The Emergency Department at Parkland Memorial Hospital has installed computerized kiosks allowing patients to input their data at check-in kiosks. These were designed to be visually navigable and take precious nursing time out of checking people in; focusing them instead on delivering care to those who most urgently need it. And, patients get to stop waiting in line. Sounds great at first glance. But it gets even better
Certain ailments, combined with information like the person’s age, are immediately flagged. Monitors in the nurses’ station keep a tally of who is waiting, and blinking dots cue them to people who should be seen right away – like an older person with chest pains, for example.
It looks like the triage equipment incorporates clinical flags using software. This is great if you think about the need to move on certain symptoms quickly– like with new guidelines or a clinical trial. It is already capturing more data, that can be used to better understand what happens to people entering the emergency department.
Parkland is already using the new data to analyze how long people have to wait for care. A patient’s record previously didn’t start until he or she made it through the first line. Now, that record starts almost immediately.
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Newspapers today, including the WSJ and its blog, showed headlines that suggested financial incentives from Medicare Pay for Performance had little impact.
When looking past the headlines, however, a different picture emerges–a study with small financial incentives and strong confounding factors is unlikely to tell you anything.
Compliance rose to 94.2% from 87% at the pay-for-performance hospitals. At the others, compliance also rose, to 93.6% from 88%. Researchers found a “slightly higher rate of improvement for 2 of 6 targeted therapies” but concluded that “overall, there was no evidence that improvements in in-hospital mortality were incrementally greater at pay-for-performance sites.”
Dr. Peterson also noted that all of the 500 hospitals evaluated had separately volunteered to be part of an initiative to improve heart-attack treatment to comport with treatment guidelines of the American College of Cardiology and the American Heart Association. He said the fact that the hospitals had volunteered could have improved results in the hospitals that weren’t pay-for-performance.
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The NYtimes highlights an overlooked issue in the health reform debate: HOW we spend money is more important than WHO spends the money in taming the health care beast.
This article focuses on the wild and wooly world of spinal fusion…an unclear fix to lower back pain that runs the system somewhere on the order of $50,000 dollars a pop. Medicare spends $600M a year on it…and we don’t know that it works to fix back pain.
Hmmm…frightening indeed. The article also sites the Dartmouth atlas, a wonderful resource in analyzing physician variation, which shows a 20X variation in the procedure between the US cities with the highest and lowest incidence of spinal fusion surgery. Sadly enough, no one to this point can definitively prove that spinal fusion works better for back pain than time, acupuncture, chiropractic, or any other treatment that people use out there.
What is a more reliable predictor of how many surgeries for back pain are performed are the number of surgeons performing spinal fusions in an area…again that 50K/pop isn’t so bad and a surgeon certainly isn’t going to send you to an acupuncturist.
If a consumer’s asked to pay the 50K, I’m sure you’ll find them shopping for options…
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There’s a new test that takes a somewhat obvious approach to fertility testing: it takes two to tango. The NYTimes reports that Fertell combines tests for both men and women, allowing a couple to perform the tests from the privacy and convenience of their own home.
From a consumer-focused lens (this is, after all, what this blog is about), this makes a lot of sense, as having one partner drag the other to a doctor’s office multiple times is a real hassle. Instead, it provides a quick and dirty read into common problems, especially with the men’s reproductive system.
The test results could give couples early warning that they should see a doctor, Dr. Fisch said. “Couples often don’t appreciate this,” he said. “So many times the woman goes through all these tests, and the guy doesn’t even have a semen analysis.”
At-home testing that expands options for busy couples to investigate potential medical issues seems to create value for consumers.
Thomas Goetz makes a plea for use of an open-source platform to encourage adoption of Electronic Medical Records in an op-ed to the NYTimes.
GO into almost any medical office, hospital or clinic in the United States and your records will still be handled the old-fashioned way — on paper. You can use a computer to pay your taxes, to program your TiVo or to read a message from your great-aunt, but your doctor has to practically level a forest just to examine your medical files. The cost, however, isn’t calculated in trees but in human lives: Electronic medical records would reduce the risk of medical errors and spare hospitals the expense of missing records and unnecessary treatment.
While compelling and better for medical practice, unfortunately, a lower cost EMR is not the answer that will cause doctors to leap into the electronic age. Why? If you look at the market, physicians have responded pretty well to hard science and to financial incentives (see use of injectibles with changes in reimbursement).
The hard truth is that EMRs are tough to implement, as most docs don’t know how to optimize their process and face financial disincentives from using them.
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Barack Obama today released the details of his plan for reforming health care. Per the NYTimes he’s focusing on using money from the expiration of Bush’s tax cuts on high earners and instead using this to bolster employer-based insurance and take on catastrophic illness.
