Interoperability in Healthcare
Getting to Nationwide Interoperability
Unfortunately, the existing healthcare system incentives behavior that is in opposition to the goal of scalable, nationwide, vendor-neutral interoperability. Our model has multiple groups who have a vested interest in the control and ownership of data (for example Payors, Providers, Patients). Each has their own economic and commercial drivers and in many instances, these do not coincide with the open sharing of data. In a system that is driven by activity and delivering care (Fee for Service) sharing data could mean a reduction in work and income. Until our reimbursement system moves to a more holistic care model that focuses on wellness and outcomes and incentivizes behavior that delivers better health and outcomes for patients through cooperative and coordinated care and ultimately equitably rewards all the contributors to these outcomes we will remain stuck in the quagmire of limited interoperability.
The Patient at the Center of Data Exchange
I believe as do many others that the patient is at the center of everything we do and deliver in healthcare. By placing the patient and their information at the center of care we empower them and enable a model that moves away from the historical paternalistic delivery of healthcare to patient-centered and enabled care. It does come with challenges since many people contribute to that care and the current administrative and financial configuration focus the management and ownership of data with providers, healthcare systems and payors. While many patients want access to their data and some even want to own and manage it, many do not and are ill-equipped to be responsible for this data. What may emerge are independent services and providers who aggregate, manage, secure and service patient data on behalf of patients – much as banks do with our money. There are many technologies on the horizon that offer a potential path to achieve this and blockchain represents an interesting innovation of decentralized secured data that offers individualized control and dynamic revocation options for access.
Frictionless Data Flow
The key to an interconnected care model is the free flow of data between all the various areas that are responsible for delivering care. We moved away from the single index card medical record held by your personal physician who was the focal point of your care and care coordination to a distributed team-based model of care that encompasses multiple areas and people. The only way this team can deliver excellent care is through the frictionless flow of enhanced data and knowledge. This information flow must include the patient and all their family members that are authorized, interested and engaged in their care. Data should be shared with the patient’s consent with everyone concerned and available for as long as it is needed to deliver care but this access should be flexible enough to allow it to be revoked or removed when it is no longer needed or necessary
Interoperability in Healthcare was originally published on Dr Nick – The Incrementalist
The NHS at 70
The crown jewels of British society
The NHS was the crown jewels of British society providing healthcare to every member of society no matter who they were, where they came from and what personal resources they had. It was the great leveler of society creating a single standard of care and service that was accessible to rich, poor and disenfranchised and it was well loved.
To me personally, it was my guide and educator – I was lucky to attend one of the great London medical schools – The Royal Free Hospital School of Medicine. The “Free” hospital created to treat all comers and the original medical school (The London School of Medicine for Women) for women created in an era when women were not admitted to British Medical schools
That hospital and the NHS provided me with a first-class medical school education, access to groundbreaking research that included the early work and discoveries around HIV/AIDS, Hemophilia, Liver disorders and beyond.
The staff in every department were friends, colleagues and members of a community that were family and all pulled in the same direction – that of the patient. I spent time working in different areas during my time, staffing the manual telephone switchboard, helping the porters and security staff, nurses, technologists, and maintenance and quickly realized the well-oiled NHS machine demanded a family of committed people to make it work and deliver outstanding care each and every day.
What Could We Do Better
As we know today, and probably knew 70 years ago and before, healthcare is as much about our environment and resources as it is about medical treatments, technology, and innovation. We know that 60-80% of health is attributable to lifestyle but fail to take account of this in the NHS and in the majority of health systems from around the world.
We need a WellCare system not Healthcare
The system spends large sums of money providing medications to the population but fails to take account of the most basic needs of the population and acknowledge that food is also a drug. What we put into our bodies contributes to our health and well-being. Failing to acknowledge and manage these elements of health with sleep as the foundation and exercise and nutrition built on top has created a system that treats the failing of these issues at great financial and personal patient cost. Investing in the prevention would create a WellCare system and not the Healthcare System that the NHS is.
