Google, the other 800-pound gorilla, has its own plans

I was going to wait until the big concept was more crystalized. But "Google preparing health portal; pitching WebMD and Intuit as partners," an entry by the senior writer of The Deal, a VC investor site, spills the beans on what Google intends to do in healthcare. And I could no longer remain patient.

The plan, as it stands now, calls for there to be four different directories for each different type of user. The prospect of listing a separate directory for medical devices seems to have been scrapped. Users will be able to log in with their own account information and do things such as add a new medical provider, check their medical records or pay their bills.

The product would also provide information about hospitals such as the frequency that a hospital performs a specific type of procedure or which hospitals perform which procedures most often.

It's interesting to see Silicon Valley shifting its eyes to healthcare in such a big way. This is likely a good thing, as good uses of info tech could go a long way in making the entire experience better. The question is: Will people trust a private Internet company, even Google, with their sensitive personal data? Especially since people fear how they'll be perceived by potential employers, insurers and individuals when their ailments are exposed; people are perhaps fear security break-ins even more.

Google's current "offering" in healthcare, Co-Op, a directory of search results for health-related terms, is definitely induces much less anxiety.

The 800-pound gorilla a.k.a. Microsoft enters the arena

My good friend Karthik N., a budding clincial informatician, emailed me about Microsoft's new foray into healthcare and its acquisition of a company called Azyxxi.

"Microsoft plans to offer software tailored for the health care industry, a change from its usual strategy of encouraging others to create industry-specific products using its operating system and programming tools," according to this week's NY Times article "Microsoft to Offer Health Care Software."

The company’s first step, announced today is to purchase clinical health care software developed by doctors and researchers at a nonprofit hospital in Washington [called Azyxii]. Microsoft is also hiring two of the three doctors who created the software system and 40 members of the development team at Washington Hospital Center.

What's compelling Microsoft? Endorsements of "moving health care into the digital age and handling patient records and tracking treatments electronically" by "[h]ospitals, doctors and policymakers worldwide [who] have high hopes for saving money and improving the quality of care." This is a policy supported by both political parties and President Bush, and so digitizing clinical information can potentially be a big business.

But Azyxxi isn't just another Electronic Medical Records application. Instead it's an app that solves the problem of incompatability. "Many hospitals and clinics, they say, have many different kinds of patient information in electronic form, but the different computer systems and software programs cannot share the data. That is the principal problem the Azyxxi system addresses, analysts say."

I ran into this problem first-hand. On a rotation two months ago, I split time between two hospitals, Methodist and St Luke's. (Each had its own EMR system.) In a matter of weeks, one particular patient I saw earlier at Methodist turned up with a repeat problem at St Luke's.

When I most needed it, I was not able to review the patient's medical records from Methodist -- unless I left his bedside, closed my account at St Luke's and walked all the way to Methodist to where the patient first checked in and logged on there. Which is precisely what I did.

This is where Azyxxi, a system "designed to retrieve and quickly display patient information from many sources, including scanned documents, E.K.G.’s, X-rays, M.R.I. scans, angiograms and ultrasound images," steps in.

It was first used in Washington Hospital Center’s emergency department in 1996, and has since been adopted at six other hospitals, including the Georgetown University Hospital, in the MedStar Health group, a nonprofit network in the Baltimore-Washington region.

If installed at both hospitals, Azyxii would allow me to access that patient's Methodist records while remaining at his side at St Luke's. Thus it would have saved time, eased the job of working the patient up and starting his treatment plan, and enhanced each EMR system's ability to save costs and improve care.

Multiply this a thousand times for all the medical caretakers experiencing this problem on weekly, and it's easy to see why Azyxii is valuable.

A big plus is that neither Methodist or St Luke's would need to buy into the same EMR application to allow their people to share patient data or tweak their pre-existing systems. And the federal government would not need to create a national patient database, meaning tax dollars aren't spent on something the private market is able to resolve quite well.

The app has already proven itself effective in making doctors and their staff more efficient:

In 1995, before the system was introduced, the emergency ward handled 37,000 patients a year, waits stretched up to nine hours, and there seemed to be an urgent need for more doctors and rooms, Dr. [Craig F.] Feied, [a principal designer of the software] recalled. Today, the emergency department handles nearly 80,000 patients a year and 70 percent of them are diagnosed, treated or admitted in three hours or less. The staff has increased only 5 percent, and few rooms were added.

The problem, Dr. Feied said, was mostly that patients were waiting in rooms because doctors could not quickly find the patient records, treatment history and other information to treat them.

“We weren’t doctor-poor or bed-poor,” he said. “We were information-poor.”

***

From the Washington Post, the story of how Azyxii was created.

It is noteworthy that Azyxxi did not come out of the hospital's IT department, after the appointment of a task force, the drawing up of a detailed needs analysis and approval of a long-term capital budget. There was no request for proposals, no campaign to win "buy-in" from staff, nor was a dime allocated for training. The system was designed largely by two extraordinary doctors who were lured from George Washington University a decade ago with a mandate to fix an under-performing emergency room with nine-hour waits, dissatisfied patients and an unhappy staff.

Mark Smith and Craig Feied quickly discovered that the main reason for the frustration and wait times was the delay in getting test results and other information to ER doctors and nurses. For Smith, who came to medicine from a PhD program in computer science at Stanford, and Feied, who started his career as a biophysicist and knows 25 computer languages, the obvious answer was to write a computer program that could eliminate the bottlenecks.

Sixteen months later, they installed the first terminal in the middle of the ER with a handwritten sign taped on it: "Beta Test. Do Not Use." But as they had hoped, people began using it anyway -- and were astounded by what they could do. And before long, doctors were coming from other departments to retrieve information on patients who had come to them through the emergency room.

