is the vibrant Holistic Nutritionist behind Joyous Health. Author of JOYOUS HEALTH: Eat & Live Well without Dieting, professional speaker, nutrition expert on Global’s Morning Show, Faculty Member at Institute of Holistic Nutrition and co-creator of Eat Well Feel Well. Read more…

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The Low Hanging Fruit is Lying on the Ground

By J.K. Wall

With hospitals and doctors under tremendous pressure to improve costs and quality fast, clichéd calls to “aim for the low-hanging fruit” are ringing in every boardroom and bedpan from Sarasota to Seattle.

But medical providers should set their sights a bit lower.

Why? Because “in health care, the low-hanging fruit isn’t just low-hanging fruit; the fruit is lying on the ground, and we have to be careful not to trip over it.” 

That’s the axiom that Indiana University management professor Mohan Tatikonda repeats regularly to the physicians in an MBA program for MDs started in 2013 by IU’s Kelley School of Business in Indianapolis. His students, who hail from around the country and have been practicing medicine for an average of 20 years, shortened the phrase to simply “watermelons on the ground.”

It means that first-year MBA concept employed decades ago in most other industries can yield huge results among health care providers.

“On average, the state of operations in health care delivery is primitive. Fundamentally primitive,” Tatikonda said. “Just the basic understanding of patient flows, materials flows, information flows. Having them documented and diagrammed. This kind of thing until very recently was just not very common.”

It’s not that things such as Six Sigma or Lean are unknown to health care leaders. Consultant Chip Caldwell estimates that about 75 percent of hospital systems are using Lean in some way, compared with 53 percent identified by a 2009 survey by the Association Society for Quality. Only about one in 10 hospital systems is using Six Sigma currently, Caldwell estimates, down from a peak of popularity in the 2000s.

Some hospitals, such Virginia Mason and Barnes-Jewish, have employed these techniques to wide acclaim.

What few health care provider organizations have done, Tatikonda said, is make a regular, sustained habit of using process improvement concepts, so that all the people in their organizations became used to thinking that way.

The Affordable Care Act has now given health care providers the financial motivation to do exactly that. And the good news is that even small-scale projects that MBA students do for class can have a big impact in real-world health care environments.

Here’s one example: Tatikonda paired up one of his students, an ophthalmologist, with a Six Sigma expert from an Indiana manufacturing company to redesign the patient flow process at the Midwest Eye Institute in Indianapolis.

They found that that nearly all the eye patients took one of five paths through the office. So they figured out how they could eliminate time in a waiting room by having staff members immediately start patients into one of those five paths.

The result? Average visit time dropped by 20 minutes—or about 16 percent—while patient and employee satisfaction scores shot up.

Dr. Tom Ciulla, the ophthalmologist, who is a retinal surgeon at the Midwest Eye Institute, said Tatikonda and the Six Sigma expert were laughing, because the process of eliminating bottlenecks is the kind of efficiency work manufacturers did in the 1970s.

“That’s how far behind we are in medicine,” Ciulla said.

Here’s another example: Tatikonda worked with medical researchers at the Indiana University Vector Production Facility to develop a costing tool for the set up time, run time and materials needed for research-sized batches of gene and cell therapy agents.

The tool revealed various cost-saving strategies familiar in other industries, such as the fact that doubling a batch size only increased costs by 20 percent, not 100 percent. Their findings were published by the academic journal Human Gene Therapy and the tool is now made available to medical researchers by the National Gene Vector Biorepository.

“Set up and run time, capacity; this is MBA 101,” Tatikonda said. “It’s just so fundamental.”

At the very least, having clinicians learn these basic business concepts has given them a common language with their non-clinical administrators.

That was critical at the Indiana University Health hospital in Goshen, Indiana, which had been losing key physicians due to frustrations with what Dr. Len Henry, the hospital’s director of surgical oncology, called a “frenetic pace of change” and “metric terrorism.”

So Henry developed swim lane charts for all the people a surgeon like himself interacts with on a given day at the hospital. He then interviewed the 22 people he identified, from the receptionist to the CEO, using structured questions about the problems they saw in the hospital.

This work produced three key goals, with several actions points for each. Among them were: 1) Employ physician recommendations in decision making; 2) Consistently describe how success on metrics or finances benefit patients; and 3) Manage change more effectively by allowing time for stabilization between projects.

