Two insights in Time's article on passing on the healthcare buck

Time magazine's 30 October 2006 article "Pressure on Your Health Benefits" is about how companies are passing on more costs of the health benefits they provide onto their employees in order to reduce the cost to their bottom-lines. But two back-to-back paragraphs I found more interesting.

This one says that the model of HSAs (Health Savings Accounts) promoted by President Bush doesn't benefit the account holders in terms of both health and personal costs:

A study by benefits-consulting firm Watson Wyatt Worldwide found no correlation between high-deductible plans and companies with the lowest health-care costs. And a Rand Corp. report last week showed that people with such coverage more often forgo necessary care--which generally leads to greater expense later.

And this one is about companies recognizing that preventive healthcare is more cost-effective than treating things when they go wrong:

Indeed, most corporations are focused on giving employees incentives to stay healthy. Some 60% promote preventive care through wellness programs, including smoking cessation and health-club discounts. "More than ever before, companies are seeing the link between good health and productivity," says Beth Bierbower, vice president of product innovation for insurance provider Humana. "So they're engaging employees more on what their personal needs are."

New screening guideline for the deadliest form of cancer?

Researchers in New York report that millions of lives could be saved by detecting lung cancer early with annual CT scans and treating it immediately, when it can still be cured.

That line came from the NY Times article "Study Sees Gain on Lung Cancer," and is about the results from a study that was published in the NEJM. And as the article explains, there are many problems with the idea of having people go through regular CT scans of the chest (to look for lung cancer), similar to regular mammograms (for breast cancer), colonscopies (colon cancer), and pap smears (cervical cancer, which may be a thing of the past because of the new anti-HPV vaccine).

Austin hospitals are walking the walk on preventive care

For years many healthcare policy works and others have asserted that the our system(s) should be re-oriented around preventive care, as it's more cost-effective than treating patients for acute complications of chronic disease.

Well, it turns out that the Seton hospital system in Austin (where I used to volunteer as a college student) not only buys that assertion but does something based on it, changing the way it provides care.

In one 18-month period, Ms. Dodd, 38 [and an insulin-dependent or Type 1 diabetic], was rushed almost monthly to the emergency room, spent weeks in the intensive care unit and accumulated more than $191,000 in unpaid bills.

That is when nurses at the Seton Family of Hospitals tagged her as a “frequent flier,” a repeat visitor whose ailments — and expenses — might be curbed with more regular care. The hospital began offering her free primary care through its charity program.

With the number of uninsured people in the United States reaching a record 46.6 million last year, up by 7 million from 2000, Seton is one of a small number of hospital systems around the country to have done the math and acted on it. Officials decided that for many patients with chronic diseases, it would be cheaper to provide free preventive care than to absorb the high cost of repeated emergencies.

With patients like Ms. Dodd, “they can have better care and we can reduce the costs for the hospital,” said Dr. Melissa Smith, medical director of three community health centers run by Seton, a Roman Catholic hospital network that uses its profits and donations to provide nearly free care to 5,000 of the working poor. Over the last 18 months, Ms. Dodd’s health has improved, and her medical bills have been cut nearly in half.

Reaching out to uninsured patients, especially those with chronic conditions like diabetes, hypertension, congestive heart failure or asthma, is a recent tactic of “a handful of visionary hospital systems around the country,” said Karen Davis, president of the Commonwealth Fund, a foundation in New York that concentrates on health care. These institutions are searching for ways to fend off disease and large debts by bringing uninsured visitors into continuing basic care.




This isn't just happening in Austin. According to the 25 October 2006 NY Times article "Hospitals Try Free Basic Care for Uninsured," hospital systems in NYC and Denver have been encouraging patients to visit community clinics for negligible to no fees, so that their chronic conditions are better managed and they themselves can avoid going to the ER.

Has picking up the tab for preventive care saved these organizations any money? Yes, according to these statements.

Denver’s public system, Denver Health, has 41,000 uninsured patients enrolled in its clinics. Officials there calculate that for every dollar they spend on prenatal care for uninsured women, they save more than $7 in newborn and child care....

A special effort to educate 631 asthma patients saved the plan $475,000 in one year, Seton officials said...

Ms. Dodd still has problems, but the use of a $3,200 insulin pump paid for by Seton, which automatically adjusts her insulin levels, along with access to an endocrinologist and home counseling have reduced their severity. Her care in the last 18 months has cost Seton $104,697, far below the $191,277 for the previous period. More important, the later figures include less hospital time and more medicines and expert advice.