Over the next eight years, Azyxxi spread through the hospital as more people used and demanded it, and more information was fed into its database. By 2002, the IT department threw in the towel and canceled a contract with an outside vendor to develop a hospital-wide electronics record system, having already spent $8 million. By the end of last year, with the help of a handful of in-house programmers, Azyxxi had been rolled out in all six sister hospitals in the MedStar system, at maybe a third of the cost of what an outside supplier would have charged, according to hospital officials.

Now, Smith and Feied have won a federal grant to help create a regional health information network that will tie together the medical records of all the hospitals, labs and doctors' offices in the region. What they bring is not only an open, flexible system that can be a centerpiece and model. They also bring the knowledge that you don't have to pay outside vendors a lot of money, or have a "grand solution," or create a lot of bureaucracy and regulations to bring health care into the information age. Just build it and they will come.

***

Microsoft's PR names a third co-creator, Fidrik Iskandar, states Azyxii was created using Microsoft tools, and names the company's VP of health strategy, Peter Neupert. After serving 11 years at Microsoft, Neupert ran Drugstore.com as CEO, was a member of the President’s Information Technology Advisory Committee, and served as co-chairman of a health technology subcommittee that published a report called “Revolutionizing Health Care Through Information Technology" (pdf file) before returning to Redmond.

Why some people distrust doctors

It was surprising to me the feds arrested a physician for promoting the off-label uses of a drug. Why?

Because so many do it. Most physicians I've worked with simply use drugs off-label when it's conventionally accepted as working. (For instance, Seroquel is FDA approved for bipolar disorder and schizophrenia, but is also used widely to reduce anxiety and agitation.)

Some doctors however, driven by greed, go too far. And for their endorsements and lectures, they're generously compensated by pharmaceutical companies that make those drugs. Drug companies haven't been immune from trouble related to promoting off-label uses of their drugs without good supporting evidence: Pfizer paid upwards of $400M in 2004 for promoting its anti-epilepsy drug for pain and bipolar disorder.

The AMA supports a doctor's unique right to prescribe medicines off-label, and to discuss off-label prescribing practices among themselves. But even its leaders would frown upon the kinds of claims the doctor in question was making.

In one seminar cited in the federal indictment, a session last August in Denver, Dr. Gleason told doctors that 'table salt is more dangerous' than Xyrem — a statement scoffed at by other experts on the drug.

That came from the July 22nd NY Times article "Indictment of Doctor Tests Drug Marketing Rules." And that wasn't the half of it.

The indictment also charges that Dr. Gleason committed fraud against insurance companies by advising doctors to leave blank an area on the Xyrem prescription form that asked for a disease diagnosis. Dr. Gleason acknowledges that he told doctors not to offer a diagnosis but says he never told them to lie if they were asked for one.

Some out there who heard about this story must be thinking -- if not already -- that if doctors can be swayed to prescribe something because of financial interests or anecdotal evidence instead of what's objectively beneficial, how can they trust that they're getting the best unbiased evidence-based care possible?

Technology's role in preventive medicine

"Why can't medicine scale the way computers do?" asks Andy Kessler, a former Wall Street financial analyst.

In information technology everything can be reduced to chips, which keep getting smaller and cheaper, making costs go down. In medicine, everything works in the opposite way. Costs keep going up. Why?

Mr. Kessler looks for the answer in places like Stanford and Harvard, and he wrote about this journey and his conclusions in a book titled "The End of Medicine." He comes to the same conclusion as many others: costs keep rising because our healthcare system(s) focuses on treatment over prevention.

Everybody from legislators and insurers to doctors and researchers are vested in the current system, so instead of fixing it they find ways to exploit it. Other players are no different. "A complicated system of mutual dependency distorts the incentives. 'The FDA is like the FCC and Big Pharma is like the regional Bells' is what Mr. Kessler hears from Don Listwin, a former Cisco executive who now heads the Canary Foundation, a Silicon Valley-based effort to promote preventive medicine."

Why an innovative "device with a wide, preventive usefulness" would stall in the regulatory process as opposed to a one-in-10,000 compound that cures or treats a select few would get the fast track is explained in paraphrase by the writer of the book review in the WSJ (sub req'd). But the book isn't an expose or written in the whistle-blower tradition. And it's not just another assault on our current system that pushes the single-payer universal healthcare or on the other end of the spectrum HSAs, or lambasts academics for putting money into esoteric research. Instead, it's visionary, and touts how technology will be transformational.

In one hilarious sequence, Mr. Kessler recounts trying to draw his own blood sample, in the hope of checking his cholesterol. But clinics won't draw blood without a doctor's orders. Drugstores think you want the syringe to shoot heroin. Unless you want to just gouge your own finger, you're in the clutches of organized medicine. Imagine how tightly it grips something a bit more sophisticated.

Yet diagnostic technology is taking off -- and that's the crux of Mr. Kessler's book. Tomography -- that is, three-dimensional imaging -- is slicing and dicing the human body (figuratively speaking) almost down to the cellular level. Exploring the inside of someone's carotid arteries is like playing a video game. In one amazing scene in "The End of Medicine" -- it still doesn't quite seem real -- Mr. Kessler describes a "face off" between five rival 3-D modeling systems at the seventh annual Multi-Detector Row Computed Tomography Symposium in San Francisco.

What is the overall vision of this book? Well, here's a stab at it by the WSJ reviewer.

Mr. Kessler's ultimate vision is that of a brave new world where hundreds of antibodies attached to carbon nanotubes monitor our blood every day -- every minute? -- for early signs of artery clogging or cancer. Then, if need be, 3-D imaging can zero-in on offending cells, holding them in the target for destruction by radiation or other proteins. People won't live forever, but they will be much healthier and happier as they get older.

