Navigating Healthcare – Patient Safety and Personal Healthcare Management

Treating Mental Health

Posted in Uncategorized by drnic on July 6, 2017

Don’t judge my path if you haven’t walked my journey

Mental Labels

Just the term “Mental” induces reactions and responses from every corner of our society, and mostly they are not positive. Perhaps part of the problem can be attributed to the broad and different definitions applied to the term that includes its use as an adjective relating to the mind or disorders of the mind but it also has an informal us as “insane” or “crazy”

It’s no wonder that when we refer to someone as having “Mental problems” or a “Mental Condition” – so perhaps we need to change the terminology to start addressing “Mental” health as part of our overall health. The precision of language and terminology is important but we have a tendency that appears to be increasingly misused, or perhaps it just appears that was because it is magnified by social media and the 24/7/365 news cycle. For example, the term “Depression” is a clinical diagnosis that has some very specific symptoms and durations but the term is used excessively in place of sadness, misery, or sorrow. SO for this article, I will refer to “Diseases of the Brain” rather than “Mental Disorders”

 

Part of Physical Health

A recent article by John Campo, MD, Professor, and chair of the Department of Psychiatry at Ohio State University pointed out the mismatch between the prevalence and impact of diseases of the brain and the lack of legitimacy as a “real disease

The treatment of mental illness has long been held back by the sense that disorders of emotion, thinking, and behavior somehow lack legitimacy and instead reflect individual weakness or poor life choices

Some of this likely stems from our lack fo understanding relative to brain disorders evidenced in history by the way we viewed and “treated” anyone deemed to be unusual or different. These attitudes date back to at leat the 13th Century and “St. Mary of Bethlehem” in London built in 1247 and used as an institution for the insane. It was colloquially referred to as “Bedlam” hospital (yes that is where the term “Bedlam” came from) that featured horrific treatments from “rotational Therapy”

Imagine being stuck on the Mad Hatters Tea Cup ride at high speed for hours

 

And extended to beatings, bloodletting, and starvation! This sordid history is covered by the Museum of Healthcare Blog. This attitude extended into my medical school training where we were dispatched to Friern Hospital (formerly Colney Hatch Lunatic Asylum) that at its peak was home to some 2,500 patients with disorders of the brain. My clinical experience there included a harrowing personal experience that still shapes my behavior to this day.

 

Long corridors with Wards radiating out

 

Moving to Whole Care

 

The disconnect between the specialty of Psychiatry and the rest of medicine is rooted in our inability to observe and explain the workings of the brain. Even some of our treatments work but we struggle to understand why or how. This manifests in the challenge of honest acceptance of having a disease of the brain and being able to find help to treat that condition. For most people, our exposure to this world is limited to the Hollywood lens, like “Awakenings” starring Robin Williams and Robert de Niro

 

 

It is sad to note that Robin Williams suffered a sometimes public struggle with a brain disorder and ultimately committed suicide secondary to his suffering of Lewy Body Dementia

Based on the true story and book “Awakenings” written by Oliver Sachs – the British Neurologist, naturalist, and author who died back in 2015. He was a prolific writer who wrote with such eloquence and mastery of language you can lose yourself in his books.

‘Healing’,
Papa would tell me,
‘is not a science,
but the intuitive art
of wooing Nature.’

The Art of Healing – W.H. Auden

 

Science is Helping

The good news is that technology and science are helping as we unlock some of the mysteries of the brain’s function and the diseases that impact function. In fact, in many instances, we are discovering that the brain plays a much larger role in many diseases and we ignore this at our peril. We continue to unlock the chemical and physiological functions in the brain and as the science advances so too does the integration of the specialty psychiatry under the same roof as the rest of medicine.

There are now a number of initiatives working to expand our understanding, coordinate research, results, and findings that included the 2013 announcement by President Obama for the “BRAIN Initiative” (Brain Research through Advancing Innovative Neurotechnologies) that is homed at the National Institute of Health (NIH) and complemented by the The Human Brain Project from the European Union. The initiatives are not without problems and uncertainty of funding continues to challenge progress but understanding, science, and data remain a central requirement to progress.

There are some areas of progress from industry and Arshya Vahabzadeh, MD, the Chief Medical Officer at Brainpower has been championing Virtual Reality and Augmented Reality as a tool to help the growing population of Autism patients handle the complex world of emotions and human interactions. As he highlighted Virtual and Augmented Reality was a hot topic at the recent American Psychiatric Association Meeting

 

And was featured in this Medscape article: Virtual Reality a Game Changer for Psychiatry (Medscape)

 

Incremental Improvements in Brain Disorders

As Dr. Campo pointed out

Better understanding of the human brain and the biological nature of the mind will help, but it won’t be enough. How we think about mental health matters. When mental health is ultimately recognized as essential to physical health, not an extraneous element of it, then we will have access to true, complete, modern medicine

Changing the narrative and words may seem trivial but for any change to take place we need education and awareness that removes the stigma and fear associated with disorders of the brain and deliver the same compassion and care that patients with cancer or heart disease receive.

So my thoughts for some incremental improvements you can make addressing disorders of the brain

  • Words Matter – it’s not “Mental Health/Disorder” – it is Disease or Disorder of the Brain
  • Ask, listen and most importantly digest and be there as we interact with others – read Maneesh Juneja  blog – Being Human
  • From a clinical perspective – the clinical history and the detail of the Presenting Complaint and History of Present Illness remain the mainstay of diagnosis and understanding
  • Read or listen to Oliver Sach’s – you can find his books – or watch his TED Talk, or hear him on Science Friday or NPR or read one of his articles

 

What small change have you seen that makes a difference in the support of people with disorders of the brain. What one thing could we do that would have a big impact in this area?

