Navigating Healthcare – Patient Safety and Personal Healthcare Management

How Good is BMI as a Health Indicator?

How do You Measure your Healthiness?

A recent conversation with my brother about Body Mass Index or BMI got me thinking about this data point and how we use it. Many of you are probably familiar with the value – it shows up on your weighing scales right after displaying your weight

Obesity BMI
Digital Weighing Scale

And if your scales don’t offer it you can always calculate your BMI with a multitude of online calculators (simply put weight divided height)

But there are some challenges with this simplistic value – not least of all the Obesity Paradox – the counterintuitive notion that obesity may be associated with longer survival.

Muscle Mass

A recent study published in PLOS One: Muscle mass, BMI, and mortality among adults in the United States: A population-based cohort study that delves into this deeper and offers some explanation of this counterintuitive notion that having a high BMI can be associated with longer survival. The results offered a clearer picture into our bodies and the relationship between these measures and our health status and long-term survival. There was lots to digest but this chart captured an essential point

Health
Risk of Mortality BMI and Muscle Mass

The Blue line represents people with “Preserved Muscle Mass” – in other words, those that have more muscle vs less. The Red Line for people who have lower muscle mass. I’m simplifying a complex detailed study a little but essentially but here goes

TL;dr: Healthier longer survival for people who sit in the middle range of BMI and have more muscle mass. For those with high or low BMI muscle mass has a positive impact on improving long-term survival

Listen in to find out the importance of Muscle Mass and what Incremental Steps you should be taking to improve your health

 

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How Good is BMI as a Health Indicator? was originally published on Dr Nick – The Incrementalist

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Future Failure Guaranteed in Healthcare

 Medical School Candidate Selection

MedEd Books Education books
Are we are selecting the wrong candidates for medical school and not teaching them the skills they really need to be good doctors?

I’m a doctor first – anytime anyone asks me what I do the first words out of my mouth are “I’m a Doctor”, followed by a follow-up explanation of my role today outside of day to day clinical medicine and the laying on of hands-on patients.

Many years ago I decided to give up my daily medical practice and it was a difficult decision. While I loved taking care of patients, I’d been beaten up in a system that pushed me to my limits and I did not like what I felt and saw in myself as I existed in a sleep-deprived haze courtesy of a 152-hour working week aka a 1 in 2.

I believed that the healthcare system was creating barriers for doing what patients really needed. And too much of my time was taken up with things that didn’t really matter. By moving into the world of technology and focusing on medical technology development, I hoped to create new tools that would improve our ability to help patients in the ways that they wanted to be helped.

My emotions about this move were conflicted, and I sought out a colleague who had been a mentor to me and shared my decision and mixed emotions about that decision. His response bewildered me.

“That’s terrible,” he said. “You never should have been allowed into medical school.”

From his point of view, the fact that a doctor was leaving the profession was not a sign that anything about the healthcare system needed to change. It just meant that the selection process for medical students was wrong and I was a flawed candidate that never should have been allowed to study medicine.

That unwillingness to examine the status quo is not uncommon in the world of medicine, especially when it comes to medical education. The current curriculum has changed very little over the past century. While science has been updated, the basic structure of medical education hasn’t changed. The daily practice of medicine, however, has changed. And it has changed a lot. Medical education isn’t preparing new doctors for the challenges they will face, and many of the skills they will need are never addressed during the four years of medical school.

But there is an even bigger problem with the medical education system: acceptance into medical school isn’t based on characteristics that are important in medical practice. We have become very focused on academic perfection and MCAT scores, with little consideration for the personality traits that lead to highly effective and compassionate physicians. We get lucky with many people, who have the academic performance and the needed personality traits, but we also train people who are not inherently suited to the practice of medicine or who have what compassion they had entering the system crushed out of them with debilitating academic testing with multiple choice questions systems. And we exacerbate the problem with a system that encourages isolation with a monstrous amount of academic study and rote learning. To excel or even survive the rigors of the system you diminish social interactions and limit them to others who are stuck in the same academic sinkhole.

We are failing to train medical students in the skills and thinking habits that make good doctors.