Medicare challenged by task of changing focus to prevention

I didn't realize Medicare, the government's health insurance program for the elderly, is behind private insurers in preventive care.

"If you take a big step back and look at Medicare spending, 90%-plus of what we are spending is going for the complications of chronic disease," Medicare Administrator Mark B. McClellan said in an interview. "We can get healthier beneficiaries and a lot lower costs related to complications if we can get more prevention."

(Dr. McClellan is an interesting person situated to make broad changes in healthcare at the national level, has doctorates in both medicine and economics, and served as commissioner of the FDA prior to his current role... plus he was also a Plan II honors major at UT!)

Seems the problem isn't Medicare's ability to provide for preventive care, but getting seniors to comply with it.

In the last two years, the program has expanded what had been a relatively limited set of preventive benefits by adding a "Welcome to Medicare" physical exam for new enrollees, blood tests for cardiac risk factors such as high cholesterol, diabetes screening and training to help diabetics keep their blood sugar under control.

Some services are free, such as a blood glucose test for signs of diabetes. Others, such as the physical, require patients to pay part of the cost.

But some of the results have been disappointing to Medicare officials. For example, about 2% of eligible seniors have taken advantage of the physical, according to preliminary statistics.

The track record also is uneven for established preventive benefits that were added to the program in earlier years.

For example, only 36% of female beneficiaries get Pap tests and pelvic exams to screen for cervical cancer, although Medicare covers most of the costs of such services.

And 54% of male beneficiaries get prostate-specific antigen, or PSA, blood tests — prostate cancer screenings that are free.

Too bad because there are tremendous cost savings for taxpayers in getting people to develop a "preventive care" habit rather than having them develop acute emergencies and treating them for it. "A Medicare analysis using data from 2001 found that the program paid nearly $13 billion that year for potentially preventable hospitalizations for a variety of illnesses, including pneumonia and uncontrolled diabetes. A reduction of as little as 5% in the hospitalization rate would produce more than $500 million in savings, the analysis showed."

What also ought to be mentioned by Dr. McClellan or the LA Times writer of this article, "Medicare Looks to Boost Seniors' Use of Preventive Care," is that preventive care better maintains a person's quality of life.

The medical home

What is the medical home? It is the vision of companies like Intel, Philips Electronics and the consulting firm Accenture to bring devices and IT into the homes of American elders to help them keep their health and quality of life intact while keeping costs down.

Here's what underpins the vision, according to the June 26th WSJ article "The Future of Health Care?" (sub req'd):

With health-care budgets stretched to the breaking point -- and with health-care workers in short supply -- improved use of technology is widely thought to be a solution to meeting the growing needs of an aging America.

Would these companies' vision truly do what it's intended to do when expressed in the real world? I don't know, and time will tell.

Internet enables medical tests to be low-cost

The June 20th WSJ article "New Online Services ToutLow-Cost Medical Tests" (sub req'd) explains how this works.

At least two new online services have sprung up this year touting these low-cost medical tests. MedLabUSA.com and MyMedLab.com have joined HealthCheckUSA, DirectLabs.com and others in offering to set up patients for the same diagnostic tests as walk-in lab services, hospitals and clinics. Customers visit a Web site, select a specific test, enter a ZIP Code and receive driving directions to a specimen-collection laboratory. Users pay with credit cards or a health savings account and don't need their doctor's prescription -- unlike walk-in clinics, which typically require a personal physician's approval.

Because "most insurers won't pay for such services, however, unless the patient's doctor has ordered the test," this model cuts out the HMOs, insurers and doctors, thus putting the burdens of cost and interpretation on patient-consumers.

(Thanks to sites like the US government's www.nlm.nih.gov/medlineplus, people can interpret their own lab results. Here's an example. Go to the site and type in 'cholesterol level' and click on Search. You'll see two links, What Are Healthy Levels of Cholesterol? from the American Heart Association and Cholesterol: What Your Level Means from the American Academy of Family Physicians, at the top of the search results that tells you what a doctor would tell you when they see your cholesterol numbers.)

The online nature of this model, plus the directness of it thanks to cutting out middlemen, is appealing. "Customers are attracted to the online testing services because they are convenient and cut down on trips to the doctor's office." My opinion is this is ideal for people who are not ill but want to monitor their cholestrol levels to know where their status is.

Another benefit might be that "self-test results don't become part of a medical record, so they aren't reported to insurance companies." This is assuring to those who believe their chances of being hired for full-time jobs are harmed by insurers' and potential employers' foreknowledge of their pre-existing conditions (eg, diabetes) and habits (smoking).

One clarification is due: while a visit to the doctor's office isn't necessary, doctors still are. "The online services say in-house doctors approve requests for tests -- a personal physician's signature is usually required by commercial labs, including [LabCorp], and Quest Diagnostics Inc."

So, what does the medical community think? Well, one doctor, a former AMA president, raises concerns, while another doctor gives a thumbs up.

"Do you know what to do with the results?" asked J. Edward Hill, a Tupelo, Miss., family physician and past president of the American Medical Association. Critics admit that the tests may be helpful in limited scenarios -- checkups to monitor cholesterol-fighting statin drugs, for example -- but too often they mislead patients, potentially leading to higher health costs later.

Despite such concerns, some physicians predict that more health systems will start offering online tests as a service to their patients. "Anything that can get people to a higher level of awareness of their own health status and get them to take some ownership is positive," said Bruce A. Friedman, emeritus professor of pathology at the University of Michigan Medical School.

And what are the cost savings?