You can also follow me here on medium, on twitter, or on facebook

 

 

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Who Own’s Your Medical Record

Posted in Uncategorized by drnic on August 15, 2017

You do!
To be honest this was almost as much as I was willing to write – I don’t see this as a debatable item – it’s your health, your data (about you) and therefore you own it
I know I differ from many in the healthcare field who perceive this data to be very much the domain of the health care provider.

This piece by Karoli “Who Owns the Medical Record?” reviews recent experiences trying to combat a denial for drug coverage that required full information on treatments and justification which engendered a big struggle with those folks who had the data and record

The concepts presented of the patient as the platform makes sense and creating an environment that does not require a “big system” or “Big government” owning and managing this data makes sense.

We are a long way from this position but today I would suggest each and every patient should insist on receiving a full copy of their record in a digital exchangeable form where possible but failing that in paper form.

I have mine – do you have yours?

 

Social Media Insights from MayoInOz

Posted in Healthcare Technology by drnic on July 29, 2017

I attended the MayoinOz conference some time back and captured some of the key elements of the presentations and discussions

The core principle – Teamwork

http://”//platform.twitter.com/widgets.js”

If the #Mayo Bros had Twitter: “The best interest of the #patient is the only interest to be considered” #MayoInOz pic.twitter.com/lnxBOB17fC

— ANZCA (@ANZCA) November 14, 2016

We are being disrupted  – captured perfectly in this one slide from Andrew Grills highlighting volumes of activity of WhatsApp vs the SMS text volume

Just in case you thought we had not moved to Digital: WhatsApp volume far higher than SMS text messaging #mayoinoz pic.twitter.com/Zdl4g6frw5

— Nick van Terheyden (@drnic1) November 14, 2016

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Social is not a channel – although as several commentators pointed out many companies have jumped on the Social Media Band wagon and use it as another channel to pump content to potential customers

Top skills in demands as surveyed by LinkedIn feature data analysis and statistical

Moving to the cognitive era – Humans + Machines. It is not Artificial Intelligence but rather augmented intelligence

Test out your profile ith a Watson Analysis

http://gwen-systemu.mybluemix.net/

If the #Mayo Bros had Twitter: “The best interest of the #patient is the only interest to be considered” #MayoInOz pic.twitter.com/lnxBOB17fC

— ANZCA (@ANZCA) November 14, 2016

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The last best experience has anyone has anywhere becomes the minimum expectation for the experience they want everywhere

This captures everything about competition

Your competitors are everyone – FedEx, Airlines, Hotels etc

So true. Think airlines/hotel rooms #MayoInOz pic.twitter.com/r7TXNRWP2L

— Michelle Carnovale (@M_Carnovale) November 14, 2016

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Social Media Insights from MayoInOz was originally published on DrNic1

The Appliance of Science

Posted in Uncategorized by drnic on July 27, 2017

Hurry up and Implement

Innovation has had a tendency to move at glacial pace and history is littered with scientific discoveries that took a long time to reach our world and have an impact on our lives.

Philosophiæ Naturalis Principia Mathematica – Wikipedia (Photo Wikipedia)

So many areas in our lives – math and complex numbers discovered in the 16th Century that were originally described as “imaginary” numbers as if to emphasize their impracticality and it was hundreds of years before they were used in earnest in calculations with alternating current and impedance. In physics, we have seen incredible insights from the basic observational details of Newton in the Philosophiæ Naturalis Principia Mathematica to Einstein’s astounding revelations in the Theory of Special Relativity and the Theory of General  Relativity. The insights from these continue to provide breakthroughs in our understanding of the world

In Biology, Darwin’s theories contained in his book On the Origin of Species were deemed heretical at the time and yet now are considered to be the foundation of evolutionary biology.

Medicine proves to be no different and we have seen repeated instances of rejection and challenge to new technologies and insights. When René Laennec came up with the original stethoscope it was famously referred to in the Times of London:

 

“it will never come into general use notwithstanding its value. It is extremely doubtful because its beneficial application requires much time and gives a good bit of trouble to both the patient and the practitioner; and because its hue and character are foreign and opposed to all our habits and associations. It is just not going to get used.”

New Treatments Applied Slowly

It takes on average 17 years for an innovation to reach general application in healthcare – in this paper in the Journal of the Royal Society of Medicine 17 Years is the time for Translational Research. The authors reviewed multiple papers to ascertain the time delay in the application of medical insights into clinical practice. This table from “2000 Year Book of Medical Informatics Balas Boren Managing Clinical Knowledge for HC Improvement”

 

Clinical Procedure Landmark Trial Current Rate Use (2000)
Flu Vaccination 1968 55%
Thrombolytic therapy 1971 20%
Pneumococcal vaccination 1977 35.6%
Diabetic eye exam 1981 38.4%
Beta blockers after MI 1982 61.9%
Mammography 1982 70.4%
Cholesterol screening 1984 65%
Fecal occult blood test 1986 17%
Diabetic foot care 1983 20%

 

To be clear I am not advocating the application of unproven ideas and theories but rather taking advances that have been proven with studies and expanding access to everyone.