Henry handed his finding to the hospital’s CEO. The CEO presented it to all of the hospital’s vice presidents and, within days, Henry noticed a difference in how administrators were communicating with physicians and soliciting their input.

“I see people from the C suite and they comment about it. So I now it’s been looked at and taken seriously,” Henry said. “I’ll be curious to see our next physician satisfaction survey.”

Tatikonda predicts it will take another decade or more for health care providers to gather up all the ground-level and low-hanging fruit they can harvest with sustained process improvement efforts.

“Right now,” he said, “many of them are in the walking steps of understanding their processes.”

J.K. Wall is a health care reporter at the Indianapolis Business Journal and writes The Dose blog on the business of health care.

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Of PCPs and THCB

By ROB LAMBERTS, MD

The drug test came back abnormal.  There was THC present.  I walked back to Mrs. Johnson and raised my eyebrows.

“What’s wrong?” she asked, not used to whatever kind of look I was giving her.

“Uh, you forgot to mention to me that you smoke weed.”

She blushed and then smirked.  “Well, yes, I guess I forgot to put that down on the sheet.  I don’t do it real often, but sometimes it takes mind off of things.  I just get real anxious about my kids, my husband…and my heart problems. I only smoke one or two a night”

She’s not your usual picture of a pot-head.  She’s in her sixties, has coronary heart disease, irritable bowel, hypertension, is on Medicaid, and is the essential caricature of the the poor white folk who live in the deep south.  And she smokes weed.

I was doing drug testing on her as part of my office policy.  Mrs. Johnson gets 30 Percocet per month, and so clearly poses a high risk of drug trafficking, escalation to PCP, crystal meth, and LSD, and ending up behind bars for the rest of her life.  That’s why I had to test her.  And now I caught her in a lie, trying to cover-up her use of illegal drugs.

My old practice had a policy of discharging such people immediately from the practice.  Some of our physicians had the belief that any departure from the rules should be dealt with swiftly and harshly.  It’s part of the reason I couldn’t stay in the practice.  They had taken a large step away from the most important part of the doctor-patient relationship: trust.  They saw any evidence of dishonesty on the part of the patient as a reason for discharge from the practice, even if a very good explanation existed.  I was just “too soft” in their thinking.

Thank goodness.

While I do find value in regular drug testing of patients using controlled drugs, the way in which it is often enforced in many practices is with an air of suspicion.  It’s just one more factor in the decay of trust on both sides. Yes, people who abuse the system to get drugs to abuse or sell and doctors who dole out drugs like candy are the ones to blame.  Mrs. Johnson is not part of the problem.

Physician mistrust goes far deeper than drug testing.  My patients often seem embarrassed when they have symptoms that don’t make sense because, it turns out, they are disbelieved by other doctors.  I have had many patients comment that it is “nice to have a doctor who actually listens to me and what I actually say.”  This is sad.  How can anyone give care to patients if they aren’t listening to the patient and taking what they say seriously?  It’s as if the only thing holding the doctor back from making a proper diagnosis is the patient’s ability to give their history.

The problem of mistrust works the other way as well; people don’t trust their doctors.  Just today I had a woman complain to me about the doctor she had been seeing “for the past 10 years” who made her “come in and pay $120 just to get a prescription filled!”  She went on to complain about how so many doctors are “just in it for the money.”

Her view of the motivation of doctors comes from the central dilemma our payment system puts doctors under: choosing between the business and the patient.  The ideal business scenario for doctors is to have very sick patients who require multiple procedures, yet who take as little time as possible.  This is what is good for business, as doctors can have a higher code/hour submission rate.  This, of course, is the absolute worst thing for patients, who want to be healthy, avoid unnecessary or excessive care, and have doctors who spend time with them.  On top of that, this best business scenario will invariably lead to lower value care (lower quality at a higher cost).

Doctors are forced to either give up income to do what is right for patients and for society, or to stuff their consciences securely in the overhead compartment and run the business well.  Some doctors seem to comfortably lock their consciences away, but most find a compromise on the spectrum between high income/bad medicine and low income/good medicine.  It’s the main thing that drives doctors to burn out.  It’s why I left.