A blood test on MyMedLab.com sells for $45, compared with $295 at the local hospital, says company president David Clymer. "We're trying to reach people who are stuck in a market where their only option is a hospital lab," he said. "We're not simply 20% cheaper -- we're 20% of [the hospitals' cost]. That's how consumer-driven health [care] is supposed to be."

However, is this model sustainable? Perhaps not, as "Quest Diagnostics, a leading diagnostic-testing company, ended its online retail unit, QuesTest.com, in March because of poor sales performance... Quest Diagnostics, Lyndhurst, N.J., [still] tests patients at walk-in service centers, but those require patients to have a doctor's order."

And "LabCorp doesn't offer direct-to-consumer tests, citing its desire to keep physicians in the loop. However, most of the online brokers are able to use the LabCorp network for their direct-to-consumer business." For better or worse, it's the entreprenuer who's pushing the trend.

1.5 million…

That's how many Americans are harmed every year because of medication errors, according to the latest Institute of Medicine report. This same institute made the number 98,000 infamous a few years ago. (It’s the number of hospital patients killed every year by medical mistakes in the US.)

These mistakes are happening in hospitals as well as clinics and pharmacies. And not only are they costing quality of life (or just lives), they’re costing taxpayers a staggering $3.5 billion per year.

In the NPR report titled “Drug Errors Still Common,” commentator Richard Knox speaks about computerized prescribing systems, which are better at checking for double-entries of the same drug, harmful interactions, and unique adverse effects than people are. It also elimates the problem of reading of terrible handwriting, which leads to errors too.

Sadly it took high-profile tragedies to get the ball moving on e-prescribing:

It was at Dana Farber Cancer Institute in Boston, “almost a dozen years ago, that two medication errors shook the medical world. A chemotherapy overdose killed Betsey Lehman, a Boston Globe health columnist, and damaged the heart of schoolteacher Maureen Bateman.”

“That episode is credited by many as launching the error-prevention movement. It was mentioned in the first sentence of the 2000 Institute of Medicine report and is featured again in the new report.”

In addition to e-prescribing, there’s bar-coding. I personally see both in use at the VA.

Michael Cohen is another author of the new report. He's president of the Institute for Safe Medication Practices. He says bar-coding every dose of drug and matching it to a code on patients' wristbands can also prevent mistakes. But Cohen says only one hospital in seven uses bar-coding.

Cohen recently visited a hospital that does.

"This was interesting," he says. "In a one-month period, there were 74 times when a nurse walked into the wrong patient's room, scanned the patient's wrist band, and was alerted to the fact that they were not with the right patient. That's an amazing number of people that may have gotten the drug that wasn't intended for them!"

The IOM wants all US hospitals to have e-prescribing systems in place by 2010. But hospital execs will move when they have financial incentives to do so, or have to deal with tragic deaths on their watch. Let's hope the former becomes the driver of change in all cases before the latter happens.

Radio tags make it harder to leave stuff behind

This article reminded me of one the funniest moments of the TV show Seinfeld (well, to me), when Kramer drops a junior mint into the open cavity of a patient as he's being sowed up by the surgeons.

But learning that stuff's been left behind after a patient's been sewn up isn't funny. It happens to 1,500 American patients every year, according to the AP article "E-Tags Could Prevent Surgical Errors," and the rate of this happening is 1 in every 10,000 surgeries. Not high odds, but this error is something that almost always leads to costly complications, and often death.

The article centers on a new idea being commercialized: surgical sponges implanted with RFID tags (you know, the tags that allow drivers to fly through toll booths without pressing on the brakes and that allow people to enter, or be blocked by, security-enabled doors).

According to company officials, surgeons or nurses could wave wands over patients near the end of their operations and detect any leftover sponges still in the body. According to a newly released study, none of eight patients had any problems when tagged sponges were briefly placed into their bodies during operations.

"Our study found the device works 100 percent of the time," said lead author Dr. Alex Macario, professor of anesthesia at Stanford University, in Stanford, Calif.

It's neat to find out a healthcare worker came up with the idea. "According to Macario, an operating-room nurse came up with the idea of RFID-tagged sponges and patented the idea."

Since the RFID is a controversial device, there was bound to be controversy. Katherine Albrecht, co-author of Spychips: How Major Corporations and Government Plan to Track Your Every Move With RFIDs, "said surgeons would pass the costs of the system on to patients. 'They're just shifting the cost to the consumer or the HMO,' she said."

She also questioned why the system relies on RFID chips, which can provide an identification code. Cheaper devices -- like the theft-prevention devices placed on clothes in a department store -- would work just as well, she said.

She's got a point: why pay more if cheaper devices do the same thing? The CEO of ClearCount Medical Solutions, the company commercializing the idea, maintains it's important to know how many sponges were left behind, and what kinds of sponges were they.

What's clear is that these e-tagged sponges would benefit patients and taxpayers. They would also help surgeons avoid being sued and losing patients, which is why -- according to the study (being run in the July Archives of Surgery) -- surgeons would be "willing to pay an average of $144 per [e-tagged sponge]."

More isn't better

So says Dr. David C. Goodman, a professor of pediatrics and family medicine at Dartmouth Medical School who wrote “Too Many Doctors in the House” printed July 10th in the NY Times.

Can we cure our ailing health care system by sending in more doctors? That is the treatment prescribed by the Association of American Medical Colleges, which has recommended increasing the number of doctors they train by 30 percent, in large part to keep up with the growing number of elderly patients. But the most serious problems facing our health care system — accelerating costs, poor quality of care and the rising ranks of the uninsured — cannot be solved by more doctors...

The writer's argument centers on the findings of The Dartmouth Atlas of Health Care study.

Many studies have demonstrated that quality of care does not rise along with the number of doctors. Compare Miami and Minneapolis, for example. Miami has 40 percent more doctors per capita than Minneapolis has, and 50 percent more specialists, according to The Dartmouth Atlas of Health Care, a study of American health care markets (for which I am an investigator).