Recruit for compassion and intelligence, not academic perfection

The first step in getting this right is recruiting students who have more than academic skills. Perfection in academic performance is often accompanied by self-involvement verging on narcissism. To attain perfect grades in college, you have to have enormous discipline as well as intellectual ability. You also have to sacrifice time spent in other endeavors – experiences that might broaden your worldview and increase your sense of compassion. This intense focus on your own goals can create a sense that you are more important than others.

MedEd MedicalStudentID

I watch this first hand with my daughter, who makes me proud on a daily basis with her dedication and focus towards her goal – which she has had since the tender age of 5 – of getting into medical school and qualifying as a doctor. But every step towards medical school moves her inexorably away from the compassion and caring she has demonstrated on her journey thus far. Like her peers, she fears that if she doesn’t keep an intense focus on academics she will fail in her study of medicine. I know I want her as my physician but wonder if the obstacle course she must complete will change her beyond recognition.

Medical Education

 

Teach medical students skills, not just facts

Medical education is like drinking from a scientific fire hose. Few students retain more than about 50% of that data, and we neglect other skills that are more important. Doctors can instantly look up any medical fact they need so this attempted brain download of scientific detail isn’t necessary.

What isn’t taught is how to think about health, illness, and people. Medical students should be learning root-cause analysis and the ability to connect disparate pieces of data and understand the meaning. They need to learn data search skills, listening skills, problem-solving and how to be a continuous learner. They need to flex their compassion and objectivity muscles and learn the patience that will help them understand people who are different from themselves. And they need to learn leadership and how to work with others as in a team and as a team leader. These are the skills that are hard to acquire but are crucial to accurate diagnoses, more effective treatment decisions and effective management of chronic diseases.

The change is beginning

Medical schools are starting to respond to the need. In 2013, the American Medical Association gave $11 million in grants to medical schools that are developing flexible, competency-based pathways. They are making changes that will narrow the gap between how physicians are trained and how medicine is practiced. As of 2015, grants have been given to 32 medical schools, each with an innovative approach intended to prepare students for the real world of medical care. None of these programs are focused on the science of medicine, but rather the thinking, leadership and management skills needed to effectively use the science of medicine.

This is a great start, but there are 141 accredited medical schools in the U.S., and nearly 2,500 worldwide, many still using a curriculum developed more than a century ago. I hope the leaders of these schools are paying close attention to the innovations being tested under the AMA program. We all need them to do a better job of recruiting and training medical students who have the right stuff for the medical environment of this century, not the last.

Some Early Progress

The Dell UT Medical School which was funded in part with support from the Michael and Susan Dell Foundation and by a vote from local residents to increase their personal taxes to fund the development and ongoing management of this facility. They are trying a new funding model that gets rid of the conflict of interest that hamstrings many medical schools that are dependent on fee-for-service hospitals for revenue. The financial model will emphasize outcomes and cost-effective care overpayment for individual procedures and the medical school is taking a different approach to education while still encumbered by the need to meet the regulatory requirements to satisfy the medical education definitions and allow their students to compete on the current playing field for medical education the United States Medical Licensing System (USMLE) testing system

What do we need in Healthcare

More accurate diagnosis early in the disease process (12 million people annually are misdiagnosed, and about a quarter of those errors are life-threatening)

MedEd Costs

86% of healthcare spending in the U.S. was used to treat patients with one or more chronic conditions, and most of that goes for treating complications due to poor management.

Clinicians are under increasing stress and committing suicide at extraordinary rates (A systematic literature review of physician suicide shows that the suicide rate among physicians is 28 to 40 per 100,000, more than double that in the general population)

Incremental Steps to Improving Medical Education

  1. Let’s start by acknowledging the current system and trajectory is not matched to the requirements of our future doctors
  2. Find one element of the curriculum suited to a different method of teaching and change the approach. Match this with an approach to changing the testing methodology to match this more closely
  3. Enlist support to bring about change with the examining board, the clinical teachers and mentors and recently graduated doctors who can all provide relevant insights on the deficiencies of training in preparing for a medical career and what can and needs to be changed

 

Do you think I’m wrong – is our system well suited to the current requirements and just in need of some minor tuning? If I am right – what changes can we work on immediately to change the course and direction for the students now to bring about lasting improvements?