So the patient is left wondering if the reason the doctor can “only handle one problem at each visit” is because it makes more money.  The patient wonders if the doctor doesn’t talk to them on the phone because they only make money when they come to the office.  The abbreviated care most doctors provide further undermines any belief that the doctor has the patient’s best interest in mind.  This care is abbreviated even more by the onerous demands of coding, defensive documentation, and data submission for “quality measures.”  How can good care occur when what little time the doctor spends with the patient is dominated by the doctor-computer relationship?  Those of us who are bothered by such things are the ones who go home feeling terrible about the poor care we are giving.

One of the main reasons I don’t charge a copay for office visits in my current practice is that I wanted nothing to undermine my patients’ trust.  The reality is that charging a copay would do little to increase my income, but a patient could question my motivation for requiring an office visit.  Some doctors, criticizing my approach, recapitulate the mistrust of patients wondering if some patients would “take advantage of this and want to be seen all the time.”  I have over 600 patients now and that has never happened.  Why would someone want to go to the doctor all the time?  It simply doesn’t happen.  I think it’s because people feel fortunate to have me as their doctor and don’t want to abuse the system.  They seem more apologetic about coming in and “bothering me” than ready to gorge themselves at the all-you-can-eat Dr. Rob buffet.

I see an enormous difference in the trust between me and my patients since starting the new (sort-of new) practice.  I tell them that my business model works best when they are healthy, happy, have their questions answered, and paying their monthly fee. I explain that the re-alignment of my business success to coincide with what they want for themselves (and what works best for the healthcare system), and they like it.  They want me to succeed.  Some have even offered to pay me extra when they were particularly complicated.

It takes a while for people to actually be in a position of trust with their doctor.  They look for some catch or some way in which I am going to short-change them.  Yet I have every motivation to keep them happy and healthy.  Once they realize this, they seem to relish our relationship, not wanting to jeopardize it by being “too demanding.”  I think it’s remarkable to both sides: I am amazed that my patients want me to be wildly successful in my business, and my patients are amazed that I want them to be incredibly healthy, off of medications, and only needing me infrequently.

So when Mrs. Johnson’s drug test came back, I wasn’t inclined to kick her out of my practice or even lecture her about telling the complete truth.  After all, isn’t smoking a little weed better than taking daily Valium or Xanax?  Isn’t it better than drinking moonshine, or asking me for more Percocet to “calm her nerves?”

Instead, I laughed.  The craziness of this “country bumpkin” doing her best Cheech and Chong imitation just seemed funny.

“Just don’t smoke too much, Mrs. Johnson,” I said.  “And be careful getting that stuff.  I don’t treat people who are in jail!”

She laughed, and gave me a hug before she left.  On her blouse I noted a faint but familiar smell from my high school days.  Yes, the test was right.

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We Designed An Industrialized Healthcare System

By ANDY DELAO

Process improvement. The 80 / 20 rule. 6 Sigma. Lean. Defects. Waste. Efficiency. Output. Production. Value added. Automation. Productivity. Workflow. Capacity Management. Quality. Access. Costs. Scale.

I have noticed over the past few years that as I travel and speak to patients, physicians, ministry of health officials, CEO/COO/CFO, and various hospital administrators that the above words often come up in the midst of our conversations.

What surprises me the most is the above words originate from manufacturing, not healthcare. As we identify opportunities to improve quality and access while reducing costs in healthcare, many leadership teams have looked to hire the best minds from Toyota, Kimberly Clark, and Boeing.

Do not get me wrong; I believe there is richness in building a diverse cross functional team, borrowing from other businesses, and finding news ways of connecting the dots to drive innovation.

However, I am not convinced we have historically done this well in healthcare. I believe the only thing we have accomplished is the design of an industrialized healthcare system.

 

We collectively managed to mass produce average care, scale it, and make everyone mediocre.

The industrial revolution is that period of time that brought innovation which allowed us to move from making goods by hand to being able to make goods with machines. As time moved on, technology began to evolve, and we continued to improve our ability to produce more goods. Technology such as the power loom and the cotton gin improved the output of a worker by 40 to 50 times. The steam engine gained in efficiency and was able to go further, do more work, and use less fuel.

Moving from charcoal to the use of coke in iron making allowed us to drive the cost of iron down, produce more, and achieve economies of scale.