The elderly in Miami are subjected to more medical interventions — more echocardiograms and mechanical ventilation in their last six months of life, for example — than elderly patients in Minneapolis are. This also means more hospitalizations, more days in intensive care units, more visits to specialists and more diagnostic tests for the elderly in Miami. It certainly leads to many more doctors employed in Florida. But does this expensive additional medical activity benefit patients?

"Apparently not."

The elderly in places like Miami do not live longer than those in cities like Minneapolis. According to the Medicare Current Beneficiary Survey, which polls some 12,000 elderly Americans about their health care three times a year, residents of regions with relatively large numbers of doctors are no more satisfied with their care than the elderly who live in places with fewer doctors. And various studies have demonstrated that the essential quality of care in places like Miami — whether you are talking about the treatment of colon cancer, heart attacks or any other specific ailment — is no higher than in cities like Minneapolis.

Another finding, same conclusion:

The Mayo Clinic in Rochester, Minn., and the University of California, San Francisco, Medical Center each have about one doctor treating every 100 elderly patients with chronic illnesses in their last six months of life. New York University Medical Center has 2.8 doctors for every 100 such patients and the University of California, Los Angeles, Medical Center has 1.7. The elderly patients at N.Y.U. and U.C.L.A., as compared with those at the Mayo Clinic and the San Francisco hospital, see more specialists and are subjected to more imaging tests and other procedures. But the quality of their care, as judged by doctors, is no better.

So apparently even physicians believe more doctors do not make for better quality care.

How can it be that more spending and greater physician effort does not lead to better health or to improvements in patient satisfaction? One explanation may be that when more doctors are around, patients spend more time in hospitals, and hospitals are risky places. More than 100,000 deaths a year are estimated to be caused by medical mishaps.

The writer asserts that physician surpluses do not "remedy regional shortages," a stated aim of the AAMC. "But in the past 20 years, as the number of doctors per capita grew by more than 50 percent, according to our measurements, most of the new ones settled in areas where the supply was already above average — places like Florida or New York — rather than in regions that lack doctors, like the rural South."

This seems counter-intuitive. A doctor surplus in the city would drive salaries down. Thus, many doctors wanting greater financial reward would move elsewhere. But simple supply-and-demand economic incentives is, well, just that: simple. It does not prevail over every consideration as living in the city confers advantages that money can't necessarily buy.

Coming back to his argument, the writer believes adding more doctors is like throwing more grease to take out a fire.

By training more doctors than we need, we will continue to fill more hospital beds, order more diagnostic tests — in short, spend more money. But our resources would be better directed toward improving efforts to prevent illness and manage chronic ailments like diabetes and heart disease.

Better coordination of care is also worth investment. Small physician groups in disconnected offices often provide fragmented treatments, while multispecialty practices integrated with hospitals — prevalent in Minneapolis and some other cities — are associated with lower cost and higher quality of care.

All these strategies have been shown to improve patient outcomes without adding physicians. Instead of training more doctors, let's make better use of the ones we already have.

Do docs-to-be feel threatened by technology?

“Medicine is two things, the human thing and informatics.” Thus spoke my attending this past Thursday. During a powwow session at the VA between him, myself, two interns (1st year residents), a sub-intern (4th year med student) and our upper-level resident, the attending asked, “Has anyone here heard of Big Blue?”

While that's the nickname given to IBM, one of us correctly guessed he meant the IBM supercomputer that beat the world’s best chess player some years ago. (That computer's name is Deep Blue actually.)

The attending then posed this question: Does computer “brainpower” already exceed human brainpower? The consensus was a qualified yes. Yes, the computer can process vast amounts of data & information faster than a person can. But "instinct" (as he called it, or "intuition" as I call it) based on hundreds if not thousands of instances of some particular experience allows in some cases that our brains to work faster than a computer chip.

Here's a hypothetical to explain that. A pulmonologist sees hundreds of COPD cases in his 30 years of practice and develops a diagnostic sense (or instinct or intution) for COPD, so that he no longer has to consider all the data made available from labs, images, history & physical exam, fit the relevant stuff into an algorithm, and consider all the possibilities before picking COPD from the differential diagnoses. He does it instantaneously. A computer on the other hand becomes mired down in crunching everything it gets before making the correct diagnosis.

But to me this notion doesn't hold up well. Advances in computing speed and artificial intelligence (which aims to mimic such shortcuts in human thinking) may soon make this notion obsolete.

The attending said there's another advantage we human physicians have over future robots who would be competing for our jobs: a computer can’t give comfort to people because it lacks what we have, this nebulous thing named “the human connection.” This seems to hold up on firmer ground. Even the anthromorphised robots in films like “I, Robot” and “A.I.,” which are two visions of what what robots will be like, gave people the creeps.

Let me now shift the focus onto the reaction of my fellow doctors-to-be during this 15 minute chat. Basically, some felt threatened, and perhaps became more comfortable when they saw that technology doesn't necessarily have to replace the doctor. Here, let me explain.

One intern said it's entirely conceivable that at some point tubes could be plugged into a patient's body and all the labs will be taken, thereby providing a quick diagnosis that considers a more thorough picture of the body than we're capable of. Think of the OBD reader a car mechanic plugs into the shiftboard in your car to quickly diagnose what’s the problem with you car. It provides diagnostic codes within a few minutes and tells the mechanic if anything is wrong, and if so, where.