 

Future Failure Guaranteed in Healthcare was originally published on Dr Nick – The Incrementalist

Change Behavior, Change the World

Change Behavior, Change the World

The Incrementalist Graphic Adam Pelligrini

This week I am talking to Adam Pelligrini,(@adampelligrini) the General Manager and SVP for Fitbit Health Solutions. Adam has had a long career in the Digital Health coming from the Digital Health group for Walgreens Boots Alliance where he built a range of digital and mHealth platforms. He recently ran and hosted the highly successful FitBit Captivate conference where over 300 employers, health systems and health organizations from around the country gathered in Chicago to hear about the latest innovation in wearable personalized health technology. You can read more about it here.

The new digital space and innovations in wearables are an exploding and Adam shares his insights into what it takes to be successful in the wearable space. FitBit’s focus is on an open platform and incorporating behavioral change into the DNA of the company and these solutions have been instrumental in getting 6.8 Million people participating in population health programs with their devices!

Connecting Data Wearables

They found Incremental steps to getting people engaged in the United Healthcare Motion Program which was founded on the principle of connecting people to their data and making it simple. Their program was focused on simple small steps of  “FIT – Frequency, Intensity and Tenacity” that were tied to rewards back to the individual

 

 

Listen in to find out how they managed to record 6.5 Billion nights of sleep and added 2.9 Million participants to a new female health tracking feature with just native word of mouth!


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.


Listen along on HealthcareNowRadio or on SoundCloud

Change Behavior, Change the World was originally published on Dr Nick – The Incrementalist

Flu and Flu Vaccination

Flu and Flu Vaccination

Vaccine
Flu Season is Approaching

This week we are focusing on the Flu and the Flu Vaccination

What is the Flu

What is flu and how does it differ from a common cold. It’s a highly contagious viral illness that does not respond to antibiotics and changes every year and infects between 5-20% of the population every year and kills anywhere from 3000 to 49,000 each year and far worse worldwide based on a recent Lancet Study that estimates deaths up to 650,000 vs Previous 250-500k

In the US the uptake of the Flu vaccination is a little over 40% in adults and a little higher in children from 6 months – 17 years at around 59%

For anyone aged 6 months and older getting your flu vaccination or shot is the best thing you can do to prevent catching the flu this winter based on your own personal health status and not having any contraindications to receiving the flu shot. Getting your  shot also contributes to the “Community Immunity” – better known as Herd Immunity:

Herd Immunity
Why Community or Herd Immunity is Important

Listen in to find out why you need to get your flu vaccination each and every year and

 

Can I ask a favor – if you like the video, please subscribe to my channel, and if you don’t leave me your feedback/thoughts on how I can improve things?

Flu and Flu Vaccination was originally published on Dr Nick – The Incrementalist

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Sleep – The Foundation of Health

Sleep The Wonder Drug

Sleep, Insomnia
Sleep is a Wonder Drug

This week I am focusing on sleep – a hot topic given the recent tweets from Eric Topol

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and

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In fact, the value of sleep is well understood – just poorly implemented

 

Good news there’s been an AMAZING BREAKTHROUGH! Scientists have discovered a revolutionary new treatment that makes you live longer. It enhances your memory and makes you more creative. It makes you look more attractive. It keeps you slim and lowers food cravings. It protects you from cancer and dementia. It wards off colds and the flu. It lowers your risk of heart attacks and stroke, not to mention diabetes. You’ll even feel happier, less depressed, and less anxious. Are you interested?

The above quote is from Matthew Walker (@sleepDiplomat)- researcher and Author of the excellent book “Why We Sleep”. Essential reading for anyone wanting to deep dive into what we know about sleep and its incredible positive effect on our health and brains.

The science is in and the benefits of sleep are clear so how do you get yours.