Patient Engagement

We have seen multiple instances of patients who have refused to accept the current state of affairs in their conditions and treatment – Dave deBronkart (aka ePatient Dave) was an early advocate and trailblazer. In January 2007 he received a diagnosis of Stage 4, Grade 4 Renal Carcinoma and his prognosis was not good (that’s an understatement). Had he accepted the prognosis and the standard treatment he would not be here today. He did not and together with his care team he pushed the boundaries of the disease and our understanding and joined a clinical trial for a new therapy that was successful. 10 years on he is thankfully here and continues to advocate and push the boundaries of patient engagement and participation.

Not all therapies apply and not all patients are good candidates for new therapies but it’s a fair assessment that most of us would want a similar life-saving therapy for a catastrophic disease. Teasing out what works and what does not remains an ongoing challenge in science. Science and Discovery are littered with many blind alleys, failures and course corrections but it is these failures that contribute to our continued progress.

 

 

The new age of “all the data” is going to change the way we innovate and discover as Chris Anderson from Wired asked, “What can Science Learn from Google as he suggested, The end of Theory: The Data Deluge makes the Scientific Method Obsolete“.

At the petabyte scale, information is not a matter of simple three- and four-dimensional taxonomy and order but of dimensionally agnostic statistics. It calls for an entirely different approach, one that requires us to lose the tether of data as something that can be visualized in its totality. It forces us to view data mathematically first and establish a context for it later

Learning to use a “computer” of this scale may be challenging. But the opportunity is great: The new availability of huge amounts of data, along with the statistical tools to crunch these numbers, offers a whole new way of understanding the world. Correlation supersedes causation, and science can advance even without coherent models, unified theories, or really any mechanistic explanation at all.

Applying Knowledge Today

So now we are facing a future where information and discoveries are arriving at an increasing rate – look no further than the Exponential Medicine site (Part of Singularity University) and attend the great Exponential Medicine Conference that takes place each year in San Diego to get an idea of the Tsunami of innovation coming our way. So how do we capitalize on this increase knowledge acquisition so that the best information is applied each and every time we look for insights and treatments in medicine.

Incremental Improvements to Adoption of Innovation

For the incremental approach, it’s turning these insights into small actionable pieces that can be applied at each of the intersection points

  • It’s making the information available in its entirety to everyone involved in the care – this includes not just the clinicians but also the patients and their family and friends (with the approval of the owner of the data – the patient)
  • Abolish Selective reporting – Make the research data widely available and importantly publish all the data, not just the data that matches the desired outcome or result
  • Be open to change and alternatives – recognize the resistance to change is inherent in all of, acceptance can be the first step in change
  • Find common ground and practice guidelines where possible to reach agreement and limit the variation in care that occurs in treatment that comes with your location and treating entity

Do you have any better suggestions? What small change have you seen that makes a difference to speed up the appliance of science in healthcare? What one thing could we do that would have a big impact in this area?


You can also follow me here on medium, on twitter, or on facebook

Why The Patient Story Should Always Take Center Stage

Posted in Uncategorized by drnic on July 21, 2017

I recently discovered that one of the great storytellers of our day – Malcolm Gladwell has a new podcast – Revisionist History. Each episode (he is now into Season 2) takes a look at some piece of history and through some delightful storytelling revisits the history and our perceptions of events. It reminded me of this piece I wrote some time back focused on the importance of storytelling in and the history we capture from our patients.

The Patient Story

Stories are the backbone of who we are. They provide context, insight, subtle and not-so-subtle hints about ourselves and those around us. They teach us lessons and help us determine similarities and differences so that we can avoid mistakes and replicate success.

Much like Malcolm Gladwell’s new podcast, the popular Serial podcast is dedicated to deeply exploring different narratives, stories, and evidence, in order to find insight into a mystery. I found it fascinating for myriad reasons, but mostly for the way it was told. And, at the beginning of each episode is the reminder: “This is Serial: one story told week by week.”

It’s engaging and thought-provoking, but what I like most is that it forces the listener to consider the same principle case from different perspectives. I was struck by how similar this journalistic process of poring over reports and talking with people to hear their perspectives is to the art of medicine. When a patient comes to see you with a set of symptoms, you have your checklist: you examine him, you ask questions, maybe order lab tests.

If your patient’s condition persists, you might talk to his son, who brought him into the follow-up appointment, and he might mention something his father had forgotten or dismissed as irrelevant. You carefully listen to what is said, and what is not said, noting anything that is out of the ordinary. You use that patient’s chart as your journalist’s notepad.

The Luxury of Time

The difference is that physicians don’t always have the luxury of time. Whether it’s because treatment decisions need to be made or there is a line of patients waiting to be seen, they need to have quick access to the most relevant data and best practices so they can make informed decisions and recommendations to their patients. They need to be able to collaborate with a specialist to look at a medical image and report together, discussing whether that secondary finding is something more than it appears.

Compounding matters are that as the healthcare industry awkwardly shifts to value-based care, physicians have been forced to precariously straddle the line between two oppositional models, and amidst it all, they try desperately to not let the tumult affect their patients. They’re beholden to the regulatory bodies that govern how they practice and they have sworn an oath to protect and care for those who have entrusted them with one of their most valuable gifts: their health.

As Drs. Patrick Ober and William Applegate so eloquently as succinctly articulated in their recent article “The electronic health record: Are we the tools of our tools?”:

 

“Attentiveness to the nuances of communication is an essential attribute of a skilled physician; in its quest for medical standardization, the EHR discourages nuances and promotes functional medical illiteracy.”