So in such a world, is there a real need for human diagnosticians? Probably not if this vision comes true. The upper level resident asserted how bad this would be for people, but didn't say why. The sub-intern, considering a vision that's more realistic, said if we doctors carry around tablet PCs that gets all the pertinent history/physical exam information electronically, perhaps after a nurse checks the patient out and types in what she heard and saw, won't we just stand by a patient’s room, download the info into their PCs, and not ever take a single step into the room or exchange a single word with their patients?

Technology, he implied -- and it's often the case in other arenas -- would disrupt the doctor-patient relationship. It would get in the way of the human connection. So then I asked why we couldn't use technology, like simple diagnostic software, as tools? If we do, we can become better doctors.

When put that way, the upper level, seemingly the most upset by the mere notion that info technology could replicate the work of doctors, agreed. Technology, if used by humans to augment their abilities instead of replacing them, would be a good thing.

We had two lovely pharmacists with us, and their perspective was interesting. Apparently mechanized robots already dispense medications and have replaced pharmacists who worked as mere dispensers. Not only at the VA, but in mail-order pharmacy companies and in some high-volume retail spots like CVS that find advantages in automating the filling of thousands of prescriptions.

So what have pharmacists done to deal with this? “We’ve had to change our roles.”

“Y’all don’t just dispense medicines any more, right?” I asked.

“No actually, we counsel patients and help doctors get the right drugs to their patients.”

At this point I mentioned Dan Pink’s book A Whole New Mind to make a point that automation of low-end routine work allows people to do more high-end, less routine work, work that's more valuable. (If you want to read his thesis, here's his Wired essay "Revenge of the Right Brain" from early 2005)

One form of routine work is diagnosing common ailments. In fact, Mr. Pink writes about software in use that uses decision trees that patients use by answer questions to arrive at a preliminary diagnosis. "Health care consumers have begun to use such tools both to 'figure out their risk of serious diseases -- such as heart failure, coronary artery disease and some of the most common cancers -- [and] to make life-and-death treatment decisions once they are diagnosed,' reports the Wall Street Journal" (45).

During our powwow I briefly mentioned the narrative medicine movement which aims to train future physicians to see patients' histories as literary narratives that follow an arc, helping them better read between the lines and thus getting more out of patient interviews.

I’m not sure if I accept the premise that reading a patient history as a short story will make one a better doctor quite yet, but the movement is certainly there because some people passionately believe it will. Mr. Pink writes, "Several leaders in the medical field are urging that the profession shift its overarching approach from 'detached concern to empathy,'... The detached scientific model isn't inappropriate, they say. It's insufficient... Rules-based medicine builds on the accumulated evidence of hundreds, and sometimes thousands, of cases... But the truth is, computers could some of this work. What they can't do -- remember, when it comes to human relations, computers are 'autistic' -- is to be empathetic" (168).

The idea struck a chord in my attending’s mind. He said, “So what you Raj, and I guess Dan Pink actually, is trying to say is that technology, instead of getting in the way of the human relationship as [our sub-intern] believes, actually allows physicians to build on it.”

I think so. Again quoting Mr. Pink, "According to Newsweek, '72 percent of Americans say they would welcome a conversation with their physician about faith'" (223). But medical students don't learn how to do this, and as importantly, there are too many biomedically relevant facts and numbers to get out of patients and their charts, and then to consider and play with and throw into algorithms, that there is almost not time left to talk about spiritual and other social matters, despite desires to do so and the medical acceptance that such matters do make a difference in recovery. It's likely if doctors were trained in how to use new technology to help make proper diagnoses, they'd be able to spend more time getting to know their patients in practice.

In the end, my attending was undecided (or perhaps kept his opinions to himself) as to how technology would influence medicine and the role of physicians.

But technology and its cultural effects are already changing medical education as "the curriculum at American medical schools are undergoing its greatest change in a generation" (52). Mr. Pink documents the narrative medicine program at Columbia, how Yale med students take art classes to hone their observation skills, that "more than fifty medical schools across the United States have incorporated spirituality in their coursework," how UCLA established a "Hospital Overnight Program" to have its students playact as patients going through the entire admission program to learn what they go through, and a new measure of physician effectivness centered on empathy developed by Jefferson Medical School.

While these changes in medical education aren't centered around learning new technologies per se (which is probably unnecessary for students who grew up playing on computers and surfing the web), it's definitely advances in technology that have allowed for, nay pushed, the humanistic aspect of being a doctor to more prominence, and perhaps eye-to-eye with the eternally desired aspect of being supremely knowledgeable.

And so like fellow pharmacists and many other professionals and blue-collar workers, technology will force physicians to change the way they do things. Is technology a threat? Yes, it's a threat to the status quo.

But it's not a threat to physicians who are willing to change. Technology, used as a tool, will allow competent physicians to be faster, more accurate, and more empathetic. Better able to manage people's overall well-being, physicians will be as important in people's lives as they have always been. Technology will make good doctors better, not obsolete. After all, a computer may gain the upper hand in scientific competence compared to the human mind, but it can never replicate the compassion that pours forth from the human heart.

You can tweak your physiology to lower your blood pressure with this nifty device

Hypertension is easily controllable through a combination of medications (calcium channel blockers, beta blockers and vasodilators like nitrates and ACE inhibitors) & lifestyle changes (quitting cessation, reducing salt in the diet, being more physcially active), but an interesting device claims to reduce blood pressure by simply changing the way one breathes.

It's not too wild an idea, for it's (almost) common knowledge that changing your breathing pattern to deeper, slower breaths that "go all the way down to the stomach" (in reality, down to the base of the lungs) can reduce symptoms of anxiety very swiftly.

According to its Amazon product page, this is what the product does specifically.

RESPeRATE is a portable, computerized electronic device that guides you through sessions of interactive, therapeutic breathing powerful enough to lower blood pressure.

