Mark Dimor

Notes & Links: August 2, 2013

Read the Fine Print Before You Burn Your Obamacare Card

A guest post by Aaron Carroll on The Incidental Economist speaks to the conservative organizations pushing young adults to skip joining ACA and pay the penalty.

People pushing young adults to skip the exchanges aren’t saying, “Don’t enroll now… but hey, if you get sick in a few months, we’ll understand if you have a change of heart.” They’re saying, “Don’t enroll now; pay the penalty instead. And if you fall ill, or become pregnant, or get stabbed while doing a good deed and you can’t buy a plan, well, them’s the breaks. That’s the gamble we asked of you.”

Some of these young adults must have seen their parents loose jobs, loose coverage, loose their homes, and life without healthcare coverage. I would think that is enough motivation to want healthcare insurance. It would be for me. I know when I had a bunch of employees working for me I made sure healthcare insurance was offered at a great price and for many many years with no employee contribution. I believed in its value. Hopefully these young adults see the value as well. We’ll know soon enough.

Countdown to The Physician Sunshine Act: Gloomy Days Ahead

Jonathan Govette posting on HealthWorks Collective speaks to the Sunshine Acts and its August 1, 2013 start of data collection. The title kind of says it all about his position and attitude. And the site is sponsored by Siemens a medical device manufacturer.

So basically every doctor in the country will now have to report his private financial information to the world. Seems like this is a complete waste of time and will cause more harm than good.

I would agree about flashing personal income all over the web. But these are payments that have been well documented and associated with prescribing and often not associated with evidence based medicine or the best Rx for that patient. Patients and colleagues should know what the financial association with pharma or device manufactures are. That’s why they call it transparency.

Sunlight as Disinfectant

Professor Meredith Rosenthal Ph.D. and Michelle Mello, J.D., Ph.D writing in the NEJM have a much better and more salient review of the Sunshine Act and its benefits vs. the problems. They capture two key point here:

Disclosure rules aim to influence the behavior of both the subjects of reporting and those making decisions about whether to do business with them. Thus, one mechanism through which the Sunshine Act could reduce health care costs is that patients, having learned of a physician’s involvement with industry, might alter their view of the physician’s trustworthiness. They might be less inclined to accept treatment recommendations from these physicians or even to receive care from them. Given the evidence that greater physician financial involvement with manufacturers is associated with higher utilization of expensive, brand-name products, such dynamics could reduce costs.

Experience gives reason for skepticism about the potential force of patients’ response to disclosures, however. Decades of public reporting of provider quality information have underscored the difficulty of engaging consumers in seeking even the most salient information about their providers, such as a cardiothoracic surgeon’s predicted mortality rate, from a passive report.3Consumers are typically unaware of these data and, even when they know about them, tend to choose their providers on the basis of other factors. The payment data are also complex, and even with the educational information CMS plans to provide, patients may have difficulty evaluating the undesirable and beneficial aspects of various types of payments.

Read both articles and see which one rings as a true well balanced examination of the Sunshine Act and which one is grinding a whinny ax?

Spike Lee Shares His NYU Teaching List of 87 Essential Films Every Aspiring Director Should See

Thanks to Doc Searls for this link. I would love to be an aspiring director but I am more of a film freak so I wanted to see what was on his list. I’ve seen 62 of the 87 and need to revisit most of them (memory sucks) besides what I haven’t seen. Guess me and Netflix will be busy this year.

You Don’t Have To Be A Data GeekTo Love Consumer Health Devices—But It Helps

David Shaywitz writing on Forbes.com writing about capturing health data from phones, devices, and apps. I think for some of us he captures what and why for these devices

In other words, my gadgets don’t provide essential information I couldn’t get elsewhere, but they motivate me to pursue and sustain activities I might otherwise avoid – like regularly checking my blood pressure, or finding time for a run. They facilitate data sharing, whether with my doctor, as I’ve described, or with friends and family who can offer encouragement and motivation

I agree because on my bike I have a HR monitor and a computer to capture speed, cadence, max and average speed. I just love the data and comparing one ride to another. I no longer make a spread sheet with it. Maybe I will start again. But the bigger question is who are the others that capture data? What do they do with it? Do they share it with their physician? To what end?

We need to know more about the new world of consumer data.

Hamptonites Are All Smiles Over Newest House Call

For the fee of $999, more than double what it costs for services in their office, the husband-and-wife dental team of Dr. Jeffrey Rappaport and Dr. Michelle Katz will perform professional teeth whitening in the comfort of a client’s living room.

The only thing that comes to mind here is “Qu’ils mangent de la brioche“. But we live in a free market for some.

Notes & Links: October 1, 2013

Is Your Hospital Website Costing You Revenue?
Nicola Ziady posting at HealthWorks Collective points out that 8 out of 10 consumers are visiting hospital websites but 90% are going somewhere else making an appointment. The reasons for this are:

Competition
Confusion
Dissatisfaction

The lead in to the dissatisfaction bullets is the statement that “8 out of 10 Prospective patient will visit your website before converting.”

I shared this with a good and wicked smart colleague Scott. His thoughts on this were:

Since it is impossible that 83% of hospital patients are going in for elective reasons where they could choose, and the primary driver is physician privileges at a particular institution, the reason consumers are visiting hospital websites before converting into patients has to be to fill out paperwork, or gain more information about what to expect – not to choose a hospital.

I agree with that and I would add that conversion is the wrong goal. The goal for the hospital especially going forward is improving outcomes since that is what and where they will be competing. The forward facing message for a hospital to patients should be to continually engaged with them so they learn, improve self care, and drive improved outcomes. I would look at improving expanding retaining and showing GREAT outcomes from current patients. Current patients are where your message to new patients should come from.