“The money we save,” Dr. Smith, of Seton, said, “money that is not hemorrhaging through the I.C.U., is money we can do so much more with to help her upfront.”

Seton has gone a step further by offering free preventive care for patients not traditionally eligible for free care from their charity fund.

In a more unusual step, Seton officials also look for frequent emergency room users who do not qualify for the hospital’s charity plan because they live in a different county, like Ms. Dodd, or have incomes just above the threshold. In a dozen cases so far, all involving diabetics, a committee has judged that it makes financial sense to bring these people into the charity plan anyway and provide intensive support.

The article highlights state efforts to reduce costs and increase coverage with "the creation of subsidized, bare-bones policies for small businesses. Vermont, Maine and especially Massachusetts are using combinations of state and federal money and employer mandates to extend insurance. "

But this isn't the case here, where "without counting the large immigrant population, Texas has the country’s highest share of uninsured, at 21 percent." Which is why Seton's model is more interesting, since it may provide a lesson for all hospital systems in Texas.

In addition to Seton, another Austin hospital named St. David's runs the People's Community Clinic to care for about twice as many patients as are covered by Seton's charity fund. And luckily for locals, "Austin hospitals and charity clinics have also joined in a pioneering data-sharing system to track visits by uninsured patients and fight unnecessary use of the emergency room."

While Seton and St. David's are addressing the cliched problems of our healthcare system(s) in innovative ways, their measures are considered a "band-aid." Still, with little motivation from our national and state leaders to more drastically reform healthcare, a band-aid is what's needed in the immediate. And thus, Seton and the other progressive hospital systems provide not only a beacon of hope, but models that can be applied by others.

Food playing a bigger role in health consciousness

As many people move from thinking of health from the perspective of something going wrong to thinking of it from the perspective of keeping things right, food is becoming more important.

This 16 October 2006 Marketplace radio episode titled "An unhealthy obsession with eating healthy?" shows how some may be taking this desire to eat healthily too far, and according to one doctor, how this condition labeled "Orthorexia" could be an eating disorder.

But, as Kai Ryssdal put it, "here's the thing about orthorexia: Unlike most afflictions, the worse it gets, the better you feel."

You can listen to this Marketplace piece by clicking here.

Greatest medical breakthrough since 1840?

So asks the British Medical Journal in this webpage, and many have responded with posts offering an array of answers. Check it out as it's being constantly updated.

My vote? Penicillin, which was discovered accidentally by Dr. Fleming and kicked off the era of antibiotics, which made possible the taming (of course not the end) of infectious disease, which had been the most common killer of people for thousands of years. (It still is the most common killer of people in most developing nations.)

First they attacked smoking inside restaurants and bars, and now it's trans fats

New York City proposed banning trans fat in all food served in its restaurants, one of two public health measures to be discussed in a public hearing on October 30th. This is the specifics of the trans fat ban, according to the advocacy website BanTransFats.com:

The first initiative is a partial phase-out of artificial trans fat in all New York City restaurants. This proposal allows restaurants six months to switch to oils, margarines and shortening that have less than 0.5 grams of trans fat per serving. After 18 months, all other food items would need to contain less than 0.5 grams of trans fat per serving. Packaged food items still in the manufacturer’s original packaging when served would be exempt.

The second initiative would require restaurants that already make calorie content publicly available to also post it on their menus and menu boards commencing March 1, 2007.

(These proposals can be seen in official form at this NYC health department webpage.)

While the second initiative seems sensible to me, the first does not. How could the city regulate such a broad-sweeping law? Are there enough staff to run lab tests on all the pizza, burgers and whatever else is served in the Big Apple? So one problem is logistics. Also, loopholes about. According to The Week Magazin's interpretation of John Tierney's piece in The New York Times, "If restaurants are compelled to eliminate trans fats, they’ll just go back to using traditional, artery-clogging fats such as butter, lard, and beef tallow, which are no healthier."

Another problem is that this ban may be unconstitutional -- after all if enactd the ban impinges on people's basic right to eat what they want and to suffer the consequences. According to the NY Post, one college student said, "I mean, I'm not a healthy eater, but if I decide I want to eat bad food and gain five pounds, that's my choice... And if I die from clogged arteries, that's my choice, too!" And this position was supported by the WSJ, according to The Week Magazine's 6 October 2006 article "Trans Fat: Banned in New York."

Why does NYC's health department want to take such a drastic measure? The Week Magazine cites that "trans fats play a major role in the ongoing epidemic of obesity, heart disease, and premature death."