Creating goods cheaply, while increasing revenues and allowing more people the ability to purchase more goods enabled the emergence of the middle class. For the first time in history, there was an economic advantage that was widespread across the population. The standards of living increased with the ability to provide adequate housing, acquire proper nutrition, and allow life expectancy to increase.

The middle class meant that there was more people able, willing, and wanting to be employed to provide for themselves as well as their family.

Increase the middle class and you develop a need for more goods.

Then came along a man named Henry Ford. He developed the assembly line and the ability to mass-produce a product. Henry’s assembly line principles were simple:

1. Place the tools and the men in the sequence of the operation so that each component part shall travel the least possible distance while in the process of finishing.
2. Use work slides or some other form of carrier so that when a workman completes his operation, he drops the part always in the same place—which place must always be the most convenient place to his hand—and if possible have gravity carry the part to the next workman for his own.
3. Use sliding assembling lines by which the parts to be assembled are delivered at convenient distances.

As time progressed, technology improved, and capitalism grew. We continued to see more and more ways to mass-produce goods. We realized that if you can develop a process that is well documented that you could begin to automate it. The more automated a job, the less defects, the more cheaply you can produce a good, and the more profits our capitalist can reap.

Remove the people, remove the connections, remove the art, and you increase quality, access, and lower costs.

Looking to the once shining example of industrial might, Detroit, the assembly lines are now empty; and the few remaining are filled with workers: robot workers. Fewer men, more machines.

We scaled mediocrity to the point of making the extraordinary truly extra ordinary.

In a June 15, 2012 article published in HBR called, “Five Keys To Prepare For The Business of Aging” written by Marta Elvira, Carlos Rodriguez Lluesma, and Nuria Mas, they outlined one of the major global problems healthcare had to face- an increase in the aging population.

In the article, they clearly stated that there are two ways in which healthcare will need to tackle the topic. The first is to moderate consumption of healthcare by introducing copayments to certain services. The second recommendation is borrow from manufacturing, and focus on the reduction of “waste” in the production of healthcare, or to focus on the efficiency. (same answer, just different framing)

Is designing a mass production system to manufacture care for people the right answer?

Is healthcare moving towards the same demise as the world of manufacturing? Are we designing a system that takes all of the art, all of the humanity, all of the connections between patients and their care team out?

Did we design a system that was initially all about people, care, healing, and moved it into an automation assembly line? Have we mass-produced care inside of a factory that we call a hospital? If we can adopt processes, repeat them, and apply them to all cars, I mean patients, we can then build more factories, oops, I mean hospitals.

Are we “leaning” the care out of our hospitals and clinics? Have we “6 Sigma-d” ourselves into a false reality that being human and making mistakes will never happen?

We have adopted the 80-20 rule. We believe that for 80% of the patients that the same care is going to work, most of the time. We believe that for the ‘outliers’ or the 20% of patients diagnosed with a chronic disease, comorbidities, or extenuating circumstances that our process do NOT work well; Or ever. We do a subpar job managing those patients, caring for them, or meeting their needs. Our factories, I mean hospitals, can’t handle producing care for those patients. So our costs have skyrocketed.

The adoption of EMR/EHR, clinic decision support, computer assisted detection (CAD), Watson Health, and pathways are all technologies that allow us to automate the care we deliver.

We schedule patients early in the morning so that we can fill our surgical suites. We have developed a 10-minute time slot to get cancer patients in and out of radiation oncology. I have seen Radiology departments that can see as many as 20-25 patients in an hour on a single scanner.

All in the promise of caring for more people, reducing the costs to the healthcare system, and improving outcomes for patients. Yet the price that we pay continues to grow.

As prices continue to rise, so does the mediocrity.

Healthcare isn’t producing Lamborghini’s or even Toyota’s. Our hospitals are producing Geo’s (yes, I specifically picked an old unreliable unprofitable production of cars that is now obsolete).

There is not a lot of difference between Hospital A and Hospital B. They each are a big box, with 4 walls, and technology. Both hospitals produce care that lives and breathes by the same metrics all in hopes of being paid and reimbursed in the same manner.

Both hospitals are filled with people.

When physicians and other members of the care team are subjected to being measured and paid on productivity, process improvement, and other manufacturing measures they are encouraged to become a cog in the factory of healthcare. They are essentially “incentivized,,” or paid, to increase the production of extra ordinary care.