Remember hospitals have spent millions to buy physicians practices. Half the patients in those physician practices do not need hospital care. And when they do since that MD is an attending w/privileges will get them. My goal would be to get current patients engaged w/the hospital as a healthcare knowledge provider because that meta data from those active and engaged patients I am currently treating will inspire conversion. Make sense?

Patient Engagement, Negaclaims Can Rehabilitate Health Insurance
Dave Chase a contributor to Forbes has a deep dive on cost for care and patient engagement and how HCP are ‘selling’ care in the fee for service model. Chase introduces the concept of Negaclaim which is TM’d. And what is that? It is when patients are fully educated on trade-offs with interventions and they choose the less invasive approach which is generally less expensive. Chase lists a number of examples showing the benefit of curbing unnecessary care while improving patient experience.

Direct Primary Care
High Cost Procedures
End of Life

Clearly incentives driven by a flawed reimbursement system is driving waste in spending. And another confounding factor are health insurance providers. Most people consider them the Darth Vader of healthcare. Most people consider health insurers to only want to deny deny deny. They need to fix that image.

Chase ends on a topic near and dear to me.

Leonard Kish made the case that if patient engagement was a drug, it would eclipse all blockbuster drugs before it.

Chase offers this interesting insight. Insurers should stop denying claims and invest in getting customers to engage in healthcare and with their physicians because these customers would self-deny their own claims.

As I said this is deep dive but rewarding in that Chase is looking at the value of patient engagement not only it being the new black in healthcare.

The issue is summed up nicely in an AP story by Marilynn Marchione:
Obese people are less likely to survive cancer, and one reason may be a surprising inequality: The overweight are undertreated.

Doctors often short them on chemotherapy by not basing the dose on size, as they should. They use ideal weight or cap the dose out of fear about how much treatment an obese patient can bear. Yet research shows that bigger people handle chemo better than smaller people do.

Even a little less chemo can mean worse odds of survival, and studies suggest that as many as 40 percent of obese cancer patients have been getting less than 85 percent of the right dose for their size.

Now, the largest organization of doctors who treat cancer, the American Society of Clinical Oncology, aims to change that. The group has adopted guidelines urging full, weight-based doses for the obese.

Orac presents a lot of data and logic on why clinical oncologist may feel it is necessary to dial back dosing for obese patients with comorbidities etc. Further there is some great information where in healthy weight patients dose reduction was 9% to 37% in obese patients. This was from a study in 2005 Jennifer Griggs, MD from University of Michigan. And from that study this finding:

Interestingly, Griggs also found that severe obesity was actually associated with a lower likelihood of being admitted for febrile neutropenia (fever with a low white blood cell count, indicating potential infection in an immunosuppressed patient), was actually less common (odds ratio, 0.61; 95% confidence interval, 0.38-0.97) in the severely obese even in patients who received full dose, and there was a trend towards less admissions for febrile neutropenia associated with increasing body mass index that only became statistically significant at a BMI ≥ 35.

There is a considerable amount of data here which is well presented and documented. It is a great place to continue your education on weight and chemo.

Dermatology Smartphone Apps No Substitute for Doctor’s Visit
Bill Crounse posting on Healthworks Collective gives us some solid advice which comes on the heels of the FDA guidance for medical apps. I would give you a link to it but since those morons in Congress shut down the government in order to ensure only the privileged have healthcare the FDA site is working like crap.

Crounse makes the case for seeing a trained dermatologist and not leaving possible life and death decisions to an app. He has cred having been diagnosed with three of the most common types of skin cancer, basal cell, squamous cell, and melanoma. His melanoma was caught early and he was cured.

Researchers tested four different smartphone skin cancer apps. One of the apps sends photos to board certified dermatologists for review. In the research study, that particular app was, as you might expect, quite good. It missed diagnosing just one of 53 pictures of melanoma that were used to test its accuracy. However, taken together the accuracy of all four smartphone apps was determined to be just 33 to 42 percent.

His primary point is that a smartphone app should not replace a trained dermatologist. I concur because I am reminded of a comment at a dermatology advisory board I ran with some nationally KOLs. One physician chair of her department said that when they are offering residents and fellows a position they have found those with an interest or background in art are better at diagnosis since their eyes are well trained and tuned by an art background. When you think about that it rings true. The majority of dermatology diagnosis is based on visual not lab values or listening to the heart or an MRI. I would not trust me to look at an app and my skin and say nah that is not that. Would you?

Cancer Chemotherapy and Obesity
Orac writing on ScienceBlogs takes a long hard well balance look at this recent mainstream press topic of obese patient and cancer chemotherapy.

The topic is straight forward enough most chemotherapy is dosed based on weight and obese patient are not always getting full weight-based doses.

The issue is summed up nicely in an AP story by Marilynn Marchione:
Obese people are less likely to survive cancer, and one reason may be a surprising inequality: The overweight are undertreated.

Doctors often short them on chemotherapy by not basing the dose on size, as they should. They use ideal weight or cap the dose out of fear about how much treatment an obese patient can bear. Yet research shows that bigger people handle chemo better than smaller people do.

Even a little less chemo can mean worse odds of survival, and studies suggest that as many as 40 percent of obese cancer patients have been getting less than 85 percent of the right dose for their size.

Now, the largest organization of doctors who treat cancer, the American Society of Clinical Oncology, aims to change that. The group has adopted guidelines urging full, weight-based doses for the obese.

Interestingly, Griggs also found that severe obesity was actually associated with a lower likelihood of being admitted for febrile neutropenia (fever with a low white blood cell count, indicating potential infection in an immunosuppressed patient), was actually less common (odds ratio, 0.61; 95% confidence interval, 0.38-0.97) in the severely obese even in patients who received full dose, and there was a trend towards less admissions for febrile neutropenia associated with increasing body mass index that only became statistically significant at a BMI ≥ 35.