I hadn’t previously heard a proposal for the federal government to focus on catastrophic care/ sick pools, so this is an interesting approach. However, as 20% of care recipients generate 80% of the health care expenditures, it would seem that Obama’s approach to funding this proposal seem a bit meager. If he was looking to put real funding behind it, this plan could have some teeth, and address the major issues behind individual insurance. Of course, it might make the need for individual insurance itself go away, and we’d have a hybrid HSA/ govt catastrophic care system.
While one would expect that insurance would become much more affordable if the government stepped in for catastrophic care, I’m not sure that society can afford the ensuing budgetary implications. Government policies would drive care for all significant illnesses, much as is done in the UK. Policies (always slow to adjust) would become driven by bureaucrats in the federal space. Companies would lobby heavily to get on formulary. All-in-all, it looks like it could do wonders for affordability, but at the cost of squashing freedom of choice through a top-down, highly regulated, infrastructure.
Thoughts?
Can I tell you how much I detest the BMI as a metric for monitoring an individual’s levels of fat? It really equates to a statistical chart for insurance companies that does a simple calculation based on height and weight and spits out a number.
Unfortunately for consumers, that number really doesn’t tell you anything. Weight consists of a couple of factors: Lean body mass (including water) and fat (not water soluble). Knowing what percent of your body weight is fat (and its distribution) can be really useful information. Having a number solely based on weight is extremely misleading (to individuals, as BMI was made for populations) especially to track progress from a new diet and exercise plan.
In med school, I was horrified when a patient had come to tell us her story of getting a gastric bypass operation when her diet and exercise program “didn’t work” because she was losing inches, but not pounds (i.e., she was lifting weights, gaining muscle, and losing fat…the best outcome you can get from starting an exercise program).
The WSJ has an article this week on new ways for consumers to measure their body fat. All may at some point be coming to a weight-loss clinic near you…
Secretary Leavitt made some interesting comments reported in the Washington Post around living wills and the potential for cost savings.
“It may be that we could build into Medicare a means by which there was a consultation as part of the Medicare physical where that decision could be discussed and potentially made and . . . it would not just save families anguish but would likely save the system a remarkable amount of money, allowing that money to be spent in other ways and in other places,” he said, according to a transcript by the Associated Press. Leavitt said the idea was suggested to him by a member of Congress.
Although the potential for cost savings is disputed later in the article, the comment is interesting in that it highlights the gaps around paying for diseases that come up and working with decisions made in the heat of the moment, vs. contemplating what is really important ahead of time. Not only is this important with end of life, but eventually, I believe that catastrophic insurance will become more affordable as well…as people decide where they want to invest in insurance and where they prefer to invest that money in other things.
Has anyone done a study on the proportion of “rescue” care vs. investment in everyday care? I know from experience that the medical system is focused highly on a rescue reflex…and that society would be much better off if resources were invested in the process of improving health earlier on.
A NYTimes article highlights that the FDA reaffirmed its stance on a lifetime ban on gay men as blood donors, a policy it has kept since the 1980′s. While the AIDS epidemic and poor quality of testing made that policy make sense from a public health perspective, the heavy-handed nature of the decision makes much less sense today.
In March 2006, the Red Cross, the international blood association AABB and America’s Blood Centers proposed replacing the lifetime ban with a one-year deferral after male-to-male sexual contact. New and improved tests, which can detect H.I.V.-positive donors within 10 to 21 days of infection, make the lifetime ban unnecessary, the blood groups told the F.D.A.
In a document posted Wednesday, the drug agency said it would change its policy if it received data proving that doing so would not pose a “significant and preventable” risk to blood recipients.
The agency said the H.I.V. tests now in use were highly accurate, but still could not detect the virus 100 percent of the time.
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The NYTimes highlighted the impact publication of all trial data could have on drug makers. Its good to see transparency starting to have some impact, although some of the immediate backlash against drugs like Avandia may decrease the moves companies are making toward transparency. I do find the simple nature of the response to be somewhat frightening…in an era of personalized information, the world of medicine has one uniform response to data that affected ~1% of the patients under treatment.
This highlights three issues with the way pharmaceutical information is distributed today:
1) Most studies are never reported (lack of proof of efficacy doesn’t make headlines)
2) Most results are against placebo vs. head to head. We really don’t have much proof that any one drug is better than any other drug in its class, as most trials compare different populations.
3) Results reported tend to be expressed as a relative factor vs. absolute. For instance, where a drug prevents 1 heart attack in 100 people (where 2 is the baseline), it sounds much cooler to say 50% reduction in heart attacks vs. 1% of the study population was saved from heart attack.
Overall, it highlights how far away medicine is from 1) making information transparent, and then 2) applying what we know to optimize outcomes for each individual.