Dr. Thomas Frieden, MD, MPH, NYC's Health Commissioner would agree. He writes this in an essay printed by the New York Daily News.

Like lead in paint, artificial trans fat in food is a hazardous, unnecessary additive that causes serious health problems. We can act today. Or we can wait, as other cities did with lead paint, while it continues to harm thousands of people.

That's why this week, the Board of Health approved for public comment a proposal to get artificial trans fat out of our restaurants.

The case for such restrictions is clear. Our responsibility is to protect New Yorkers' health. When scientific evidence is clear and we can do something about a problem, we would be negligent not to act.

Dr. Frieden writes that it will not be difficult for restaurants to stop using trans fats, since many food items that used to be cooked with trans fats no longer are and still taste as good, like Oreo cookies.

And what is his response to the assertion that it isn't the government's business to decide on people's food habits?

Despite the overwhelming evidence, some insist that government should not be involved in curbing trans fat consumption. But that's what people thought when New York City established a safe water supply, banned lead in paint, and fluoridated our water. Each of those measures was controversial. And each of them has helped millions of people stay healthier.

If we take this step, we'll have the same wonderful variety of great-tasting food we've always had. But it will be safer, and we'll all be around to enjoy it longer.

Taming the Peanut Gallery

It's interesting to learn how antibodies are being created (or induced by artificial antigens) to stimulate the body's immune system to fight disease. But this is a twist: antibodies are being created (or induced) to reduce the anaphylactic reaction that occurs when peanut proteins stimulate mast cell release of inflammatory reactants into the bloodstream. In other words, these antibodies are supposed to reduce peanut allergies.

An estimated 1.5 million Americans, including some 600,000 children, experience allergic reactions to peanuts, ranging from hives to nausea to sometimes-fatal anaphylactic shock. With most of the annual 150 food-allergy deaths blamed on peanuts, many schools have created peanut-free zones or gone totally "peanut free."

The number of children with peanut allergies has skyrocketed, doubling from 1997 to 2002, according to a study in the Journal of Allergy and Clinical Immunology.

Nobody knows why, and the peanut association continues to funnel millions to develop ways to reduce peanut allergy. Some of the other ways researchers are tackling the problem.

There is a vaccine being developed made of "slightly modified the three peanut proteins responsible for most reactions so they don't trigger such strong reactions from human mast cells. By administering the modified proteins to subjects in slowly increasing doses, they hope to condition their immune systems to tolerate more."

Another approach with some success so far: "powdered or liquid peanut proteins [is administered] to patients in incrementally increasing doses, starting with 0.001 peanut the first day, to one whole peanut six months later. They hope one day to develop a drug or a physician-administered therapy. In a trial completed on eight patients, Dr. Burks says the subjects tolerated 13 peanuts before experiencing a reaction -- enough, in theory, to save an allergic child's life in case of accidental ingestion."

Yet another take is going to the root of the problem: "to disable the Ara h 2 gene [' responsible for a protein that causes reactions in about 90% of patients with peanut allergy'] by modifying the peanut plant's genetic structure."

(Courtesy of the 29 Sept 2006 WSJ article "Taming Peanut Allergy Takes Researchers Down Uncertain Road" by Jane Zhang.)

"The Rise of the Medical Prosumer"

This essay by Dr. Tom Ferguson, MD (who unfortunately passed away this past spring -- may he r.i.p.) was so well-written I reprint it in its entirety below.

The term "prosumer" was coined by futurist Alvin Toffler in his book The Third Wave. Toffler suggests that for most of the last 200 years, our society has been divided into two groups: the producers, who make or deliver our goods and services, and the consumers, who use them. He believes that one of the hallmarks of the new information age is the rise of a third group, prosumers, who produce many of their own goods and services.

Thus while a consumer might go to the local McDonald's, a prosumer might shop at a local natural food store, pick some vegetables from a home garden, and whip up a tasty, nutritious meal. The term "prosumer" is a most fitting term for those of us who have a strong personal commitment to self-care.

Physicians usually call their clients patients, or, more recently, health consumers. Both these terms have always made me squirm. My dictionary defines patient as " . . . a sufferer . . . one who bears misfortune, provocation, or pain without complaint.... an invalid.... a long-suffering person who is compliant and resigned."

So much for "patient." "Health consumer," isn't much better. We don't really "consume" health, nor do professional health workers produce it.

Based on statistics derived from his market research, John Fiorillo of New York's Health Strategy Group and I have described three levels of selfcare involvement: People minimally, moderately, and strongly committed to self-care. I've come to think of these three groups as passive patients, concerned consumers, and health-active prosumers:

[Go to the article here to see the chart.]