There is a considerable amount of data here which is well presented and documented. It is a great place to continue your education on weight and chemo.

Notes & Links: September 27, 2013

A Field Test of Web-Based Screening for Dry Eye Disease to Enhance Awareness of Eye Problems Among General Internet Users A Latent Strategy to Promote Health.
File this under ‘It Didn’t Take That Long”. Kawashima, Uchino, Kawazoe, et. al publishing in JMIR demonstrate that we are now seeing the Internet and Web 2.0 mimicking what we’ve come to love on TV the shilling of diseases to promote either a product or service.

The Web site they reference is for self-checking by consumers/patients to draw attention to dry eye disease through the use of a questionnaire and identifying those with a higher risk. Dry eye exists.

The increasing prevalence of dry eye disease worldwide is an important public health problem, especially in developed countries with advanced information technology and those with an aging population. In Japan, the incidence rates of dry eye disease are almost 22% and are over 10% in female and male computer users, respectively, implying that the country has more than 24 million affected individuals. One reason for the rapid rise in the number of cases of dry eye disease over the last few years is thought to be prolonged visual display terminal (VDT) exposure because of increased computer use. VDT exposure is also becoming common in the general population because of the widespread use of mobile technology and portable information terminals, especially smartphones, among all age groups. The number of Internet users worldwide has doubled in the past 5 years. Japan had approximately 94 million Internet users in 2010, representing 78.2% of the Japanese population

The study had two parts. First, a Web based survey with self screening on dry eye symptoms. The second phase was the measurement of tear secretion and physical survey with lifestyle questionnaire. The second part was directed at those respondents with subjective dry eye symptoms based on part one.

Here are the principle results:

In this study, a Web-based self-screening questionnaire was used to draw attention to dry eye disease among general Internet users and identify those at higher risk. Of the 1689 visitors to the survey website, 58.0% (980/1689) completed the first phase of the study, 36.2% (355/980) had five or more dry eye symptoms, 27.9% (99/355) completed the second phase of the study, and 32.3% (32/99) had tear production of ≤5 mm. This self-screening tool therefore identified a few individuals with probable dry eye disease. We speculate that a high number of general Internet users have latent dry eye symptomatology

A couple of points to note. The authors say they have not identified what factors encourage people with probable dry eye to seek medical help. Second, the study was organized by Carepro, Inc. which offers a convenience for commuters at Yokohama Station for just $6.50. Anyone can be tested for dry eyes, bone density, or lung function.

I am at sixes and sevens over this because the Web based survey to drive patients to a physical exam smacks of creating a disease to drive revenue. At the same time offering commuters a place to have examines performed while on their way home or to work seems valuable. What is that balance and how can we achieve it?

Physicians care about patients and money, ctd.
Austin Frakat writing in The Incidental Economist examines a reanalysis of data from study published in 2011 “How payment systems affect physicians’ provision behavior–An experimental investigation” Frakat first look at this is here

In the reanalysis the author states:

We find that most subjects attach a positive weight to patients’ health and, further, we observe substantial heterogeneity in the degrees of physician altruism. Our results indicate that some subjects attach a higher value to their own profit than to the patient benefit (26%), while others either attach equal weights to profit and health benefit (29%) or put an even higher weight on the patient (44%).

Frakat captures best what this means here: (I added the bold.)

The model that the doctor always and only cares about what’s best for the patient is old fashioned and, frankly, dangerous. Even if and when it’s true, patients would be better served if they played a more active role in their own care. Don’t presume your doctor’s values and incentives are aligned with your own. Ask questions. Do research. Behave like the consumer you should be. It’s your body, health, and life. And, if your doctor isn’t responding the way you’d like, fire him.

This is the money shot because it speaks to the current trend of patients using the Internet to learn about their health. And the mirror of that, the majority of physicians still uncomfortable with active, engaged, aggressive, and smart patients who question. It would be interesting to look at the physician participants in another study to determine if one, medical students today are more interested in active engaged patients and will they foster that.And, second to see how it matches the groups above. Are those more interesting in patient care more willing to engage with active patients? Or are those interested in revenue less interested in active engaged patients since it may be a cost/time issue.

This trend in engaged patients is as important as Obamacare, new drug discoveries, bending the cost curve on healthcare, etc. It is how the buyer and the seller find the balance that benefits both.

Delivering High Quality Cancer Care: Trend or Wishful Thinking?

A couple of days ago the Washington Post offered this “The best cancer care ins’t always the most expensive” written by Harold Pollack. The author takes a look at a recent report published by the Institute of Medicine (IMO) “Delivering high-quality cancer care: Charting a new course for a system in crisis.” His opening paragraph captures the report well…

Like many IOM publications, this report makes for depressing reading, not because it contains dramatic or frightening revelations, but because many of its recommendations are so obvious and yet would be so difficult to execute in our high-tech but unwieldy, costly and fragmented health-care delivery system.

Pollack summarizes the report well:

Too many patients having punishing and futile treatments
Costly imaging with little or no therapeutic benefit
Costly supportive care
Failure to use EHR
Fragmented care that drives miscommunication and errors

Cancer costs America 5% of the $2.8 billion healthcare economy and patients can benefit from more thoughtful and less toxic treatment when cure is not possible. Reading this I saw my film project “Care When There is No Cure“. And I thought of Donna and her care in the face of a Stage IV diagnosis for NSCLC. Donna was told she had 6 months. Her skilled and brilliant oncologist who I believe put care into healthcare told Donna when she asked him if she would die in 6 months “Not so fast”. He proceeded to create a course of therapy and care including a craniotomy that extended her life with excellent quality for nearly three years. I will say that the care Donna received looked like the chart below

I would take a look at the Washington Post article because there is an interview with Amy Berman who is a cancer patient diagnosed with Stage IV inflammatory breast cancer. She chose to receive palliative care three years ago. And her video is on the WP Web site as well as provided by the IMO. The video is excellent but, I must say the transcript from the discussion between Berman and Pollack is eye opening for its insight and candor.