Time Pressure is Killing the Story

Physicians are being forced to make hard choices, and one of these sacrifices often comes at the expense of the patient story. And when you lose that story, the patient becomes a collection of somewhat unconnected data points. This has a profound downstream impact as the next attending physician will have to go through the same rigorous exercise of asking questions and sleuthing around, which not only frustrates the patient, it can lead to unnecessary wasted time.

The overall health IT endgame is the right one: creating a continuous and integrated care cycle that helps drive the best care outcomes. While technology is a key component in the healthcare ecosystem, it should only play a supporting role. It helps sifts through the massive amounts of data and appeases the regulatory requirements so that the physician can listen attentively to his patient as she walks him through the series of changes and symptoms she has experienced.

In healthcare, the story is everything. Nothing happens in a vacuum. As physicians, it is our responsibility to listen to our patients and their family members, noting the details, and helping them understand and treat their symptoms. We can’t do this if we’re not paying attention.

 

Capturing the Story

It’s not a lack of willingness on the part of the healthcare professionals but rather the time pressures of other tasks that have precluded the capture of the story. What small improvements could we make in the system to increase the time for patients to share their story?

  • Maximizing the time with the clinician requires we ease the burden of administrative tasks from the clinical team
  • Identify any tasks that can be carried out by others – simple administrative functions that could be assigned to other members of the team
  • Patient engagement can occur long before the face to face visit with their clinicians and allow patients access to their records and the ability to validate and update their information
  • Move the healthcare payment model to value-based care and drop the requirement of documentation for the purposes of billing would change the focus of the consultation to be clinical, not financial

This is an important area for clinicians – we recognize the value of the history and to this day the history still contributes some 80% to the diagnosis of a patient’s condition. This alone should provide the impetus to change the system to allow the patient story to be front and center.

Do you have any better suggestions? What small change have you seen that makes a difference in the use of Telehealth services. What one thing could we do that would have a big impact in this area?

 

 

This piece originally appeared on HITConusltant


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Employee Empowerment to Help Patients

Posted in Uncategorized by drnic on July 18, 2017

Delivering Outstanding Service

I had a frustrating experience with a bank this week that had so many opportunities for correction and improvement. The short version was a requirement to follow a policy that no one could explain requiring additional steps necessary because the bank had taken so long to follow their process. At various points, the employees were forced to follow a senseless protocol and policy and given no flexibility. In some cases, it may not be possible to bend policy – perhaps because of regulatory requirements but when we reached of an extraordinarily frustrating experience I tried to tease out an apology or even an acceptance that perhaps this was not the best outcome and there might have been a better way. The lack of employee empowerment prevented them from accepting any responsibility, offering an apology and they were firmly stuck to a script filled with hollow “I understand your frustration” statements.

 

Healthcare and Satisfaction

There is an interesting connection between the soft aspects of the patient experience and customer satisfaction. The actual clinical experience and quality is important – and some would suggest the most important component. But in talking to patients, simple aspects of the experience that included reducing waiting times, personal interactions and communications. But if the staff are not enabled to deliver a good experience and find themselves pressured by production metrics that preclude the important human connection and support that patient crave. It is easy to lose sight of the human elements as we strive for efficiency and the system pushes us to squeeze more and more cost out of any activity.

 

Customer is Always Right

This is an age-old adage that no matter what “The Customer is always Right”. In healthcare, this can be a difficult strategy especially when given the poor information available for making decisions and the inherent bias built into our system to provide unnecessary care. Take the prescribing of antibiotics that has reached epic proportions that recent data suggests has reached levels as high as 30% that are unnecessary.

 

Incremental Improvements in Employee Empowerment

Recognizing the challenge of changing policy which can be a long journey my suggestions for incremental improvements start with empowerment

For any staff that deal with patients/customers

  • Empower your employees to make localized instant decisions
  • Provide them with a set fo guidelines on what they can do and offer
  • Set the boundary conditions but empower them to respond in cases of unhappy/upset patients
  • It could be as simple as offering a Gift Card for a Coffee or Snack accompanied by a genuine heartfelt apology
  • Provide a pathway for problems to be reported, reviewed by the team with input from everyone and accept suggestions and ideas on how things could have been improved or even fixed

 

You won’t just get happier patients – you will get happier employees

 

Do you have any better suggestions? What small change have you seen that makes a difference empowering your employees? What one thing could we do that would have a big impact in this area?

 

You can also follow me here on medium, on twitter, or on facebook

The Internet of Things Changes Everything in Healthcare

Posted in Healthcare Technology by drnic on July 16, 2017
Remote Consultation for Pre-operative Assessment

The Internet of Things is Changing Everything in Healthcare

While there remains some resistance to the idea of tracking everything there is increasing use and now results from the IoT. It ranges from the simple – weighing scales that record and report weight loss and gain, not just for health and fitness but as an early indicator of problems in Congestive Heart Failure to the complex ideas of tracking pills and compliance with RFI tagged medication

Expect this sector to explode

The Internet of Things Changes Everything in Healthcare was originally published on Dr Nick – The Incrementalist

Telehealth for Everyone

Posted in Uncategorized by drnic on July 10, 2017

Working from Home

 

Americans are doing more and more activities from the comfort of their home and its no surprise – the frustration of showing up to a business only to find they are closed or worse short staffed and instead of dealing with the customer in front of them the staff are on the phone answering queries. Bypass the line and move to the front of a virtual queue from the comfort of your own home is appealing.