If our predictions are correct, the number of health-active prosumers should grow more than 10-fold by the year 2000.

Who are these new health-active prosumers? They're the ones who feel responsible for their own health, who believe that they can do more to keep themselves healthy manage illness problems than their doctors can. They're the ones that order the vegetarian special and the salad with oil and vinegar on the side. Get up early enough and you'll see them in your neighborhood, running or walking to stay in shape.

Who are these new health-active prosumers? Get up early enough and you’ll see them in your neighborhood, running or walking to stay in shape.

Many passive patients feel they needn't worry about their health. When they fall ill, some magical doctor will make everything all right. If they develop heart disease, their doctors will simply pop in an artificial heart.

Health-active prosumers no longer subscribe to this old Marcus Welby model of medicine. They have a much more realistic understanding of what doctors can and can't do. They know that heart disease risk increases with smoking, stress, high blood pressure, lack of exercise, and lack of social connections, and they no longer harbor unrealistic expectations of being "saved" from self-induced illness. They work hard at keeping themselves healthy because they know that if they fall ill, there may not be much their doctors can do.

Passive patients expect doctors to take care of them. In exchange, they are willing to be helpless and passive, giving physicians the control.

Concerned consumers want to participate as respected junior partners in the doctor-patient relationship. While they may ask questions and seek out second opinions, they generally go along with whatever the doctor recommends.

Health-active prosumers, on the other hand, take care of themselves— either on their own or with the help of whatever advisors or consultants they choose, be they orthodox or alternative. They frequently seek advice, but generally retain the final decision for themselves. They do not hesitate to disagree with their health advisors.

Although they may consult physicians, health-active prosumers do not commit themselves in advance to follow their doctor's orders. If they aren't satisfied with a doctor's opinion, they have no qualms about seeking additional information, trying new approaches, or simply waiting and watching.

Health-active prosumers appreciate physicians who listen and are willing to negotiate. They like to pinpoint areas of agreement and disagreement, and hammer out a mutually acceptable compromise. This process, similar to that found around any bargaining table, is all too rare in doctor's offices.

Health-active prosumers prefer physicians who communicate clearly and respectfully, avoid jargon and time pressure, and keep interruptions to a minimum. A physician shows respect by listening without interruption, by making eye contact, and by responding directly to both spoken and implied questions. Doctors who interrupt constantly, who refuse to be interrupted, who use such common responses as "Let me worry about that," or "Don't concern yourself with that," or who conclude a complex set of instructions with a hasty, "Any questions?" will in all likelihood not see the health-active prosumer a second time.

Post-heart attack prescriptions: aspirin, beta-blocker, ACE inhibitor... and fish oil?

In Germany, St. John's Wort is first-line treatment for mild depression, thanks to findings by the country's government-funded Commission E. But not here in the States, where SJW is not taught as being a therapy for depression, at least at my school. And there may be reason for that, as two US trials (with some funding by drug companies, apparently) found the herbal pills to be ineffective.

I learned earlier today that this isn't the only discrepancy between what is prescribed here versus what is prescribed across the Atlantic for the same exact ailment. From a 3 October 2006 NY Times artcle entitled "In Europe It’s Fish Oil After Heart Attacks, but Not in U.S.":

Every patient in the cardiac care unit at the San Filippo Neri Hospital who survives a heart attack goes home with a prescription for purified fish oil, or omega-3 fatty acids.

“It is clearly recommended in international guidelines,” said Dr. Massimo Santini, the hospital’s chief of cardiology, who added that it would be considered tantamount to malpractice in Italy to omit the drug.

In a large number of studies, prescription fish oil has been shown to improve survival after heart attacks and to reduce fatal heart rhythms. The American College of Cardiology recently strengthened its position on the medical benefit of fish oil, although some critics say that studies have not defined the magnitude of the effect.

The article's author Ms. Rosenthal then writes about the way American patients are dealt with post-myocardial infarction:

But in the United States, heart attack victims are not generally given omega-3 fatty acids, even as they are routinely offered more expensive and invasive treatments, like pills to lower cholesterol or implantable defibrillators. Prescription fish oil, sold under the brand name Omacor, is not even approved by the Food and Drug Administration for use in heart patients.

There are two websites for Omacor, one tailored to Continentals it seems, and the other seems British.

“Most cardiologists here are not giving omega-3’s even though the data supports it — there’s a real disconnect,” said Dr. Terry Jacobson, a preventive cardiologist at Emory University in Atlanta. “They have been very slow to incorporate the therapy.”