On the IOM Web site they have a complete list of items regarding this report from briefing slides, press release, questions patients ask, report brief, and videos. It is very complete resource for this important topic and issue. Did I say slide deck my fav format. The link to the deck is here.

The above slide is early in the deck but triggered my thoughts about communications, advertising, adult learning, and driving change. But the IOM speaks to the reality that as a nation we will be facing this growing cancer crisis and not just in the prevalence of the disease but in the fact the crisis of how are we as HCP and caregivers are going to manage it and care for everyone. The fact is by 2022 30% of our aging population will have a cancer diagnosis. And consider the cost. By 2020 the cost of cancer care is anticipated to be $173 billion and increase of 39% from the $125 billion in 2010. And lest we consider just the toll on life there will be 18 million survivors of cancer by 2022. That number includes those less then a year to 15+ years.

These are the report goals and clearly they will change the face of cancer care as we move forward. Each one is a task in and of itself with subsequent issues, problems, and outcomes. Following each of these goals are a listing of recommendations. I am struck not only by the reality of the list and recommendations but of the weight of each one to be started/implemented/accomplished either at the provider level or nationally. These are not small tasks nor are they all clinically driven.Which means can they be executed by the HCP alone or in a practice? Some of these are communications and educational. They are centered on the need to create programs, messages, tools, and more that is strategically driven and based on principles of education and marketing. Some of these are the soft arts not evidence based medicine or a p value.

I question the ability of the medical and clinical community to drive the educational and communication goals they have laid out. Creating communications goals and aligned strategies are not easily achieved with measurable outcomes that meet and exceed the goals. What is needed are proven marketers who have shown success at driving HCP and patient change. In fact what is needed here are the very same people who convinced HCP to prescribe products that are only marginally more effective then placebo. And those very same experts got consumers to ask there HCP about treatments. Yes these are people who worked for the dark side but, they are the people who know communications and marketing. They are the people that know the science of medicine and can create strategies that change peoples opinions and drive action. And they are the people that providers tend to shun.

Of course there are some sour grapes in my fruit basket and I will not deny that I must take responsibility for this but it strikes me that if we are to marshall a nation to know about and deliver high quality cancer care it should not be left to academics or clinicians alone. It requires all hands on deck and the talents and expertise of proven marketing and communications specialists with expertise not only clinical credentials. Whatever you think about those of us who worked for or are from the dark side we could drive a message, sell an idea, and get an Eskimo to buy ice cubes. The goals of IOM and cancer care will not be achieved quickly and easily. And will require disparate talents.

Notes & Links: September 26, 2013

Thoughts on diagnosis-Reflections of #SIDM2013
A thought provoking post at db’s Medical Rants who reflects on attending the 6th annual Diagnostic Error in Medicine Conference. First, this is new to me and second there were over 200 attendees. I am of that age when I remember ASCO was only a 1,000 attendees and the exhibit hall was primarily folding tables with drapes. Not sure the Society to Improve Diagnosis in Medicine will be where ASCO is today but we can hope because this is a critical area especially today with treatments being specific to a diagnosis and a patient.

db captures this discussion clearly:

Back in the day (the 1970s and before), diagnosis was clearly job #1. Somehow focus shifted away from correct diagnosis to management strategies, performance measures and report cards. Wonks and politicians assume that we can make correct diagnoses. Unfortunately, the diagnostic process is difficult. We have problems of missed diagnoses, over diagnosis, and lack of diagnosis. One important policy influencing physician told us a story about a patient being treated aggressively without a diagnosis, a diagnosis that he (an internist) figured out with 2 questions. Having a correct diagnosis dramatically changed his relatives quality of life.

A Sick Stigma
Charlotte Huff writing in Slate addresses the question that haunted me when I would speak about Donna’s cancer, “Why are cancer patients blamed for their illness?”

I never really addressed the issue of smoking and Donna’s illness. In fact I got very angry when someone asked if she smoked because I knew, or thought I knew, that they would get all in my grill with their judgements. I never really got my head wrapped around it and what to do. Well the article written by Huff in Slate addresses the “hierarchy of the cancer blame game.”

Judgments about behavior not only unsettle and stigmatize the patient, but reflect the interrogator’s own insecurities. Frequently, those disease detectives are attempting to regain a sense of control amid the inherently random and sometimes unjust world that we all reside in, according to researchers who have studied stigma. Psychologists refer to this as the “just-world hypothesis,” a bias in thinking and perception that was first described by psychologist Melvin Lerner and colleagues more than four decades ago, and which has since been documented in numerous books and articles.

I cannot agree more completely with this statement but what is really telling about this blame game is the following.

Stigma also can undercut research spending, as the National Lung Cancer Partnership details with a stark 2012 analysis. Each year, nearly 157,000 Americans die of lung cancer, compared with 49,380 from colon cancer and 39,970 from breast cancer. Yet, far fewer research dollars are spent per lung cancer death—$1,490 versus $6,339 for colon cancer and $21,641 for breast cancer.

The reasons for this do not solely rest on the fact we all hate smokers and wish them harm. Because lung cancer is inextricably linked in everyones mind getting patients and their families to organize around and for lung cancer is difficult. Unlike say breast cancer which has the great support nearly three times greater than colon cancer. And least we forget the incidence of lung cancer for nonsmoking men is four in 1,000.