Online Queuing Systems

There is even sophisticated queuing mechanism when there is limited availability for a resource as I discovered when I tried to score tickets to the Harry Potter show in London

You had to be quick to join this queue virtually

 

 

This experience was managed comfortably from my laptop as I sat sipping coffee and checking in occasionally while I continued to work on other things on my laptop. I think it would have been an even bigger disappointment to have spent that time in a line somewhere only to find there were no more tickets left by the time it was my turn.

Compared to my experience getting tickets to the Kusama Infinity Mirrors Exhibition at the Hirshhorn Museum which was a physical process I went through recently having failed to score tickets in the online system. This process required early rising, driving into town, expensive parking and then standing in line for 4 hours to get a ticket (it was worth it)

Getting an Appointment

Telehealth has many of the same elements to recommend it. The hassle of making an appointment – which in a recent post online was filled with frustration that started with doctors offices, not taking new patients and the ones that did not have available appointments for 6 months! Assuming you can make it past this assault course and get an appointment that is convenient for you the system requires driving to the office, sitting in a waiting room and being subjected to loud obnoxious daytime television broadcast while you wait for your physician encounter that could last minutes. Some physician exams do involve more serious health issues, but most are routine visits to refill prescriptions and see to minor illnesses and infections, needs that could easily be met with video chat.

Why Has Telehealth Not Taken Off

Discussing this with a colleague recently he highlighted the fact that the leaders of the American Telemedicine Association were famous for saying  “This is the year for Telehealth”, every year for the past 20 years

This reminds me of an article I wrote back in 2005, I wrote a piece that continues to show up in my inbox as being used and linked to. It was featured in the Health Management Technology Journal titled “Is Speech Recognition the Holy Grail”. I was frequently quoted and referenced as saying

“Speech Recognition has been 2 years away for the last 10 years and its still 2 years away”

So what happened and why do studies suggest that instead of reducing visits and costs it has the opposite effect? Telehealth drives up healthcare utilization and spending – yes you read that correctly. The report, published Monday in the journal Health Affairs, found that although telehealth appointments are cheaper than in-person and emergency room visits, the online and virtual resources encourage vast new utilization, ultimately driving up healthcare spending

The report, published Monday in the journal Health Affairs, found that although telehealth appointments are cheaper than in-person and emergency room visits, the online and virtual resources encourage vast new utilization, ultimately driving up healthcare spending

In one of those perverse unintended consequences – providing easy(ier) access to healthcare services

The convenience of telemedicine is encouraging people to seek care when they normally wouldn’t, ….You don’t even have to go anywhere … you just have to pick up the phone

Their recommendation – encourage more cost sharing for consultations to encourage patients to think more critically what they elect to seek a medical consultation for. It’s a familiar argument and one that circulated frequently amongst General Practitioners in the United Kingdom’s National Health Service (NHS) who faced a barrage of requests for care at all hours of the day, night and weekend for conditions that were either trivial or at a minimum non-urgent. But when a service is valued at zero (that’s not to say that it has no value just that the perception is that it has a value or cost of zero) the usual filters fail to be applied.

Healthcare is Different

Normal economic models are hard to apply in healthcare – introducing a co-pay or shared cost model has its own set of unintended consequences. Too high and you discourage legitimate requests for help from patients and this typically affects the vulnerable and poor disproportionately. Too low and it fails to influence the behavior sufficiently to warrant the additional administrative burden and overhead of introducing these mechanisms. But that is true too in other industries – we pay for our own car maintenance and don’t look to the car insurance provider to pay for tire and brake replacement. But when funds are tight people will avoid maintenance and check-ups that ultimately could have saved significant damage and higher costs of repair. But failure in healthcare can be catastrophic and life ending – a car is just a car.

Ultimately I think it requires a retraining of the individual in better self-care and management and a stronger closer relationship with a trusted healthcare professional who is seen as a partner in the process. I have that with my local garage – I found through a personal recommendation and am a loyal user for years. I have a trusting relationship – unlike some of my experiences with garages that have set up programs that incentivize the employees to sell unnecessary services and repairs this garage does not. The inflection point for me in trust was the time I took one of my cars in to solve an intermittent problem – they had the car for 2 days trying to replicate and diagnose and ultimately were unable to reproduce the problem and could find no underlying problem – the charge for the service – zero. When I asked why I was told they had carried out no maintenance or repairs.

We can achieve the same in healthcare but it requires centering the services around the Primary Care and the Medical Home. I made this point in this piece Give consumers the telehealth option they really want: Virtual visits with their own doctor. Separating out services is like going to the cheap oil change shop like Jiffy Lube. You can get a cheaper oil change and check up but their model is designed to identify problems and sell you on other services.  In some cases, I’ve had recommendations for additional services only to be told by my trusted mechanic they are not required.

 

 

The Telehealth service providers offer a valuable and important tool – even more so for some rural communities and places that have limited access or low penetration of available clinical professionals – but ultimately if the care is not integrated it will likely have the tendency to increase utilization and has the effect that my colleague described of increasing visits to your healthcare providers.

 

A telehealth doctor or nurse practitioner can give great episodic care, but those episodes don’t look at the whole patient. Patients also need someone who looks at their risks for chronic disease, such as obesity, type II diabetes and high blood pressure, and guides them toward lifestyle choices that prevent those diseases. And patients also need someone who can connect the dots — a provider who knows and understands their history and can view current symptoms in the context of the patient’s overall health. That’s tough to do if you see a different provider every time, especially if that provider does not have access to your records when he or she writes a prescription or suggests a treatment. It’s why emergency rooms are not a good place to get primary care — not only is it expensive, but the doctors often lack access to critical information.