She then states that the reason behind this discrepancy is "the central role that drug companies play in disseminating medical information" in the U.S. "

“If people paid more attention to guidelines, more people would be on the drug,” Dr. Jacobson said. “But pharmaceutical companies can’t drive this change. The fact that it’s not licensed for this has definitely kept doctors away.”

Interestingly, Europeans have found that Omega 3 fatty acids are so cardio-protective that it is unwise to not prescribe them. Even critics arguing that the benefit is overstated still swallow their fish oil pills.

“Using this medicine is very popular here in Italy, I think partly because so many cardiologists in this country participated in the studies and were aware of the results,” said Dr. Maria Franzosi, a researcher at the Mario Negri Institute in Milan. “In other countries, uptake may be harder because doctors think of it as just a dietary intervention.”

In the largest study of fish oil — conducted more than a decade ago — Italian researchers from the Gissi Group (Gruppo Italiano per lo Studio della Sopravvivenza nell’Infarto), gave 11,000 patients one gram of prescription fish oil a day after heart attacks. After three years, the study found that the number of deaths was reduced by 20 percent and that the number of sudden deaths by 40 percent, compared with a control group.

Later studies have continued to yield positive results, although some scientists say there are still gaps in knowledge.

This summer, a critical review of existing research in BMJ, The British Medical Journal, “cast doubt over the size of the effect of these medications” for the general population, said Dr. Roger Harrison, an author of the paper, “but still suggested that they might benefit some people as a treatment.”

Dr. Harrison said he believed that people should generally increase their intake of omega-3 acids, best done by eating more fish.

Still, he acknowledged that it was difficult to eat foods containing a gram of omega-3 acids each day. “If you ask me do I take omega-3 supplements every day, then, embarrassingly, the answer is yes,” said Dr. Harrison, a professor at Bolton Primary Care Trust of the University of Manchester in England.

“I, too, am caught up in this hectic world where I have little time to shop and prepare the healthy foods I know I should be eating,” he said.

Since the 1990s, much praise has been showered on the "Mediterranean diet," which is high in fats and yet seemingly causes less cardiac events than other diets. This counterintuitive phenomenon may be explained outright by the high content of Omega 3 fatty acids found in fish and nuts that are integral parts of the Mediterranean diet. And likely this is why Italy has been home to the most research on the effects of fish oil, and why it is so popular among doctors there.

Nonetheless, the practice of prescribing fish oil by American doctors for cardio-protection may be increasing thanks to guidelines and the existence of a purified fish oil in the form of Omacor.

The American College of Cardiology now advises patients with coronary artery disease to increase their consumption of omega-3 acids to one gram a day, but it does not specify if this should be achieved by eating fish or by taking capsules. But over-the-counter preparations of fish oil have much less rigorous quality control and are often blends of the two fish oils know to be beneficial in heart disease with other less useful fatty acids.

For that reason, Dr. Jacobson of Emory gives the prescription drug, “off label,” to cardiac patients, even though the F.D.A. has not approved it for that use. “Then I know exactly what they’re getting, and there is no mercury,” he said.

Patients & doctors better monitor side effects with the aid of I.T.

Information technology is making it easier for people who use medications to report their side (a.k.a. adverse) effects and thus improve the completeness of drugs' profiles, taking this out of the hands of pharmaceutical companies.

Currently, accoring to the 3 October 2006 WSJ article "Researchers Ask PatientsTo Help Fill Gap in DataOn Side Effects of Statins," there is a reporting system in place: the FDA's Adverse Event Reporting System, which collects reports on drugs from "doctors, pharmacists, pharmaceutical companies and patients."

Predictably, the drug companies assert that the AERS works fine. In response to UCSD's Statin Effects Survey site, drug companies "say there already are extensive data on statin side effects. Pfizer, maker of the top statin brand, Lipitor, says 400 clinical trials of 80,000 patients have produced a 'substantial amount of data by which to assess the drug's safety,' says Barbara LePetri, senior medical director in Pfizer's cardiovascular group."

While that is a substantial sample size, drug companes are perceived to be less than trustworthy, and the AERS upon which many reports are based has flaws.

[B]etween 1999 and 2002, the number of adverse events being reported dropped 21%, due in large part to procedural changes that mean "non-serious" events are less likely to be entered into the database, either because the drug has been around for three or more years or because the product labeling already warns consumers about the issue, according to a report last summer in the Archives of Internal Medicine.