Using a breathing sensor, RESPeRATE automatically analyzes your individual breathing pattern and creates a personalized melody composed of two distinct inhale and exhale guiding tones, delivered through comfortable earphones.

Of the 29 reviews, most are 4-5 stars (5 being the best score for an item sold on the webseller's site). Of course, there are limits to the device's effectiveness. One reviewer writes, "If your high plood pressure is caused by stress and the cares of life, RESPeRATE may work for you. But there is no mechanism by which it can address or cure arteriosclerosis."

And it is also costly at $299. Still, it may be cheaper than having to take a single medicine for 20 years (assuming co-pay for a generic remains $15). And the device is clearly superior than drugs in one regard: no side effects.

It is side effects that often bring patients to the hospital. And on the flip side, they compel people to not take their meds. This latter effect leads many patients to develop complications which end up requiring expensive and not-so-healthy hospital stays.

Does RESPeRATE work? Yes, according to a 2003 paper published in the American Journal of Hypertension. Titled "Nonpharmacologic Treatment of Resistant Hypertensives By Device-Guided Slow Breathing Exercises," it demonstrates that in those resistant to anti-hypertensives (i.e., who do not respond as desire to medications designed to lower blood pressure), the device lowers blood pressure by 12.9 on avergae in systolic pressure and 6.4 in diastolic pressure. Not drastic reductions, but reductions nonetheless. And it encourages compliance because of no side effects. Unfortunately the sample size is too small at n=17 to extrapolate the results with certainty among the general hypertensive population.

Still, the team that developed RESPeRATE deserves praise for challenging a health problem in a novel way that uses the body's own mechanisms to promote good health, and in a way that may be cheaper and certainly eliminates side effects and increases patients' compliance.

What's in store for American healthcare? Don't consult an eight-ball, pick up the AARP's magazine instead

One need only scan the table of contents of AARP's weekly Bulletin magazine to learn what direction baby boomers and their elders want to take healthcare, and how they perceive conventional medicine today.

Here's what you'll find inside the July/August issue of the Bulletin:

Inside is a blurb on a study that ran in JAMA earlier this year that shows while older Britons spend less than half what older Americans spend per capita on healthcare, they live healthier lives.

(On a side note, here's a blog discussion at TPM Cafe that uses the study to criticize American healthcare, and a Reason magazine article that argues Americans are not sicker but simply "worked up" more than Brits for disease. Whatever the truth may be, it's almost certain that AARP readers perceive that Britons do live better lives and that our system(s) is terrible. And perception is truth.)



Article titled "Drugmakers May Reap Windfall From Rx Benefit": "Thanks to the new Medicare prescription drug plan, drug companies are in line to see a $2 billion bonanza."

Feature article titled "Coverage for All" about two states, Massachusettes & Vermont, which have enacted universal health care plans. "Are they leaders or simply anomalies?"

Article titled "Funding Freeze ": "NIH's budget freeze could stall crucial studies of disease. Is a slowdown in medical research avoidable?"

Short piece titled "Recipe for a Long Life": "The rewards of mixing Chinese tradition and Western science."

Section named "Health Discoveries": "Fighting fat by sleeping longer...Wobbly balance and walking problems may be signs of dementia...and shaking shingles with a new vaccine."

Finally, not truly a healthcare issue, but still a health issue people over 50 care about: "Brain Aerobics - This month's exercise requires you to supply the beginning wise words to complete sixteen proverbs."

More signs that doctors are beginning to see patients as consumers

This old NYT article (from August 20th, 2005) titled "Sick and Scared, and Waiting, Waiting, Waiting" delivers yet more evidence that more doctors & staff are waking up to the reality of consumer-led market pressures and hurrying to make the best of it.

The article addresses in particular the common patient complaint of waiting to see a doctor.

Waiting has long been part of medicine. Patients like Ms. Odlum wait for test results; others spend weeks or months waiting for appointments or stranded for hours in doctors' waiting rooms.

But health care researchers say the waiting problem has only gotten worse. Advances in technology have created more tests and procedures to wait for, and new drugs and treatments mean more people need more doctor visits. Doctors' appointments for people over 45 increased by more than 20 percent in the last decade, according to the National Center for Health Statistics. Emergency room visits increased by 23 percent, although the number of hospitals declined by 15 percent.

Some doctors say they doublebook appointments to make up for patient cancellations. And doctors say they are pulled in so many directions that, in many cases, long waits are unavoidable.

"There is nothing magic about waiting," said Dr. Charles K. Francis, president of the American College of Physicians.

"Most of us have patients in the hospital and patients in the office," Dr. Francis said. "Then the patient has to go to the lab, and medicine is unpredictable."

He added that insurance companies reimbursed doctors at lower rates than in the past, resulting in intense pressure to see large numbers of patients. "You have to work long hours and see more patients just to keep your office open," he said.

It seems market forces, in this case dictated by insurance companies, was one reason waiting time has increased. Another is more advanced technology and better diagnositic tools and therapies. The article then addresses how market forces from consumers are compelling doctors in the other direction.

Recently, however, patients, some doctors and researchers have begun to ask why medicine cannot be as accountable to its customers as any other business. And some doctors' offices and hospitals are starting to solve their waiting problems by applying techniques that businesses use.

Dr. Philip Greenland, chairman of the department of preventive medicine at the University of Michigan, woke up to the frustration of waiting when he was seeking care for his mother broke her hip and he was unable to see doctors in a reasonable amount of time.

"What was shocking about this experience to me is that it's almost the only time in my life since I've become a doctor 35 years ago that I ever experienced medicine directly, from the patient's point of view," he said. "What this tells me is that the profession has lost sight of what medicine is all about. It's not about them. It's not about their schedule. It's about the patient."