Integrated Telehealth

 

To avoid telehealth becoming a cheaper version of emergency room care we must connect telehealth to patient-centered medical homes and offer our clinicians a means to offer this service as part of their total package. We see the early stages of this albeit for an elite few that can afford it with Concierge Practices (The Doctor Is In. Co-Pay? $40,000) that customize care. Reminds me a lot of the service the General Practitioners have offered and still do in England as part of the NHS with home visits included. But enabling this for more people will require some changes to the system especially the reimbursement model that currently incentivizes activity, not wellness or care. Providing technology to offer support and guidance around minor ailments and triage the limited clinical resources directing patients to access them when necessary would help. The Family Practioner with the patient becomes the conductor and manager supporting the delivery of care and drawing on the necessary resources. Their capability is extended through Telehealth allowing them to interact with many more patients remotely and saving unnecessary trips to the office but being rewarded for the care management.

Incremental Improvements in Telehealth

We have been on the cusp of acceptance and widespread roll out for a long time – finding some small step towards that in your practice or as a patient would help move more people to this model and begin showing the value. From the patient consumer perspective being open to the channel and using it where available in lieu of care to understand the experience would help. Think back to when airlines first offered kiosk check-in. Were you one of the many people who said not me ever….. and now it’s your preferred method?

  • Accepting the value of remote access and using the existing technology in place can help jump start the process
  • Telehealth can be as simple as a telephone call – for some of the major providers that are a big part of the service they offer
  • Adding simple video chat will help expand the channel and allow an exploration of the medium to understand better how it can apply – perhaps starting unofficially with family
  • Make Telehealth one of the channels that your Patients can Access you – the reimbursement models may not support this model quite yet but it will undoubtedly induce loyalty and improve the care

 

Do you have any better suggestions? What small change have you seen that makes a difference in the use of Telehealth services. What one thing could we do that would have a big impact in this area?

 

You can also follow me here on medium, on twitter, or on facebook

 

 

 

 

 

Medical Education Broken Economic Model

Posted in Uncategorized by drnic on June 25, 2017

Medical Education Costs

I posted an article this past week featuring an article from CBS Moneywatch in 2013: $1 million mistake: Becoming a doctor that generated a few comments including comments about clinician burn out domestically and internationally and some questions about the current status and if this was getting worse or better.

Other Countries

It would seem that this problem is worse and spreading. Some countries that used to pay for higher education of doctors – the UK would have been one of those no longer do. Some time back they introduced fees that run to 9,000 GBP per year for 5 years

That’s $ 58,000 for the 5 years

– about the same as 1 years tuition in a US medical school => 1/4 the cost of medical school in the US

(Those fees rise dramatically to 39,000 GBP per term for over seas students)

There are wide variations and this article on the Student Doctor Network site: Attending Medical School on Foreign Ground offers some insights into the variations

The cost of attending medical school varies widely both inside and outside the U.S. Once tuition, fees, and the cost of living are figured in, American private schools come in on the high end of the scale and state colleges land in the middle. Average medical student debt ranges from $70K for medical students in Poland to $200K for medical students in Australia and Ireland.

  • Nearly 90% of U.S. student loans for medical schools outside the U.S. go to Caribbean medical schools, popular for proximity to home, tropical beach locations, and reasonable cost, which compares favorably to the mid-range schools in the U.S.
  • Medical schools in Mexico are cheap and so is the cost of living, but the high crime rate must also be taken into consideration.
  • Canada might be an appealing low-cost option if prospective Canadian med students were not saddled with similar issues faced by those in the U.S., more aspirants than programs.
  • The cost of attending schools in Europe range from very inexpensive Poland to astronomical prestigious schools such as St. Andrews University in Ireland…which costs over $250K in tuition alone, but comes with guaranteed admission to the University of Edinburgh for post-graduate studies.
  • The average student expenses in the Middle East are comparably low, but there are cultural and language hurdles.

Cost of Attendance

For clinicians delivering the care, all arrived at this point having selected the expensive assault course of education to train and qualify to be able to deliver care. For doctors its persistence and endurance that win out. The barriers to entry are high and tied to economics. If you manage to complete your first degree at a conservative estimate of $40,000 only then are you ready to apply to medical schools and that’s going to put you in debt to the tune of $240,000 or so. Taken together that is at least $280,000 of debt hanging over your shoulder when you conservatively emerge as a qualified doctor aged 26 with at least another 3-4 years on average of low-income work while you finish your apprenticeship as a resident. So by the time you are fully qualified and ready to start serving the public and doing the work you originally signed dup to do when you set your sights on medicine you lost 12 years of time to earn an income and accused a debt of $280,000. At age 30 this equates to a repayment (calculated based on the current educational loan rates averaged out of 5.31%) is a monthly payment of

  • 10 year repayment $3,012
  • 20 year repayment $1,896
  • 30 year repayment $1,556

 

Lost Earning Potential

This lost income earning opportunity that is a minimum of 8 years in the US – 4 years for an undergraduate degree and 4 years in medical school. Add in a few years of post-graduate training, required to enter any specialty and you have a decade of lost income that at an average salary of $50,000 equates to a cool half a million dollars. Paying off the debt with interest pile on the burden and put newly minted doctors at least a $1,000,000 in the hole before they even start thinking about a family and a life.

Our clinical professionals all have the same desire to help patients – but economics and the burden of the educational system can overwhelm just about anyone and the post qualification economics drive them towards higher paying specialties to help ease the debt burden and are certain contributors to the high run our rates and extreme levels of dissatisfaction with the career of medicine.