AERS is particularly problematic when it comes to statin therapy, some doctors say. For one, men are the biggest users of statins, but the Archives report noted that women are far more likely to report adverse drug effects than men. But perhaps the bigger problem is that many purported side effects of statins -- muscle aches, thinking problems and fatigue, among others -- are common complaints associated with aging. As a result, patients may talk to their doctor about mild aches, memory problems or fatigue, but many doctors just tell them it's part of getting old and don't think to report the complaint as a side effect of statin use.

UCSD's effort, funded by a Robert Wood Johnson Foundation grant, was founded to address patients' frustrations. "'They say "My doctor won't listen to me or my doctor says it can't be related to the drugs,"' says Dr. [Beatrice ] Golomb," who is the creator of the statin site.

There is a far more ambitious project brewing between the FDA and MIT, so reports a CBS News HealthWatch article from 18 August 2006. Their system would "detect unanticipated problems with prescription drugs and medical devices" by scanning through "federal and private health care databases in real time for unusual and emerging patterns that could indicate potential safety concerns."

A more automated system capable of mining on the fly multiple databases, including those compiled by health insurance providers and agencies like the Veterans Administration, would be better at recognizing patterns suggestive of emerging problems, [the FDA's deputy commissioner for scientific and medical affairs Scott] Gottlieb said[, comparing it to the current AERS.]...

The FDA also plans to begin publishing reports for doctors that would alert them to potential problems with drugs and devices, Gottlieb said. That could prompt doctors to watch for similar problems and report them when found to the FDA. The reports would resemble the Centers for Disease Control and Prevention's Morbidity and Mortality Weekly Report, which regularly alerts doctors to outbreaks of disease.

This push to use I.T. to improve the monitoring of drugs is likely the result of the Vioxx tragedy.

Software can help make better diagnoses

I don't have the best memory, and often rely on my PDA to find out what dosages to recommend or what esoteric disease i'm leaving off a differential diagnosis. And I wonder how doctors, so far removed from their training years, can remember what they learned -- especially the rare diseases -- all the while keep up with new diseases and treatments.

Apparently, this is a problem. It certain was for one young girl who's father decided to do something about it. This, from the 23 May 2005 WSJ article "Software for Symptoms":

To the several doctors who examined three-year-old Isabel Maude in 1999, her malady at first seemed to be a routine case of chicken pox. But the fever wouldn't drop, her skin had developed a bluish discoloring and she complained of increasing pain.

Eventually rushed to the emergency room, the toddler spent two months in the hospital -- half that time in intensive care -- suffering from multiple organ failure and cardiac arrest brought on by toxic shock syndrome and necrotizing fasciitis (sometimes called the "flesh eating" disease).

Isabel's brush with death was a life-changing experience for her father, Jason Maude. He eventually left his career as an insurance company's investment manager in London to become one of the founders of a venture that makes software designed to help physicians make diagnoses. Mr. Maude believes that "diagnostic-decision support software," which aims to reduce misdiagnoses by presenting physicians with a full array of possible conditions, might have made all the difference for his daughter.

"We all know computers are better at remembering things than we are," he says.

He started a company named Isabel (after his daughter -- who survived).

Most of today's DDS programs work in a similar fashion: The physician enters basic data about the patient, such as age and sex, along with the patient's symptoms. The program then lists various diseases and conditions to consider, sometimes ranking them by likelihood or organizing them by medical category -- gastroenterology, cardiology, oncology, etc. The systems also enable doctors to look up background material, such as articles from medical journals with the latest disease research.

These programs often suggest maladies that aren't always obvious even to experienced physicians. Consider the case of a 10-year-old boy who came to an emergency room after suffering from nausea and dizziness for two weeks. Harold Cross of Beaufort, S.C., the attending emergency-room physician, says the case was puzzling because the boy had a good appetite, no abdominal pain and only one headache over the two-week period. Dr. Cross found no other physical or neurological problems.

To aid in the diagnosis, Dr. Cross turned to software from Problem-Knowledge Coupler Corp., based in Burlington, Vt. A common thread emerged among the possible causes the program suggested for each of the boy's symptoms: trouble in the back portion of the brain. Dr. Cross ordered an MRI scan, which revealed a tumor in the back of the boy's brain. "My personal knowledge of the literature and physical findings would not have prompted me to suspect a brain tumor," Dr. Cross says. The tumor was removed two days later.

A study published in the February 2005 issue of Casebook, a journal published by the United Kingdom's Medical Protection Society, tested the diagnostic software called Isabel -- Mr. Maude's project -- against 88 cases where doctors had missed the correct diagnosis or had made a delayed diagnosis.