He added: "Doctors are not victims here. If they are unable to handle the workload, they need more help. If it means inconvenience, they have to live with it."

Another physician suffered burnout from the problems generated by the practice of medicine that was generating the waiting problem for patients. Instead of using slowly changing aspects of his practice, he did something drastic. "He quit his three-doctor practice and started a new one.
'I started with one room, an exam table and no employees, just me,' he said. Instead of having about 2,000 patients, he cut back to 500. Not only did he get rid of waiting times, but, by getting rid of most of his office and all of his staff, he eliminated his overhead, making his practice affordable."

Oddly, the article ends rather cynically (perhaps realistically).

But few doctors are ready for such a solution. Most, Dr. Murray says, tell him, "Waiting times are not bad, waiting times are acceptable."

That attitude, he noted, is part of the culture of medicine.

"It grows out of that insularity that we get to decide who waits and who doesn't," Dr. Murray said.

To keep your heart healthy, follow good habits & drop the bad ones

Most people accept the above as common knowledge. But some, especially people in the medical profession, need scientific proof before accepting it as a truism, and rightly so. And a recent study finally provides some.

The AP article "Lifestyle trumps drugs for a healthy heart: study" reports on a study which will be run in the American Heart Association's journal Ciruculation. Says lead researcher Stephanie Chiuve, Sc.D. of Harvard, "This shows there's no substitute for a healthy lifestyle." According to the results,

Middle-aged men on these medications [for high blood pressure and cholesterol] can reduce their chances of heart problems by 57 percent by eating right, not smoking, drinking in moderation and maintaining a healthy weight while exercising regularly, the researchers said.
Those who do not take the drugs can cut their risk of heart ailments by 87 percent if they adopt these lifestyle choices.

Being a long-term study with a large sample size ("43,000 men between 40 and 75 who were free of diabetes, heart disease and other chronic conditions when the study began in 1986 [who] completed biannual questionnaires and [where] researchers used the data to tease out correlations between heart disease and lifestyle habits.") means the results are more likely to be statistically valid and applicable for the same group in the general population.

Since not smoking alone reduced risk for heart problems by 50%, we would drastically reduce the number of heart attacks and strokes if there were more effective nicotine abstinence programs for the at-risk group and if insurance companies paid them to go.

(My attending at the VA, an oncologist, said today that of all the patients who develop cancer in their lifetimes, fully "1/3rd" would not do so if absolutely no one smoked tobacco. And another side note, a new drug named Varenicline, an antibody which blocks nicotime receptors in the brain and thus prevents the dopamine rush from smoking, seems to be more effective in helping people quit smoking than the conventional therapy Bupropion, or Wellbutrin as it's commonly known, according to a study cited in JAMA. The drawback is that there are some unwanted side effects. Point is there are effective interventions for tobacco addictions already, and it's time they were more commonly used by people who wish to quit.)

Those people & companies who try to help middle-aged and older men & women develop the five beneficial lifestyle factors noted in the study -- eating right, not smoking, drinking in moderation, maintaining a healthy weight, and exercising regularly -- will find that there is a big collective demand for this help that our current healthcare system(s) is not designed to meet.

And any organization that ventures to provide all the parts -- the medical personnel to monitor a person's heart and cardiovascular system and give proper medications, drug-abstinence coaches and support groups, nutritionists, educators, a gym with exercise equipment and trainiers -- will find that there is profit to be made.

Just imagine a YMCA combined with a specialized clinic oriented around heart care, and stocked with the right lab machines and people, providing resources and perhaps more importantly encouragement for people to develop and follow healthy habits.

This concept isn't stuck in the world of ideas, however. It is in fact operating in the real world for diabetes management in Houston at clinics run by Diabetes Centers of America.

A book made me think about the Internet

I recently put down "The Victorian Internet," a book about the creation, early adoption, mass acceptance & demise of the telegraph. In it, Tom Standage points out how the telegraph & its effects are similar to the Internet. (Sometimes the comparisons are a stretch, but mostly they hold.)

Out of the many ideas presented, two provoked me:

The telegraph and its inventor [Morse] were praised for uniting the people of the world, promoting world peace, and revolutionizing commerce. The telegraph was said to have "widened the range of human thought"; it was credited with improving the standard of journalism and literature; it was described as "the greatest instrument of power over earth which the ages of human history have revealed."

Before and after this passage Mr. Standage points out the anticipated effects of telegraphy were overstated and overhyped: people did not unite, world peace did not come & business was still business but only faster. I wonder if the same could be said of the Internet, often hailed as revolutionary and as important as the printing press in the course of human history, and which I believed to be the case rather blindly until reading this book.

Of course the telegraph-based network differed from the Internet in one critical way: accessibility. The Internet is accessible by anyone who can read and has in front of him or her a connected computer. People who don't own a computer can get on the web at their local library. The telegaph on the other hand was not accessible like this. Additionally, one needed to be highly skilled to decipher and to send messages using the telegraph. This isn't the case for the Internet.

Which brings me to the other passage: "Thanks to the relentless pace of technological change, telegraphy was changing from a high-skill to a low-skill occupation; from a carefully learned craft to something anyone could pick up." This is because when automatic telegraphs that decipher electrical impulses into letters and numbers mechanicistically hit the scene, they became fully operable by unskilled labor.

And this reminded me of a meeting I had with a clinical informatics professor last week. He was showing me his nifty diagnostic software made for the Internet. It let the user seeing a patient answer questions that would build a history & physical report and then answer more questions to lead to a diagnosis. Which made me think that if a group of doctors are simply specialists in "diagnosis", and such a diagnostic "device" is accessible to anybody on the web, then where is the big demand for this group? Can the Internet lead to such drastical changes in medicine?