Huff shares with the reader that her mother was a smoker who was diagnosed with lung cancer survived for six years before it returned metastasized and untreatable. She ends with this

Because she died at age 51, she was never able to enjoy my husband’s wry sense of humor or my son’s ebullience. Was her death just desserts, or just tragic? If people would just stop implying that this is an underlying question, I wouldn’t be forced to provide the answer.

Indeed why do we have to provide the answer to the question does someone who smokes got what they deserved?

Notes & Links: September 24, 2013

Stunning News on Preventable Deaths in Hospitals
Leah Binder contributor to Forbes guides us through the most recent data on preventable deaths in US hospitals. Binder provided some reference points that are worth noting and keeping on file.

In 1999 98,000 patients were dying annually from preventable errors in hospitals
Today it appears we are seeing 440,000 deaths from preventable errors in hospitals
Medical errors are the third leading cause of death in the US way ahead of auto accidents, diabetes, etc.

The reason for these deaths?

These people are not dying from the illnesses that caused them to seek hospital care in the first place. They are dying from mishaps that hospitals could have prevented. What do these errors look like? The sponge left inside the surgical patient, prompting weeks of mysterious, agonizing abdominal pain before the infection overcomes bodily functions. The medication injected into a baby’s IV at a dose calculated for a 200 pound man. The excruciating infection from contaminated equipment used at the bedside. Sadly, over a thousand people a day are dying from these kinds of mistakes.

This bears repeating. Over 1,000 people a day are dying from preventable errors in hospitals in the US.

I was not surprised to learn that hospitals are shifting the cost of these 1,000+ errors a day to the patient, taxpayer, and business buying healthcare. Well here is a surprise, a study by JAMA found that employers paid an additional $39,000 extra each time an employee had a surgical site infection. Cost shifting at it most stunning.

As Binder points out this trend falls squarely on our shoulders since we allow lobbyist to hide errors, we fail to insist on safety when we seek care, and we don’t demand safety. I agree and perhaps once the price transparency of hospital costs is begun safety will be next. It has to be.

Social and Self-Reflective Use of a Web-Based Personally Controlled Health Management System
Lau, Dunn, Mortimer, et. al take deep prospective look at how consumers use social media and diary/personal health records of a Web-site to support their physical and emotional well-being. Compare their work to the link below on Understanding the Drivers of the Patient Experience. What would you use to understand and improve patient centric medicine at your hospital or practice?

The authors present the issue this way:

To date, it remains unclear how we can best integrate online social networking features and self-reflective tools (such as PHRs) into the design of PCHMSs in order to maximize consumers’ uptake, improve their health behaviors and outcomes, and facilitate their long-term use. In particular, few studies have examined the mutual relationship between self and the crowd in influencing one’s health behaviors. Utilizing a multimethod approach (statistical, content analysis, and social network analysis), the aims of this paper were as follows: (1) to measure how consumers used the most common self-reflective features in a PCHMS, (2) to measure how consumers interacted within the community created by the social features of the PCHMS, and (3) to provide recommendations on ways to engineer a socially driven and self-reflective PCHMS that would improve individual health behaviors.

Self reflection is one of the key components in learning and changing behavior. Reflection in action as described by Schon is the reflection that occurs during the time a problem is bing examined and understood. It is how we add new knowledge to a problem we have and create a new set of data to act on.

The conclusions of the authors speak to my contention that we find ways to help consumers “become familiar with their personal concerns” as in solve problems. That is what we healthcare is doing at its most basic, solving problems. And I believe the more active all participants are in solution finding, behavior, and measure the better we will find our healthcare system.

Incorporating the two major trends in consumer eHealth research (ie, PHRs and online social networks) to inform the next generation design of consumer systems requires several novel considerations. This study provides preliminary findings that suggest a PCHMS should include both social and self-reflective features that allow consumers to become familiar with their personal concerns and connect with others to seek help. With the rapid growth of online social networking websites and PHRs, future designs of PCHMSs should explore novel ways in which we can intervene in a person’s level of self-awareness and social network and examine their efficacy as a complex social and self-reflective intervention for health.

This is an important and valuable study that points to ways EMR and Web sites can be leveraged to improve patient care and outcomes. Less market research and more outcomes driven knowledge upon which to act.

Understanding the Drivers of the Patient Experience
Merlino and Raman writing in the Harvard Business Network Blog offer some valuable insight on how hospital administrators have NO insight. The authors examine and question the reality of being patient centric and what is the patient experience.

Drivers of the patient experience are the new black in healthcare and critical in the brave new world of Obamacare. But are hospitals taking a serious and critical cut at what is or will drive the patient experience? I will add my own thoughts here, the patient experience is a moving target. As new healthcare rules are implemented and health related data is released drivers will be changing and becoming more focused on care and outcomes and less on rooms with a view and curtains.

Least we forget, the patient experience today is being driven by social media and what the patient needs to learn in order to becoming an active and receptive healthcare consumer. In my opinion it is less about market research and more about needs assessment and identifying the problems patients are seeking to solve in order to ensure hospitals and their HCP become a trusted and valuable learning source.

Merlino and Raman state:

A 2012 industry survey asked top hospital leaders (CEOs, COOs, and others) what was necessary to improve the patient experience. The top six recommendations included: new facilities, private rooms, food on demand, bedside-interactive computers, unrestricted visiting hours, and more quiet time so patients could rest. There was one problem with them: They were not based on a systematic examination of what most patients really wanted. In other words, hospital executives wanted to focus on what they felt were important drivers of the patient experience but didn’t know for sure.

The authors list four approaches to identifying patient drivers.

Advisory councils
Deeper look into patient experiences
Rounds with hospital leaders
Tell Stories

These are excellent tools and exercises but I worry they will only determine what is de rigueur and not the ongoing long-term needs and goals of patients.