Manage and Allocate the Limited Resources with Transparency
It’s an unpleasant fact that few want to address or even acknowledge but the reality of treating people is that in this day and age of innovation, scientific progress and developments we could spend every last penny on treating patients. There is an unlimited supply of possible treatments and a never-ending procession of people needing those treatments. But not all treatments are created equally – some don’t work, some are harmful and in the cases of those that do work there is the wide disparity in the effectiveness and cost. Any healthcare system needs a means of assessing the effectiveness of treatments that includes the financial and resource cost linked to the improvements. The problem with a “free” (the NHS is not free – it is simply free at the point of care, paid for through taxation of the individuals) is the inducement of un-economic behavior by individuals looking for every last treatment option no matter the cost or effectiveness. That path is unsustainable and breaks the system and ultimately harms patients.
Enable Informed Decision Making for Everyone
Doctors Die Differently and do so because they understand the economic and personal tradeoffs between treatments and quality of life. In the data presented by the Johns Hopkins Study of a Lifetime we see a big discrepancy in treatment choices between doctors and everyone else. We make our choices in the context of the knowledge of effectiveness weighed against the personal cost of treatments and quality of life impact. An open an honest assessment of treatment that is clinically effective would level the disparity in treatment choices selected by patients. As a society, we struggle to discuss end of life but it is a reality that everyone faces and we must find ways to educate and support people through all aspects of life and death.
Technology and innovation is essential to the future of the NHS
The future of a scalable meritocratic system accessible to all that does not bankrupt society will be dependent on technology and innovation. Humans remain the core constituents of any compassionate caring system and technology is a supporting player. But as Michael Dell put it:
Technology has always been about enabling human potential
Technology does not replace the human beings or interaction but rather augments it in ways that extend our capabilities and improves the accessibility and economics.
It is an impossible task for humans to process the amount of data currently being generated about our patients, the knowledge derived from research and advances in science and put it into the context of treatments at the point of care when it is needed most.
We have expanded beyond the human brains capacity to absorb, process and apply the knowledge and must rely on technology to augment the brains abilities and place information into the context of the individual patient and the care choices available.
Selecting the innovations that deliver the most value
Innovation impacts each and every area of the NHS and will continue to do so but the challenge will be to select the innovations that deliver the most value to the largest number of people based on scientific peer reviews.
Innovation is not confined to the clinical treatment but extends to every element of the NHS system and the delivery of wellness care. It is changing the design of facilities to include features that improve care and outcomes – for example by adding natural light and open spaces.
Innovation is allowing patients the option to access their care team at any time and from any location – for example bringing the care team to the patient as we used to do with home visits but now using technology to extend the reach and scalability.
Innovation is building rooms and beds that can be efficiently and effectively cleaned between visits while maintaining comfort and welcoming surroundings. It is using available data to predict potential health issues before they occur and reaching out to patients helping to guide them to better healthier choices and wellness. Innovation is allowing parents to stay with their child in the hospital when they are sick and in need of care in comfortable and caring surroundings.
Innovation is offering dignity and compassion to those facing death and offering realistic options for no treatment and hospice care.
What can Britain and the NHS learn from the rest of the world?
Over 700 years ago, China had village doctors who were paid by the villagers when they were well but received no money when the patients were sick. This is the principle of wellness over sickness care. In Norway, they have a wide and uniform implementation of a digital health record that is accessible to everyone that needs it including the patient – tied together with a unique patient identifier designed for that purpose. One Citizen, one record.
The European Union allows citizens to cross borders and different health systems but to receive urgent care while traveling and administers the cross-country charges, managing fees and removing the patient from worrying about payments while they are sick and abroad.
Look also to Africa and the innovation that takes place on a continent with access to far fewer resources and technology to see what’s possible with the existing technology. Small incremental steps in using technology to boost healthcare services such as text messaging have been wildly successful and yet remain simple, easy to implement and understand and accessible through all social groups in society.
In Rwanda, they have integrated drone delivery for hard-to-reach locations, offering lifesaving support that was previously almost impossible. Expect to see more of this and bi-directional capabilities for resources, tests, and samples as well as lifesaving treatments.
Finally, in Korea, they have a culture of celebrating aging and the elderly that includes dignity in end of life and the inclusion of everyone in the family and their health. Korean culture sees the 60th and 70th birthday as a big family affair and the inclusion and the universal expectation that roles reverse once parents age, and that it is an adult child’s honorable duty to care for his or her parents’ health.”