How do we Fix Medical Education Economics

There are some programs attempting to address this by steering newly qualified doctors to under served areas with a promise of paying off outstanding loans after 10 years of time committed to these areas. What to do about the fundamental issue for the many already saddled with this debt and struggling to find a path and how do we change rebalance the system? Given the reports that suggest the looming dearth of doctors available to treat the exploding populations – something that is amplified in many other parts of the world where there are many fewer doctors per head of population than we have here in the United States.

Its and urgent problem and one that I see few solutions or paths – do you have any ideas. Are there are simple incremental changes we could make that might start to move the needle and change this system to attract and support the type of doctors and clinicians we want treating patients. Is there an incremental change that could be applied to shift the cost of education or change the outcome that pushes so many into specialization when we need internists and family practitioners. Is it as simple as increasing the salaries/rates of pay for the specialties we want to encourage doctors to enter?

Leave your thoughts and comments below – I’d love to hear your ideas.

Healthcare – Its Personal

The Great Healthcare Debate

Healthcare is personal and front and center in our minds not just because we all intersect with it in some way but it employs 1 in 9 people in the United States. With the current state of our media and political system with polarized debates, he said she said talking heads on the media, the echo chamber of social media and the 24/7/365 barrage of news and fake news it can be hard to see a pathway out of the quagmire we find ourselves in. But we all want to see that path. I just don’t believe that people get up in the morning wondering how they can decimate the healthcare services and the lives of their fellow human beings. We don’t get up out of bed every day wondering how best to punish people who may have made bad choices in their lives or who find themselves in unfortunate positions though geography (the zip code effect) or genetics. I know I don’t and I don’t think you do either.

Yet the stream of coverage and what we read, see and hear online and sometimes even in person suggests that this is the case. I can’t answer the reasons why but I’ve read a string of articles and reporting that variably suggests its always been like this to this is the fault – and then insert the name of your favorite whipping horse. Ultimately it does not matter – unless you believe that people wake up with malintent every morning it’s better to start with an understanding of the problem and then thinking about possible solutions and how we can apply them quickly and effectively

So Let’s Start with some of the fundamental problems in our healthcare system – to be clear we are not alone in the world. I have seen and heard from many others in different countries who are all struggling to varying degrees and with different focus and priorities the same issues. If I had to boil it down to one issue I would say

Limited Resources and the Prioritization of the Allocation of those resources

It’s a familiar equation to anyone trying to balance their budget or allocate their time. If you are like me you may find there are just not enough hours in the day for the task list you created in the morning and wishing either to stretch time (time dilation) or perhaps be able to turn time back with the Wizarding world’s  Time Turner. There are two basic options available – reduce the inputs or reduce the outputs. In the vernacular of budgeting – either spend less or make more money. Both may be viable and depend on personal circumstance but undoubtedly there will be easier and harder solutions. Ultimately we all have to make our own personal decisions – so one solution or size does not fit all.

Photo from jenga.com

It would be foolish to suggest that this covers all the complexity of the healthcare system as we all know healthcare is incredibly complex and always reminds me of the game Jenga.

 

This does not cover everything and there are many other elements in play but it is certainly a start and one that individuals and organizations can focus on to start to make incremental improvements.

As one Chinese proverb states:

Every journey starts with a single step

And turning that step into a habit is one of the best ways of setting a path to improvement.

Demand Side of Healthcare

This is the access and use of the system and the burden does not just fall on the individual. But it does start there as it is out personal choices to access and use available services that creates demand. Historically in the United States, the cost and payment of this access have been disassociated from the individual. When you visit the doctor or pharmacy you don’t pay the actual cost of the service – your insurance carrier does. Ultimately we do all pay for this through our insurance premiums and for many the contributions made on our behalf by our employer that is part of the compensation we receive for working for them but at the point of care, we are disconnected from the price and cost of a service.

Patient Accessing Care

To a varying degree individuals have some form of co-pay – a personal cost that is defined by the insurance coverage and is shifting increasingly to the individual under the new insurance plans called High Deductible Health Plans (HDHP). One of the intentions of this policy is to make the individual responsible for this cost in an attempt to influence behavior and decrease unnecessary access. But this comes with the inevitable unintended consequences with cost avoidance strategies by individuals who knowing they will be held responsible for the full cost of a visit, drug or test may elect to decline to have or use the service.

 

I’d count myself in that crowd having been on a HDHP plan for several years. I can point to several decision where I have declined tests, treatment and access to care because of the nature of my personal responsibility – I have an associated health savings account (HSA) which should cover the capped amount of cost for the year. But the crippling nature of potential costs associated with a catastrophic medical problem – a serious accident, cancer, heart attack are all so terrifying that I see the HSA as a buffer against the potential of medical insolvency that might result especially when you consider the impact on a family with one source of income that would be impacted by any medical disability.

 

Insurers Paying for Care

Insurers want to reduce their costs – and even the non-profits have to make money so are focused on the bottom line if they want to continue to serve their customers and population. So they look to find ways to reduce the unnecessary access to care imposing barriers and limits. There was a gate keeper concept that requires a referral letter from a primary care physician before you can access s specialist – that service by the way costing you additional fees to see the primary care provider. There are formulary requirements that exclude certain drugs from coverage and attempts to limit access to specific doctors and networks to strengthen the buying and negotiation power of the payor with the providers in the system.