Swarming Toward Knowledge in the Era of Evidence Based Medicine

Swarm-Based Medicine
Putora and Oldenburg publishing in JMIR.org present a fascinating and insightful review of how medical decisions are made in the “absence of evidence-bsed guidelines”. Using crowd sourcing or “swarm-based medicine physicians add a further source of information to evidence based medicine or eminence-based medicine.

There are many concerns about the limitations of evidence-based medicine, but there are two obvious ones. First, evidence-based medicine is based on available data. However, relevant data is not available for all relevant issues. Also, trials with a negative outcome are underrepresented in medical literature, rendering the evidence base biased and the view of reality skewed

What struck me as I was reading this paper was how much of what the authors present fits with the work of Malcolm Knowles and the subsequent work of Dr. Hank Slotnick. Knowles is considered the father of adult learning theory and practice. His primary idea was that adults will learn only when faced with a problem.

Knowles characterized adult learning as follows:

Self-concept: As a person matures his self concept moves from one of being a dependent personality toward one of being a self-directed human being
Experience: As a person matures he accumulates a growing reservoir of experience that becomes an increasing resource for learning.
Readiness to learn. As a person matures his readiness to learn becomes oriented increasingly to the developmental tasks of his social roles.
Orientation to learning. As a person matures his time perspective changes from one of postponed application of knowledge to immediacy of application, and accordingly his orientation toward learning shifts from one of subject-centeredness to one of problem centredness.
Motivation to learn: As a person matures the motivation to learn is internal

In the early 1999 Dr. Slotnick took wrote the following paper “How Doctors Learn: Physicians’ Self-directed Learning Episodes” which identified four stages of physician learning. They are:

Stage 0: scanning for potential problems

Stage 1: deciding whether to take on the problem

Stage 2: learning the required skill and knowledge

Stage 3: gaining experience

Two other considerations to this paper are small group learning theory where small groups tend to be more productive and effective at sharing and learning. And the idea of communities of practice where groups coalesced around the need to solve a problem. Once the problem was resolved the community went away.

I believe the authors have identified that the Internet is driving the more productive and efficient application of the above theories and principles. It will be interesting to see if educators will begin to put new Internet based learning principles in place as more work such as yours is provided.

I wrote to the authors and received the following response which is important:

Maybe if physicians become more aware of their swarm behavior it will influence how they approach learning. Possibly by integrating distribution/cooperation into these learning stages, currently they are focused around a single point of view.

It is also fascinating to reflect on how small learning groups behave, when their boundaries by which they are defined disappear through constant interaction with the outside..
Take a look at the article it is important and points to a tend.

Notes and Links: September 18, 2013

How Circumcision Broke the Internet
Mark Joseph Stern writing in Slate has a terrific and sobering review of circumcision data online and how it is horrifically biased with the tinfoil hat crazies.

Stern points out that if you go online and search for facts about circumcision you end up “assaulted by a vitriolic mob of commenters accusing the author of encouraging “genital mutilation.” The self proclaimed anti-circumcision group call themselves “intactivists”. They argue mutilation, human rights, reduction of sexual pleasure (how your foreskin will give you a life of satisfaction and joy), circumcision is equal to female genital mutilation, etc. etc.

The problem with these arguments is that they’re either entirely made up or thoroughly disproven. None of intactivists’ cornerstone beliefs are based in reality or science; rather, they’re founded in lore, devilishly clever sophistry dressed up as logic. The facts about circumcision may be hard to find on an Internet cluttered with casuistry—but they are there. And they prove that even as intactivists dominate the Internet, the real-world, fact-based consensus on circumcision is tipping in the opposite direction.

Take, for example, the key rallying cry of intactivists: That circumcision seriously reduces penis sensitivity and thus sexual pleasure. Study after study after study has proven this notion untrue. Some men circumcised as adults actually report an increase in sensitivity, while many report no appreciable difference; virtually none noted any notable decrease. Men circumcised as adults also almost universally report no adverse effect in overall sexual satisfaction following the procedure. (That fits with what my colleague Emily Bazelon found when she asked readers for their circumcision stories a few years ago.) And genital sensitivity in response to erotic stimulation is identical in circumcised and uncircumcised men. Don’t trust individual studies? Asystematic review of all available data on circumcision came to the same conclusion. Intactivists, then, aren’t disputing a few flimsy studies: They’re contradicting an entire field of research.

The article goes on about how a few have taken control of an important decision. What is striking is how a group with an agenda can dominate the Internet in such a way that good science and evidence based data is difficult or impossible to find by the average parent. And the fact these “intactivists” drive the search results they play off of parents fears at a critical time, pregnancy when clear thinking is not in the forefront of gestation.

Those of us active in healthcare on the Internet will debunk false claims of pharma and tout the benefits of the Sunshine Act and taking pharma out of the HCP’s office but where are we when an anti-circumcision mob is hijacking science and evidence?

Palliative Care and the Human Connection: Ten Steps for What to Say and Do
Diane E. Meier, MD is the Director of the Center to Advance Palliative Care (CAPC). I have recently discovered the above linked video and it is excellent. It speaks to the medical professional but has information that we can all benefit and learn from. It is one of clearest and most compelling discussions on this topic I have seen or read. Of course this is Dr. Meier and she knows her stuff as well as anyone on earth. I cannot recommend this video enough. Just a couple of gems from it:

70% of human communication is non-verbal (Donna’s oncologist demonstrated this with his discussion). And to add to that it is part and parcel of what I want to do with the film “Care When There is No Cure“.
You place the power of how the person wants to receive information in the hands of the patent

The iPhone 5S and 5C
Jon Gruber at Daring Fireball has an excellent and detailed review of the two new phones from Apple and key features including: 64 bit processor, Touch ID, the camera, and more. As usual one of the better tech writers drives a clear and well balanced message. I guess linking to John makes me a bit of fanboy but take a look at Walt Mossberg’s review of the iPhone 5S which ecohs John’s thoughts as well. And Laura Goode reviewed the iPhone 5c.