Our greatest resource, people, are being encouraged to forget their art, and their passion to become a cog in the process of producing average care.  (read: How Might Crushes Right In Healthcare)

In the beginning physicians used to make house calls. Physicians had a personal relationship with the people living in their communities. People paid with cash, chickens, bread, and other goods.

We moved into hospitals as technology evolved because it was easier to have a centralized location, usually in the center of the community, where physicians could convene, share, connect, and leverage the consolidated resources of technology and expertise. It made sense for patients to go where all the expertise was managed and the care was being produced.

Care used to be extraordinary.

Today care is extra ordinary.

The relationship, the bond, the link, the connection between a patient and their physician(s) and care team(s) would last for 25 years. They would grow old together; they could share in the successes and tragedies of life together.

Here we are in the year 2015. In a world where connection is everything, and anyone has the ability to be extraordinary; healthcare seems to be moving more and more towards a system of sameness. Creating care for the lowest common denominator.

We are scaling the mediocrity.

In all of my meetings, lectures, and discussions with patients, physicians, nurses, leadership, the C-Suite, and care teams I have never once heard anyone ask the question, “How can we become more average? How do we accelerate mediocrity?”

That is exactly what we are being asked to do on a daily basis. We concede our decision to make art and instead agree to mass-produce average care.

We do not place physicians, care teams, or the information in a proper sequence of operation when we produce care. All of our information, technology, and “healthcare networks” are fragmented. Our people are scattered.

We do not place replacement hips, regions of interest on an axial image, planning target volumes, intake forms, or labs in the same place. They are all varied because we are not producing work for an inanimate object. We produce care for living organisms. We care for humans. Humans are our patients.

We do not place our care areas in convenient locations and seldom are they in the sequence in which a patient experiences or needs the services. Primary care is not located next to radiology and pathology. Pathology is not next to radiology. Women’s Services is not adjacent to outpatient surgery. Surgery is not located within Oncology. We make our patients, those that we produce care for, maneuver the complexity and fragmentation of our production lines, our factories, our hospital networks.

We forgot Ford’s manufacturing principles.

At one point in time the workers in Detroit took great pride in meeting and/or exceeding all of their production targets, quality metrics, and process improvement goals….before they were replaced with fewer people and eventually machines.

If you do not take the time to connect with the care team or patients, a robot can replace you.

A robot will replace you.

I believe there is a Shangri-La, that combines both technology and people that allows us to make new art. Better art, Innovative art in healthcare. An art that combines the best of patients and their care teams, leverages technology, and actually delivers on a new set of metrics that matter, that differentiate. Whether it’s the new Minute Clinic by CVS, Medisafe, Ginger.IO, Medical Tourism, Telehealth, or Care Trucks, art can still be created. We haven’t lost the ability to create. Yet.

I choose to design a healthcare that defines and answers patient problems.

I choose to create art.

I choose to scale the art in caring for people.

I choose to connect.

Together we can, and will, bring back the extraordinary in healthcare.

One patient, one physician, and one care team at a time.

So to make this a reality that I believe in, here’s my offer: the first 3 healthcare leaders (patients, physicians, management, executives, care teams, professional organizations, or hospital networks) that comment (or email me) on this post with a defined healthcare challenge they are focusing on, I will donate my time to collaborate and work with your team to design an extraordinary outcome.

If you are looking for a community who is looking to change health care in the same way as this article, check out the HCLDR Twitter Chat and blog to be part of something great!

 

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The reboot for Care Innovations: Interview

By MATTHEW HOLT

I’m steadily getting all those interviews I did 3+ months ago at HIMSS up onto THCB. (For those of you not paying attention we had a bunch of tech issues at THCB needing a big change and had to forswear videos for a while. But we’re baaack…)

This interview is with Karissa Price, chief marketing officer, and Kumar Subramanian, CTO of of Care Innovations. This is the GE/Intel JV which was originally a devices and perpiherals company that has recast itself as a software and data analytics company–in the business of remote patient management–just in time for population health to get serious. When Sean Slovenski (ex-Humana) took over as CEO at Care Innovations he not only wanted to recast the company but he also wanted to impact the way the industry positioned itself, so he set up the Validation Institute (FD: I’m on the Advisory Board for the Validation Institute). You can hear more about what Care Innovations is up to in the video below.

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