 

Providers Delivering Care

On the provider side the clinal professionals delivering the care all arrived at this point having selected the expensive assault course of education to train and qualify to be able to deliver care. For doctors, it’s persistence and endurance that win out. The barriers to entry are high and tied to economics. They all have the same desire to help patients – but economics and the burden of the educational system can overwhelm just about anyone and they have bills to pay both for their education but also the infrastructure they must use to be able to both deliver care but also bill and be paid for delivering. They want to reduce their overhead and spend as much of their time and resources on the delivery of care but to survive in the system must allocate significant amounts of money to non-clinal systems and activities. Estimates of these costs suggest that at least 30% of the healthcare costs we as a society pay in the United States are tied to administrative and billing functions. The data’s still lagging but projections for 2016 put the total healthcare bill at $3.207 Trillion (thats $3,207,000,000,000 or more than $10,000 per person in the USA)

Healthcare Administrative Cost: $962 Billion Dollars

$962,100,000,000

 

Reconciling the Differences

Credit Imgur

The difference of opinion often centers on what is unnecessary – in the eyes of the patient they need and want the care they think is appropriate to them. Some of this is fed by a constant stream of information that even for an well informed clinically experienced specialist can be difficult to comprehend and make informed decision. We want wants best for our personal health and the health of our family and loved ones. But sometimes what the patient may think is best may not be – a great example is the steady stream of requests for antibiotics for treatments of minor infections. Not every sore throat or cough demands the use of antibiotics and in fact, in many cases, their use is damaging as we face a future where this line of defense is increasingly being overrun with smartly adaptive bacteria who develop resistance with terrifying speed.

 

Payors Perspectives

The same is true of payor and insurers – they face a rising tide of costs associated with care that is increasingly complicated and expensive and struggle to balance their budget.Faced with one patient who’s costs for treatment might be hundreds of thousands of dollars or more so they limit or decline this in favor of treating multiple other patients where their cost of treatment is thousands of dollars or less? The utopian answer is treat everyone but we they like each of us do not have unlimited budget or resources and have to make hard decisions. And the problem with healthcare fundedfor the population but access individually.

 

Healthcare is funded for the population but access individually

 

Clinicians Perspectives

Clinicians also have a view on what’s appropriate – and the vast majority act with total integrity (I would like to say all of them but sadly there are occasional stories of clinicians and healthcare professionals who game the system – sometimes with simple prescription based fraud or other times over treatment of stenting in cardiac cases). Sadly for a profession that is so dependent on trust the rare cases of fraud and abuse unfairly tar everyone with the same brush. As I said above – I believe everyone gets up in the morning with the best intentions and this is true of the clinal professionals who each and every day battle a system to deliver the care and compassion they set out to deliver when they took the path into healthcare. They want to say no to unnecessary treatment but the personal pressures applied and the underlying compassion and the innate drive that was the foundation of why they entered the profession can influence them to order and prescribe because they are unable to explain the lack of value and offering this option makes their patient happier and comfortable.

So how do we reconcile these differing opinions

 

Economics and Making Choices

Which path is best

There’s a sad fact in the US healthcare system – we do not talk about cost effectiveness. Its not just a taboo subject but also a forbidden topic, As Aaron Carroll (The Incidental Economist) noted in his piece Forbidden Topic in Health Policy Debate: Cost Effectiveness we avoid talking about cost-effectiveness in the United States.

Some think that discussing cost effectiveness puts us on the slippery slope to rationing, or even “death panels.”

As he points out – if there was a pill available that could extend your life by one day but costs a billion dollars, most would accept this as an unacceptable trade off and decline it. But that’ extreme – as you decrease the cost where does that line become blurred?

what’s to stop us from deciding that spending a couple hundred thousand dollars to extend grandma’s life for a year isn’t worth it either?

More troubling is the shackles that have been placed on the Patient Centered Outcomes Research Institute – who were founded but explicitly prohibited it from funding any cost-effectiveness research at all! How can an outcomes institute assess healthcare if cost effectiveness is not part of the equation?

“We don’t consider cost effectiveness to be an outcome of direct importance to patients.”

In fact, we in the United States are so averse to the idea of cost effectiveness that when the Patient Centered Outcomes Research Institute, the body specifically set up to do comparative effectiveness research, was founded, the law explicitly prohibited it from funding any cost-effectiveness research at all. As it says on its website,

PCORI was established to fund research that can help patients and those who care for them make better-informed decisions about the healthcare choices they face every day, guided by those who will use that information.

 

Quality-Adjusted Life Years

As he points out there is actually a fairly robust strategy and measure that can offer insights into the value of measuring health outcomes – QALY’s (Quality-Adjusted Life Years) which the National Health Service has been using fro some time in the National Institute for Health and Care Excellence (NICE) that provides guidance, advice, quality standards and information services for health, public health and social care. Also contains resources to help maximise use of evidence and guidance. There is no doubt they are imperfect but very little in life is perfect and perfection should not be a barrier to progress. The use of this is not a sole determinant – but offers some measure of science and data to making what are incredibly difficult tdecisions

So in the current debate of what health system we need to put in place I would advocate the inclusion of cost effectiveness as one of the factors that must be considered and the QALY and perhaps even the Incremental cost-effectiveness ratio (ICER) as part of this difficult discussion.

I’m all about incremental changes and while including a cost effectiveness as a measure may seem a bigger stretch I feel it is a smaller step in the right direction. Can we achieve this? Is there a better incremental step we can take to resolve the challenges of our healthcare system? Leave your thoughts below.

Healthcare – Its Personal was originally published on Dr Nick – The Incrementalist