My question is this how are the Apple Stores going to display and demonstrate Touch ID? I can’t imagine customers coming in and locking all the display phone with their finger pint and leaving. How crazy would that be? Entering a password is old school everyone wants to use their fingerprint.

20 Things 20-Year-Olds Don’t Get
Jason Nazar a contributor at Forbes has a great list of to-do’s for 20 year olds in business. They ring so true as I squint my eyes and look back 30+ years. Right now I am between consulting jobs, trying to identify the next business I want to open, or just throw the towel in. Whatever I figure out shortly is going to be driven by the fact that those of us of certain age are considered old, broken, and expensive. But when you consider someone has to list for 20 year olds how to act and what to do in business it eye opening. It tells me that as someone said “If you think you are getting a bargain hiring a 20 year old just think how much it will cost you to fix their mistakes.”

I don’t want to get into a generational fight here but the reality is that cost savings vs. value is not equivalent. Employers need to see beyond short term gains and look at long term strategies which a 20 year old is lacking just from being 20.

Not Quite Ready for Prime Time: The State Health Insurance Marketplaces and Google
Elaine Swift and David McCormick writing at The Health Blog address an salient issue for success of Obamacare.

Poor search engine results can create serious barriers to shopping and enrollment, the major measures of success for marketplaces and, by extension, the success of the Affordable Care Act (ACA).

Our preliminary findings show that marketplaces for four states—Idaho, Maryland, New Mexico, and New York—and Washington, DC did not appear on the first page of Google results, which generates 92% of all page views. In addition, both unpaid and paid search results for most of the remaining 12 states were frequently absent from page one.

With enrollment in the marketplaces opening October 1 for coverage beginning January 1, this would be a good time to focus on search engine optimization (SEO), the process of increasing the rankings of unpaid or “organic” search results. Once implemented, SEO results can be seen quickly, especially for a topic as popular and important as new health insurance options. However, it requires analysis, planning, and time to implement.

The authors present an excellent table of all unpaid and paid search engine results. And it shows that page 1 results for marketplaces for Idaho, Maryland, New Mexico, New York, and Washington, DC and limited for other state marketplaces.

Their advice, we need to get our act together to improve search results though they readily say it might be too soon since search engine optimization (SEO) may not have started. From my perspective besides making it easy to find we need to have broad discussions online about exchange marketplaces and how to find them what to look for. We need to help the average user improve the find of results so they can get the healthcare insurance they need and want.

Notes & Links: September 17, 2013

Hospital Cost Cutting and Productivity
Austin Frakt writing on The Incidental Economist shares his recent publication in Health Services Research on hospital cost shifting and productivity which comments on a yet to be published paper by Vivan Wu and Chapin White.

The central question that Frakt asks is this

A key question is what these cost cuts do to patients’ outcomes. That is, will hospitals become more productive, converting fewer resources into the same or better health? Or will they cut costs in ways that harm patient care?

Previously Wu and Shen found

…hospital cuts required by the 1997 Balanced Budget Act, heart attack mortality increased. Each 1% cut in payment resulted in a 0.4% increase in heart attack mortality rates. Lindroth et al. found that lower hospital service line Medicare profitability was associated with an increase in mortality

Frakt excerpted from his full commentary which is behind a pay wall a terrific chart and some cogent thoughts. In his estimation we may not be able to lower cost and improve outcomes but as an economist he sees this in terms of what is acceptable and not. If you get the PDF of his commentary let me know what you think?

What Brings Patients to Pharma Websites
Dominic Tyer writing on Digital Intelligence Blog share a new survey on how people access online health information. The survey found that physician recommendations were top influencers for traffic to pharma websites. The third survey found the average US patient visits their physician three times a year and searches the web 52 hours.

A survey of 1,000 Americans found that 42% said their physicians recommendations were key in visiting a pharma website, next at 33% were news articles, and at 30% were family, friends, or colleagues. TV was at 25%. Match that to the fact only 9% of survey respondents saying they would directly visit pharma websites for information.

Gil Bashe, practice director at Makovsky Health, said: “The survey results demonstrate that even as consumers research health-related information online, they seek trusted resources for that information – their physician, or a fellow patient.

“Healthcare providers and patient advocates serve an increasingly key role in guiding consumers to credible information and community support that can benefit their care.”

I read this data and was reminded of a study done by Annisa Lai Lee which was published in Journal of Health Communication “Who Are the Opinion Leaders? The Physicians, Pharmacist, Patients and Direct-to-Consumer Prescription Drug Advertising” Annisa’s study basically supports the value of the HCP when it comes to drug recommendations. When a patient goes to their physician and says I saw a drug on TV they will likely not get the Rx. But if the patient says my pharmacist recommending the same drug they will get the script. Speaks to the data you have the HCP remains the single most important link to patient engagement.

… the influence of drug prescription behaviors certainly has come from interpersonal influence of health care providers other than from the mass or hybrid media only. The influence is so strong that patients would switch their own physicians who go against the advice given by pharmacists. The two-step flow model is therefore still upheld in one major aspect that physicians (opinion leaders) seldom are influenced by their media-educated patients (followers) only and they are instead influenced by opinions of their colleagues or other health care opinion leaders, meaning that the power of interpersonal communication still is stronger than mass media in
the case of DTCPDA.

This also strikes me that the influence pharma remains focused on the physician. Even in the day of the Sunshine Act and physicians feeling pressure to move away from direct monetary compensation from pharma there is the fact that a physician recommendation to read this or that on this or that sites is a powerful and present influence on patients.