It found that the choices offered by the software included the correct diagnosis for 69% of those cases. (The software is sold by Isabel Healthcare Ltd. and Isabel Healthcare Inc., the two commercial subsidiaries of the U.K.-based Isabel Medical Charity.)

So why hasn't diagnostic software found more of a market? Some doctors say it takes too much time to enter extensive patient data into some systems. "If your HMO allows you 10 and a half minutes to see a patient, how are you going to do this?" asks David Goldmann, a physician who serves as vice president and editor in chief of the Physicians' Information and Education Resource, a guide to clinical care published by the American College of Physicians in Philadelphia.

Others worry about the potential for mistakes whenever computers are involved in medicine. For example, the March 9 issue of the Journal of the American Medical Association is filled with articles about errors in the computerized ordering of drugs and medical tests by physicians. Isabel Healthcare seeks to soothe such concerns by calling its program "diagnosis reminder" software -- to emphasize that diagnostic software leaves the final decision up to the doctor.

There are financial considerations as well. A doctor pays $750 a year to subscribe to Isabel, for example, while a hospital pays $180 per bed. But the majority of the roughly 700,000 practicing physicians in the U.S. are self-employed.

Despite these obstacles, DDS programs will become more popular many in the medical community believe.

Still, there are signs that these diagnostic systems may gradually gain a wider following. The increased use of personal digital assistants, or PDAs, and other handheld computers by doctors could boost the market for diagnostic software. More than half of U.S. doctors use one of these devices regularly, according to a study by the American Medical Association and Forrester Research Inc. of Cambridge, Mass.

And some DDS programs, including Isabel, can be used on PDAs as well as desktops. Doctors may be more favorably inclined toward these programs if they don't have to be tied to their desks to use the software. Meanwhile, some makers of diagnostic programs are trying to address doctors' financial concerns. The home page for Isabel Healthcare, for example, has an "ROI calculator" that doctors can click on to consider the potential return on an investment in Isabel -- including the possibility of avoiding malpractice cases.

The growing adoption of electronic medical records also presents an opportunity for makers of diagnostic software. The DXplain software developed by Massachusetts General Hospital in Boston can be linked to electronic medical records, automatically prompting doctors, for example, about potential causes for abnormal results in a patient's latest lab tests.

"Diagnostic support systems will be more widely used when we can link [more of] them" with electronic medical records, says Octo Barnett, a professor of medicine at the Harvard Medical School and senior scientific director of the Laboratory of Computer Science at Massachusetts General.

Also, Dr. Barnett suggests, as the profession becomes more accustomed to using other forms of health-care information technology, like electronic medical records and computerized ordering of medications and tests, some of the resistance to diagnostic software will fade.

Meanwhile, diagnostic-support programs have benefited from greater input from doctors in their development, as well as from the latest advances in software. The Isabel diagnostic tool, for instance, uses powerful software from U.K.-based Autonomy Corp. to analyze the vast amount of medical information that provides the basis for diagnoses of multiple symptoms. Isabel's use of Autonomy's pattern-recognition technology is a key reason why the program is able to find the most likely matches between symptoms and diseases, says a recent report by Forrester.

"Hopefully, someday these systems won't be a burden to be borne by the physician community, but a tool to be embraced," says Eric Brown, a vice president at Forrester.

According to the review article "New online diagnostic tool launched to help doctors" that ran in the British Medical Journal in 2002, "Trials in four hospitals have found that in 95 out of 100 paediatric cases, the Isabel tool came up with the correct diagnosis. More extensive trials are planned for August of this year." This means Isabel is quite accurate. However the power remains with the human professional. "Lord Hunt, health minister for IT and clinical quality, who attended the launch, emphasised that the software was a support system but it was the doctor who must use his or her clinical training to decide on a diagnosis."

The human brain is limited, and there is no surprise if a few diagnosises are wrong or missed. But according to a 22 February 2006 NY Times article "Why Doctors So Often Get It Wrong," it isn't just a few.

With all the tools available to modern medicine — the blood tests and M.R.I.'s and endoscopes — you might think that misdiagnosis has become a rare thing. But you would be wrong. Studies of autopsies have shown that doctors seriously misdiagnose fatal illnesses about 20 percent of the time. So millions of patients are being treated for the wrong disease.

As shocking as that is, the more astonishing fact may be that the rate has not really changed since the 1930's. "No improvement!" was how an article in the normally exclamation-free Journal of the American Medical Association summarized the situation.