A version of this appeared previously here
The NHS at 70 was originally published on Dr Nick – The Incrementalist
Should You be Taking a Statin
The answer to that question is complex and individual and before thinking about that you should have a basic understanding of cholesterol in your body. You can learn about this from my video and blog post
Statins
In the previous episode, I talked about Cholesterol in your body. This week as a follow up I’m talking about Statins, a group of drugs that lower the level of cholesterol in the body. They work by acting on the liver’s mechanism for producing cholesterol inhibiting the enzyme Hydroxy-methylglutaryl-coenzyme A reductase (HMG-CoA reductase).
We know that cholesterol is closely linked to atherosclerosis – the formation of plaques that build up on the walls of our arteries and contain cholesterol and that these plaques can rupture or break off and cause blockages that cause cardiovascular disease that ranges from the mild decrease in blood flow to our limbs to the severe effects that throw blood clots into our brains and heart causing strokes or heart attacks. But as we learned last time – cholesterol is not all bad – it is an essential part of our body systems making up parts of cell membranes and integral to several signaling molecules.
Statins are also known to have additional effects beyond the simple reduction in cholesterol levels and production in our body and several studies have shown that these drugs also reduce inflammation in the cell walls which is not connected to the cholesterol-lowing effect. In fact, this effect occurs rapidly and is seen as soon as 2 weeks after starting statin therapy
Statins Drugs
There are multiple Statins around the oldest and best known is Atorvastatin (widely known by its brand name Lipitor) with its breakout general usage in 1996. The good news is this drug is off patent and there are plenty of low-cost generic options available and there is lots of safety data gathered given it has been in widespread use for over 20 years.
But Statins are not side-effect free and some find themselves suffering from constipation, diarrhea, and fatigue and in some 5-10% of people muscle cramps that can make the drug intolerable. This can be mitigated with some of the newer variant drugs that can help mitigate or even completely reduce the muscle cramps and other side effects. There is a rare and significant effect of causing diabetes in a small percentage of patient’s which is an important factor to consider when considering if Statins are right for you.
New Research on Statin Therapy
There has been lots of research and trials and the most recent I mentioned in the video the HOPE-3 trial which had a multifactorial design – meaning multiple variations on treatment therapies were tested in different populations.
They had a diverse group of patients divided up into multiple groups in a 2×2 factorial design that had groups being treated with a statin, an Angiotensin-converting enzyme (ACE) inhibitor for blood pressure and a diuretic hydrochlorothiazide also for blood pressure (BP). They had 12,000 people with a follow up to 5 years and they maintained good adherence for drugs of around 75%.
Overall, the anti-hypertensives did not reduce the risk of cardiovascular events at all – but there were differences depending on whether or not you had hypertension when you entered the trial. Interestingly the combined statin with an antihypertensive treatment was no better than a statin alone. And the data offered a clear benefit for Statins for those at intermediate risk of cardiovascular disease.
The details of this are nicely summarized here and the article includes links to the 3 published studies that were published from the data. One of the specific questions answered by this study is on that one cardiologist friend of mine and I have discussed before – should Statins be placed in the drinking water like fluoride. Given the cost and the side effects associated with statins, the answer is no for economic reasons as well as increased risk of side effects.
In the intervening time since I recorded this video another paper was published:
Finding the Balance Between Benefits and Harms When Using Statins for Primary Prevention of Cardiovascular Disease: A Modeling Study, and a new set of guidelines from the American College of Cardiology (ACA)/American Heart Association (AHA) on the management of cholesterol in the blood: 2018 ACC/AHA Multi society Guideline on the Management of Blood Cholesterol
Which emphasizes a heart-healthy lifestyle but then details some very specific “high-intensity” statins to focus on specific cholesterol levels in people who are at high risk or with proven clinical cardiovascular disease (they reference ASCVD or atherosclerotic cardiovascular disease) alongside detailed clinical guidelines for stating therapy based on specific risk and disease assessments in individuals. There are too many variations to make any generalization beyond what I stated in the video – start with the incremental step of knowing your numbers and the details of your family history and medical history as contributing factors to your risk assessment to take with you and discuss with your doctor to decide what’s right for you
Once you have your numbers you should calculate your 10-year risk of heart disease or stroke using the Atherosclerotic Cardiovascular Disease (ASCVD) algorithm published in 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk. This is available from several sources including this from MDCalc or this one which includes a spreadsheet you can download to plug in your values as well.