An Exploration of Social Circles and Prescription Drug Abuse Through Twitter
Hanson, Cannon, and Giruad-Carrier out of BYU published this study in JMIR. There is no surprise regarding their conclusions. people who discuss drug abuse online surround themselves with others who do the same. I guess I wouldn’t expect Lindsey Lohan to hang out with Mother Teresa.

Beside seeing clearly that there is significant activity beyond just talking about prescription drugs on Twitter. There is the fact this type of data may point to access and new ways to reaching those abusing drugs. This is another study similar to the one on tobacco use (here) that besides showing the problem may in fact identify solutions.

Whereas Twitter is a social media platform used to discuss and reinforce prescription drug abuse, prevention specialists should be mindful of this communication channel as another setting for understanding and monitoring prescription drug abuse and potentially intervening online.

Riding the Rails: News from the Caboose
My neighbor Bob and his lovely wife Mac are blogging about what sounds like an amazing trip. They are heading to San Francisco to board a New York Central Train originally build for Harold Sterling Vanderbilt over 85 years ago. They will head to Seattle and make a return trip south through Naps Valley, Stampede Pass, head to Hanford Nuclear site just for this train, to Deschutes River Canyon Gorge, Crater Lake National Park. Klamath Falls, Modoc national Forest Lassen Volcanic National Park, Feather River Canyon.

Bob is a great story teller and his blog should be replete with some great photographs albeit touristy in style and composition. I am looking forward to following this just see this train which makes various trips throughout the nation. And I want to hear if the food and wine works as well. You can follow Bob at News from the Caboose.

Notes & Links: September 12, 2013

The Public Needs to Wise Up About Medicare Spending
Adrianna Mcintyre writing in The Incidental Economist shares data from a recent report in the NEJM “The Public and the Conflict over Future Medicare Spending“. In her opening paragraph Adrianna captures the money shot on this report.

Robert Blendon and John Benson find, among other things, that people generally don’t understand the role Medicare plays in the federal budget deficit—which matters, since the legislators responsible for reducing that deficit tend to care about reelection.

We as a community/nation/individuals don’t get Medicare and basically driven by misinformation from those seeking reelection. What is sad is that the majority of media or experts site the following three leading causes for rising Meiicare costs are: poor management, fraud and abuse, and excessive charges by hospitals. The lowest ranked reason, new drugs and treatments being offered to seniors. There is a great chart showing just the opposite. Technology is driving costs most of all. Below is a quote pulled from the NEJM article.

This article goes further and seeks to document the underlying beliefs that may shape the public response to future efforts to substantially slow projected Medicare spending. Our thesis is that there exists today a wide gap in beliefs between experts on the financial state of Medicare and the public at large. Because of the potential electoral consequences, these differences in perception are likely to have ramifications for policymakers addressing this issue.

Take the time to read the NEJM article as well as the link to it at The Incidental Economist. It is important for both the nations finances and its health we understand what is going on with Medicare.

Death of Porn Star
Tim Lahey, MD writing on the Healthcare Blog writes about the recent announcement that Cameron Bay a porn actress tested positive for HIV. Beyond the usual self righteous offensive and nasty tweets and comments Dr. Lahey makes us stop to consider the reality of this diagnosis and what it means.

Porn stars, too, are easy to oversimplify. Dressed (at least temporarily) in garish or stereotypical costumes, they have sex on camera, they say things most can’t imagine saying, and they behave on screen like simplified primal versions of the complicated people of ordinary life. We project a mixture of desire, disdain, and pity on them, and often we forget to consider the person under all that exposed skin.

Indeed the person under that skin. Take a moment to read this article and consider the person.

Majority of Viagra Bought Online May Be Fake, and Possibly Dangerous, Research Shows
Not sure I am being incentive presenting “Death of a Porn Star” followed by this but the article in Forbes written by Melanie Haiken addresses a larger issue, online pharmacies in general. And since I get about a dozen or more requests to by this stuff online I couldn’t not read the article.

The reference to Viagra was in fact an abstract presented at the World Meeting on Sexual Medicine and showed that 77% of all Viagra purchased online from 22 different sites was counterfeit. (An aside: it was an abstract funded by Pfizer).

Other data shared:

Somewhat cumbersomely titled Internet Drug Outlet Identification Program Progress Report for State and Federal Regulators, July 2013, the report revealed that only 257 of 10,275 online pharmacy sites it examined could be considered legitimate.

Not so fast:

The belief that most online pharmacies are suspect and that most Viagra sold online is fake is not universal, however. In fact, says Roger Bate, a scholar at the American Enterprise Institute and author of Phake: The Deadly World of Falsified and Substandard Medicines, his own tests of drugs sold online found the vast majority to be authentic and those sold by credentialed online pharmacies to be 100 percent authentic. Bate published a paper in 2010 finding that just 7.3 percent of Viagra samples purchased online failed spectrometry testing and proved to be fake

Who to believe? Even a small percent is fake consider what is in the fake. This is what was found.

Blue printer ink
Speed or amphetamine
The antibiotic Metronidazole (Flagyl)
Drywall and plaster
Other ingredients and dyesused to mimic the texture and color of real Viagra

Yuck

Fourteen Oddball Reasons You’re Not Dead Yet

Laura Helmuth in Slate shares, yes oddball, facts that have extended our life expectancy not one of them has to do with Obamacare or preventive medicine. Okay check that, there is a reason or two from government regulations. Here is the list. Hop over and take a look at the details.

Satellites
Fluoride
Window screens
Unconscious bias
Botts’ Dots (Those are the raised ceramic reflectors between road lanes)
Morbidity and Mortality Weekly Report
Air-conditiong
The resident of Framingham, MA
Pasteurization
Shoes
Cows
Oppressive, burdensome, over-reaching government regulations

Thanks to Liz Borkowski on ScienceBlogs for this link.