Incremental Steps to Sleep

How do you get into the habit and routine of getting a great nights sleep each and every night? Some of the highlights include:

Temperature
Habit/Routine
Light – dark quiet rooms
Say no to Drugs and Alcohol – not the right kind of sleep anyway

Here are my thoughts on Sleep Hygiene – you can also see more here “12 Sleep Hygiene Practices

 

 

Sleep – The Foundation of Health was originally published on Dr Nick – The Incrementalist

Mindfulness and Meditation

Stress
Mindfulness and Meditation

This week we are focusing on mindfulness and meditation and why it is important for your health. People that include mindfulness and meditation in their daily routing find they are better able to deal with pain, have improved immunity, sleep better, lower their blood pressure and have less inflammation.

What are the Incremental steps to get you into a regular habit of mindfulness and meditation – the first step is to find what works for you. What’s the best time and where is the best place that works for you? Once you have decided where and when, like most other incremental steps it requires you to take that first step. It can be hard and one of the important things is to understand that you don’t have to do it for very long – even a few seconds can be helpful and then work up to longer times.

There are a range of apps you can download to help you start including some great free apps and I talk about some of those choices and options
Here are 5 free apps you can download that can help you get started

Can I ask a favor – if you like the video, please subscribe to my channel, and if you don’t leave me your feedback/thoughts on how I can improve things

Mindfulness and Meditation was originally published on Dr Nick – The Incrementalist

Getting into the Exercise Habit

Exercise Routine

In this weeks video I discuss getting into the habit of exercise

Getting into a regular routine for exercise is the first step to making this part of everyday activity. How do you do that – the first step like most other incremental steps is to start. It can be hard and one of the important things is not to seek to do too much initially. If you can only get 5 minutes of exercise, get that. Once that’s a regular event and you are finding that easier, extend the time and distance to 10 minutes, 15 minutes and keep adding.

As for locations outside is always a good place to start but if that’s not ideal you can always try and find a gym, buy some cardio equipment maybe a second hand one or find a nearby mall to start your exercise program.
It can be hard to start but the most important thing is to start – if you can find a friend and start together, company always helps and if someone is expecting you it helps to keep you showing up every day.
Here are some simple suggestions for starting an exercise program

 

 

 

 

Getting into the Exercise Habit was originally published on Dr Nick – The Incrementalist

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

May the Fourth be With You

It’s the artificial holiday that celebrates the play on words from Star Wars movies – a rallying cry

The list of suggested actions from the Starwars site may not be to everyone’s taste and includes everything from

  • Holding movie marathons
  • Dress up as a Star Wars Character
  • Star wars food including blue milk!
  • Getting a Star Wars Tattoo

 

But this year I follow Yoda’s advice:

“Pass on what you have learned”

Specialty Pharmacy

This year I attended the Asembia Specialty Pharmacy Summit held this time each year in Vegas at the Wynn/Encore resort. This is the largest conference for specialty pharmacy but as Alex Fine noted and I agreed –

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All pharmacy is moving rapidly in the direction of specialty as we head into a world filled with precision medicine customized to the individual. On the one hand, this is an exciting proposition – at least to me. I am always reminded of the great scene in Monty Python’s Life of Brian

You are all individuals…..we are but medicine has not treated us that way. Historically the path to understanding disease was based on grouping patients, diseases, signs, and symptoms into logical groups that helped decode underlying cases of a disease.Just think of the seminal work of Louis Pasteur and Robert Koch who established the germ theory of disease and the resulting incredible advance in outcomes that derived from that block of work when Joseph Lister published in 1867 his Antiseptic Principle of the Practice of Surgery (met by substantial skepticism and took years to be widely accepted and adopted). This was just the start as we came to understand causative agents behind diseases that had vexed the profession. Treating someone with an infection with Penicillin thanks to Alexander Fleming’s work in 1928 was just one of many advances that grouped patients based on similarities of their disease. This methodology has served us well but the sequencing of the human genome- completed in Jun 2000 would have a big impact on this thinking.

Just think of the seminal work of Louis Pasteur and Robert Koch who established the germ theory of disease and the resulting incredible advance in outcomes that derived from that block of work when Joseph Lister published in 1867 his Antiseptic Principle of the Practice of Surgery (met by substantial skepticism and took years to be widely accepted and adopted).