To include the new updated guidelines from 2017 and the ASCVD Risk Estimator Plus tool (background available here) you can download the app with updated guidelines from 2017 for Apple iOS but Android is a little more challenging with a generalized cardiology app which does not get as good reviews.
Ultimately the decision is a very personal one and is driven by data and supported by clinical evidence. There are no quick global answers, but it is an important decision for everyone to consider, especially if you have any contributing factors in your family history, past medical history or are suffering from any aspects of cardiovascular disease.
Listen in to hear the details Statin Therapy and if its right for you
Incremental steps – Deciding on a Statin
- Measure your Blood Cholesterol
Gather the details of your medical history
Use the ASCVD calculator to give you a guide based on the clinical research
Bring everything to your doctor and discuss the evidence data and make a personalized decision together
The evidence is clear for those in the groups that have treatment with a statin recommended that the benefits outweigh the risks and side effects.
Should You be Taking a Statin was originally published on Dr Nick – The Incrementalist
Your Body and Cholesterol
This week I’m talking about Cholesterol. What it is, where does it come from (hint your diet is only a small part) and what does your body use it for
It’s interesting that when you search for cholesterol the recurring image is of Eggs which have been closely linked with Cholesterol and to some degree part of a simplistic link that associates food that contain cholesterol with cholesterol levels in our body but it’s not that simple.
Cholesterol
The word Cholesterol comes from the Greek Chole for bile and sterus for solid and adds an “ol” at the end for hydroxyl functional group or alcohol bond on the molecule. It is a lipid molecule and is found in cell membranes and in signaling molecules like our the hormones Progesterone, Estrogen and Testosterone. Suffice to say our body needs it so the idea you get rid of all your cholesterol to be healthy won’t work.
So what does it mean for your health, how much should you eat and what are all these HDL, LDL and VLDL measures your blood test and what do they mean for you? Listen in to find out the details of the cholesterol measurement and what they mean to you and what Incremental Steps you should be taking regarding cholesterol in your diet an for your health.
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Your Body and Cholesterol was originally published on Dr Nick – The Incrementalist
Using Advanced Trauma Life Support Methodology in Population Health
Preventative Health for Everyone
This week I am talking Joshua Scalar, MD, MPH, Chief Medical Officer for BioIQ where they are working to seamlessly connect people to preventative health testing by removing the friction from the system and allowing as many people as possible to access essential, cost-effective life saving preventative testing services.
Josh had an interesting path to his current role – find out how a Saxophone playing band member became a passionate advocate for patient engagement and widespread and easy access to preventative services
Hear how Advanced Trauma Life Support (ATLS) insights offer a model and guide for the triage and delivery of preventative care that should address a problem that by some estimates has only 8% of people accessing fully validated life-saving preventative care opportunities in the United States
Like many of my other guests, Josh made the point that one of the clear incremental steps to getting patients and consumers to access preventative services is
Making the right choice the easiest choice
Hear how he and his team have addressed a basic problem of colonoscopy screening that is an effective and well-tested method of picking up and preventing untimely death from colon cancer but is still poorly adopted. As he points out – colon cancer killed 50,000 people in 2017 – that’s more than the opioid epidemic did but it continues to lack the focus and attention warranted.
Listen in below to find out how this can be applied to Diabetic Retinopathy – preventing blindness that is a high risk for Diabetic patients
Listen live at 4:00 AM, 12:00 Noon or 8:00 PM ET, Monday through Friday for the next two weeks at HealthcareNOW Radio. After that, you can listen on demand (See podcast information below.) Join the conversation on Twitter at #TheIncrementalist.
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Using Advanced Trauma Life Support Methodology in Population Health was originally published on Dr Nick – The Incrementalist
Navigating Healthcare - Patient Safety and Personal Healthcare Management 
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