The writer of this article poses a question to end his piece, interestingly. "Clearly, misdiagnosis costs far more than that. But in the current health care system, hospitals have no way to recoup money they spend on programs like Isabel. We patients, on the other hand, foot the bill for all those wasted procedures and pointless drugs. So we keep getting them. Does that make any sense?"

Isabel isn't the only DSS program in the market. Here's one highlighted by Microsoft. These are but two of many.

One interesting question that takes me back to an old post is can computers become better diagnosticians than seasoned doctors? Not better doctors, but better diagnositicians.

Speaking of the VA team (which is still the best team of residents, sub-i's and attending I've been on), I remember a woman who had sudden-onset substernal chest pain mimicking a heart attack. However, the EKG and cardiac enzymes were negative for it. I had just watched a nighttime show on Broken Heart Syndome, and this woman fit the typical picture: middle-aged woman who has chest pain because of a stressor which mimics but isn't a myocardial infarction.

I suggested this disease to my sub-i (the smartest guy in his class according to his peers) and my upper-level resident, but they didn't consider it at all. In fact, my sub-i didn't even heed any attention to BHS until I showed him the Up-to-Date article on it. Why were they so dismissive of BHS? Because they never heard of it. And I think this is another place where these DSS programs can help -- a computer program can keep track of new diseases better than a doctor, especially in this age where information has gone from a trickle to a rushing river.

IDEO's forays into healthcare and insights

IDEO is a neat company I learned about when I read the book The Ten Faces of Innovation by the founder's brother David Kelley, who is the firm's general manager. In the 24 September 2006 issue of US News & World Report, an article on the firm titled "The Deans of Design" describes IDEO's many forays into healthcare.

For instance, IDEO was hired by a St. Louis hospital to improve the patient experience in its emergency room.

While the admitting and treatment process might seem logical and orderly to staff, it appears chaotic and confusing to patients. So IDEO created a simple "map" that the hospital staff could give each incoming patient outlining the seven steps of the emergency room experience, starting with the triage nurse. It also recommended cards that each member of the staff could hand out so the patients could keep track of who's who.



Another instance involves redesigning a device that would handeled often by nurses.

Years of customer observation also helped the company design a portable electronic device for use in hospitals. One option was to put the 20-pound device on a rolling cart. But IDEO realized that nurses would hate hauling the thing around. So designers decided to shape it like a classic 1930s doctor's bag, sturdy handle and all. That design not only made the device easier to carry, but the visual iconography really connected with nurses.

A third instance, though not as fully fleshed out in the article, involves a new tool designed with the involvement of surgeons. And yet another instance has IDEO working with Vocera to create a 2-way wireless device to be clipped onto a shirt pocket (labeled "Star Trek-esque") that is "ideal for hospitals."

Much of this article was about distilling IDEO's keys to innovation. There are three. One is "getting out of the office and into the field." When IDEO sought to redo the St. Louis hospital's ER, it could have interviewed patients to gain insights. But instead, "the firm went up close and personal. For instance, one IDEO anthropologist pretended to be a patient and managed to videotape his entire emergency room experience."

Two is "rapidly prototyping initial ideas and exposing them to users." An anecdote about this key is related to the surgical tool. "During a meeting with a roomful of surgeons from the company's advisory board, not much was getting done... Seeing that this sort of abstract back and forth wasn't getting the group anywhere, an IDEO engineer stepped out of the room for five minutes and came back with a crude tool model slapped together out of a whiteboard marker, a black film canister, and a clothespinlike clip. 'That prototype crystallized the conversation in the room and allowed the project to move forward,' [founder Tom] Kelley says."

And the third key is "storytelling." For Vocera, "IDEO produced a five-minute film that the firm later used to get venture-capital funds and that served as a basis for marketing the product."

Another key to innovation -- not specifically stated by the article's writer -- was mentioned at the beginning of the piece: an interdisciplinary team approach to tackling problems. This firm, "a dream come true for the concerned parents of liberal arts majors everywhere-employs anthropologists, cognitive psychologists, and sociologists, among other right-brain thinkers, to create, improve, or reimagine all manner of products, services, work spaces, and business systems."

Frankly the coolest part of this piece on IDEO is how people at the company used human anatomy to create a new mouthpiece for water bottles.

[B]ikers used a two-step process with the water bottle: pull the nozzle out with their teeth and squeeze the bottle. So, using the human tricuspid heart valve as a bit of inspirational biomimicry, the IDEO team designed a simple self-sealing valve that opens only when squeezed.