This was just the start as we came to understand causative agents behind diseases that had vexed the profession. Treating someone with an infection with Penicillin thanks to Alexander Fleming’s work in 1928 was just one of many advances that grouped patients based on similarities of their disease. This methodology has served us well but the sequencing of the human genome- completed in Jun 2000 would have a big impact on this thinking.

From: http://sandwalk.blogspot.com/2016/02/happy-birthday-human-genome-sequence.html

Over the course of the last few years, we have seen a clear move towards the individualized understanding of patients and disease accompanied by the inclusion of patients (Patient Engagement).

Patient Engagement and Access

There was a clear theme in the messages from various presenters that offered a clear vision of the push towards the consumer and patient engagement and a clear desire to find a path to delivering access to everyone that was captured by Liz Barrett from Pfizer in her keynote presentation and summarized with her slide – The 4 Tenets for Healthcare:

Access to quality
Incentives
Long-Term Value
Competitive principles

Providing access that overcomes the current challenges but builds in incentives for everyone in the system – not just the providers and hospitals but also patients and everyone involved in healthcare. This is the principle of competition without which systems tend to decline and ultimately stop working. There are people who perceive competition and capital principles as contraindicated in healthcare that we want to provide to everyone. I think these ideals can and should co-exist – without competition motivation disappears and efficiency will decline.

To achieve this we should take a book out of Yoda’s wisdom to pass on this wisdom and my key message for this day. Benefiting from the extended community. Our ability to connect and access people and resources has never been better. The need to remember data is much reduced:

GIYF

This access goes far beyond the data and to people and resources. Can you imagine making a purchase without looking at ratings and reviews on sites – I can’t. Yet the reviews are from people I don’t know and have not met – yet I trust them. This works because of the human desire to help others (this, by the way, is the reason that social engineering as carried out by hackers is so successful – this will be the subject of a post coming up in the future). But this creates an incredible set of resources and talent available to you.

Patient Communities

Some of it is formalized like the early website entry in this area: Patients Like Me. But extends to informal interactions on social media channels like facebook and one of my favorite: Paying till it Hurts. Then there is your extended family and friends who all want to help. You will find people who have been through similar experiences, will have tips and ideas on how to deal with problems that others have faced and have conquered

I was lucky to hear Arnold Schwarzenegger present as the keynote at this recent conference – his recurring theme was that he was not a self-made man but his success was the result of all the help and support he received from others

So use the power of the Force – it is your network, your friends, family and those around you.

Derive strength from them, have them provide tips on what small changes you can make to improve your health and then help keep you on track – nothing like knowing that you are being watched to help keep you on track.

One of my most successful personal health drives was base don a weekly self-reported weigh in for myself and two colleagues. Anytime I felt I was going to make a poor choice on food or exercise I just thought of the weekly chart and where my line would be relative to my colleagues and I did not want to be the outlier.

Have you had success helping friends and family? What works and what doesn’t. Is there a special trick or insight you could share that might help someone else – share it now and help the community.

 

May the Fourth be With You was originally published on Dr Nick – The Incrementalist

Patient Centered Systems

What will it take to move our healthcare system to a truly patient-centered system? We know based on multiple data points that engaged patients have a big impact on the successful outcome of treatment. Leonard Kish cited the phrase back in 2012

Patient Engagement is the Blockbuster Drug of the Century

Referencing a 2009 Kaiser study of coordinated cardiac care and comparing to those not enrolled in the study

“patients have an 88 percent reduced risk of dying of a cardiac-related cause when enrolled within 90 days of a heart attack, compared to those not in the program.”

“clinical care teams reduced overall mortality by 76 percent and cardiac mortality by 73 percent.”

And this study in Telemedicine and e-Health. Dec 2008; Vol.14 (10): 1118-1126 that showed impressive results for chronic disease management:

  • 19.74% reduction in hospital admissions
  • 25.31% reduction in bed days of care
  • 86% patient satisfaction
  • $1,600 average cost per patient per year, compared to $13,121 for primary care and $77,745 for nursing home care
  • 20% to 57% reduction in the need to be treated for the chronic diseases studied, including diabetes, COPD, heart failure, PTSD, and depression

 

Patient Data Ownership

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 and allowing them access and control 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. Perhaps what we need are some independent services and providers who aggregate, manage, secure and maintain patient data on behalf of patients – much as banks do with our money. There was some hope when Google and Microsoft jumped into healthcare offering Google Health and Microsoft Health Vault respectively. Microsoft’s version continues to this day – google withdrew theirs and Sergey Brin was widely quoted when he said

“Generally, health is just so heavily regulated. It’s just a painful business to be in, I think the regulatory burden in the US is so high that think it would dissuade a lot of entrepreneurs.”

But while complex, not insurmountable and as he rightly points out

“I am really excited about the possibility of data also, to improve health”

I am too and while there remain many challenges associated with securing and sharing that data the “entrance” of these alternative participants into the healthcare space – some perhaps looking at this from a simple employee perspective, is an opportunity for new ideas, insights, and people applying the collective brain power to one of our most pressing problems. I continue to hear from colleagues and friends of companies that are exploring and looking at healthcare. UPS highlighted their healthcare focus and the potential for 3-D printing in a recent tweet:

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And I heard from a friend that Dyson even has a healthcare “focus”.

Protecting Patients

There are some major concerns as these data-focused companies offer access but do so with agreements that contain so much legalese as to be unintelligible and opaque to the consumer who may well be giving up much more than his own personal data but potentially giving up his future health. The GINA act offers some protection to individuals who in sharing personal genomic data that tag them with a “pre-existing’ condition could have found themselves unable to access care. But the act did not go far enough failing to address the issue of other insurance and employers who can use this data to deny access or coverage and perhaps even employment?

We need the combined power of this patient data to create the insights into diseases but not at that personal expense. There are many technologies on the horizon that offer a potential path to help achieve this and blockchain represents an interesting innovation of decentralized secured data that offers individualized control and dynamic revocation options for access. If you are interested in learning more about Blockchain this article in HealthcareIt News is a good primer for its potential in Healthcare: How does blockchain actually work for healthcare?. It is not a panacea and the fundamental rights and ownership still need to be addressed without giving away the farm to corporations and businesses.

Interoperability

The existing healthcare system incentivizes behavior that is in opposition to a scalable nationwide vendor neutral interoperable patient-centered data. Our model has multiple groups who have a vested interest in the control and ownership of data (for example Payers, Providers, Patients and even employers). Each has their own economic and commercial drivers and in many instances, these do not coincide with 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 key to a patient-centered interconnected care model is the free flow of data between all the areas 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 care and care coordination to a distributed team-based model of care that encompasses multiple areas and people. In some instances, thatcher coordination may be carried out, at least in part by the patient or their family members, and they need to be included and ultimately in control of the data and its flow. 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

Welcome to the Fray

I am a big fan of learning from other industries and perspectives and spoke about this at HIMSS Conference in Orlando

The Best Exotic Marigold Hotel and I am excited to see the rush of companies and people into the healthcare space but for those stepping in and thinking about data and the ownership and control of this data, I would suggest this requires a new way of thinking. Much like security – patient access and control needs to be baked in from the start. Taking ownership and rights away from patients will stall progress and anger your constituents and community. As ePatient Dave would say or better yet sing:

Give me My Damn Data

Here’s hoping that these new players see the value of the engaged patient and include some of these principles in their march towards our common goal of better more cost effective healthcare. For the large organizations thinking about the data, remember you and your family members are patients too. The following thoughts are offered as some basic guiding principles on data stewardship:

  • Patients want control of their own data,
  • Patients want to be able to share safely and securely share their data with all their care providers and participants (this will include family members and friends)
  • Patients want granular control of some elements of the data limiting individual access to certain elements and areas
  • Patients requires a full audit capability tracking who has access and has accessed their data
  • Patients want to be able to easily and dynamically revoke access
  • Patients will share their data for research and benefit of others but their contributions need to be recognized and accounted for
  • Data cannot be used against Patients to deny coverage or increase their costs

 

What have I missed – what controls or limits would you place on your data that would make you more willing to share your data. What would stop you from sharing your data and why?

 

 

Patient Centered Systems was originally published on Dr Nick – The Incrementalist