Innovations in Healthcare

France leads in EMR

2010-11-25T12:15:00.003-05:00

I thought France was an "old country" that sticks to tradition, an image reinforced by its refusal to let English in, its veneration of rural places like Provence and of its wine and cheese, and how prominent a role agriculture plays in the French economy.

So it came as a total surprise to read that France leads the world in EMR adoption by doctor's offices and hospitals. The assertion made by Ms. Moukheiber, a Forbes blogger, is based on observations made in a book I have to pick up soon titled "The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care" by T.R. Reid.

Here's the blog post. And an excerpt:

Reid’s striking observation is that there are no file cabinets; just a desktop computer. Patients conveniently hand their doctor a green plastic card—the size of a credit card, with a chip embedded. It is their portable electronic health record, and contains every visit, diagnosis, lab test, prescription, x-ray, etc. The doctor slides the card into a special reader, and the patient’s medical history pops up on the computer screen. All payments are also recorded—to who, and how much. An insurance fund pays the doctor in as little as three days.

France’s Ministry of Health told Reid there are no privacy breaches, because the medical information is encrypted.

I don't know enough about France's healthcare system (have yet to read the book), but I imagine it is more centralized and government-controlled than ours (where government pays most healthcare costs but do not run most U.S. clinics and hospitals or employ most American healthcare workers).

Diabetes, the most expensive disease in the world?

2010-11-23T23:15:00.002-05:00

I heard earlier today that United Healthcare released a report on costs related to diabetes. A reporter on APM's Marketplace called it the most expensive disease in the world.

http://marketplace.publicradio.org/display/web/2010/11/23/pm-diabetes-to-become-most-expensive-disease

Why is it the most expensive disease in the world? Because according to UHC, as reported in Bloomberg, diabetes will cost more than $3 trillion over the next decade.

http://www.bloomberg.com/news/2010-11-23/unitedhealth-says-diabetes-will-cost-3-4-trillion-over-the-next-decade.html

Thus diabetes, the biggest cause of blindness and kidney failure in this country, poses a tremendous opportunity for innovative healthcare to address costs and save lives. Already the FDA is proactively encouraging collaboration to develop an artificial pancreas.

http://www.diabetesmine.com/2010/11/fda-artificial-pancreas-hearing-beating-a-path-to-the-real-world.html

I'm a proponent of lifestyle changes, which prevents development of diabetes, and also helps control blood sugar levels in someone with diabetes. Even here, mobile technology is being investigated that may help people make the necessary changes needed.

http://cwphs.calit2.net/index.php?option=com_content&view=article&id=52&Itemid=61

If the next decade or two will be the decade of diabetes as the world's population gets wealthier and adopts a fat- and calorie-rich diet, it will also be the decade where people invent amazing ways to deal with the disease.

Using a salad spinner to diagnose anemia

2010-07-19T21:09:00.006-05:00

Yet another cool low-tech invention in the healthcare space from Rice U., literally in walking distance from where I live: a salad-spinner that's been retrofitted to be a centrifuge that splits blood into plasma and blood cells. It's purpose is to help diagnose anemia in the field among people who live in poor, remote regions of the world. And without electricity, just a bit of muscle power.

The device is called the Sally Centrifuge and you can read about it here and, with more details and a reference to the other cool health-related invention from Rice U. I witnessed last year at a business plan contest, here. (That contest by the way was hosted by the real incubator of these and other low-tech devices, Beyond Traditional Borders.)

Here's a video with a short demonstration of the "centrifuge" and the two inventors. I'm not sure how the resulting separated blood will be interpreted, but I'm curious enough to find out.

From what I understand, it takes about 5 minutes of spinning at 10,000 RPM to get the separation right. I hope the inventors have taken this into account, and that the spinning doesn't tire the user out.

The mHealth movement

2010-07-18T15:52:00.005-05:00

mHealth is the name of the concept of promoting or providing healthcare services via mobile phones. Last year, I contacted the chair of UC-San Diego's Center for Wireless and Population Health Systems to ask about projects they had using mobile phones to promote physical activity and weight loss. He gave me the impression that they were just scratching the surface.

I'll write more of UCSD's projects and supporting data later. For now, I want to highlight a couple uses of mobile technology in personal health.

A July 16, 2010 NY Times article covers apps that display calorie information on a large number of foods and beverages (LoseIt is the one featured here) and calculate limits, which people use to help themselves better restrict their calorie consumption and hopefully lose some weight.

I am a big believer in giving people (or consumers in business-speak) more information (like calories in their diet) so that they can better choices for themselves. Not all people will make better choices, but the ones who want to are better enabled (or empowered in the lingo) to do so. People who are motivated to lose weight are more likely to track their consumption, and...

When you track calories closely, you lose more weight, said Dr. Lawrence Cheskin, associate professor of health, behavior and society at Johns Hopkins Bloomberg School of Public Health.

In another passage, modest gains (or as it were, loses in weight and average blood sugar) are reported by a healthcare provider:

Dana Green, a diabetes specialist at St. Joseph Healthcare Diabetes Institute of Behavioral Medicine in Bangor, Me., has been testing the LoseIt program with a small group of his patients, including the Dodges. Since April, almost all of the 17 patients, ranging in age from 48 to 76, have lost weight and lowered their blood sugar. One man lost six pounds; two of the women in the program were able to reduce their insulin intake by 20 percent, Mr. Green said.

“Patients begin to see their patterns and habits and so make better decisions,” he said. “I’m extremely optimistic.”

There's a companion piece with four recommended apps for losing weight.

Another interesting app keeps one's immunization records together. I like the idea of this app. I was going through my old files and found I have immunization records from elementary school, high school, medical school and from the city health department when I got vaccinated before trips.

It would be awesome to have all those papers collated into one record of vaccine shots. Why? Well, say I step on a rusty nail. And I go to the doctor and ask for a tetanus shot. I'll be asked when was the last time I had a booster shot, and I'd have to say I have no idea. It would be useful to have an idea.

Interestingly, there are apps out there that do that for adults and for children's immunizations. So there you have it. One kind of mobile app that promotes healthy behavior. A second kind that keeps all of your health info organized and easily accessible.

Forcing the hospital's hand

2007-08-18T18:16:00.000-05:00

Medicare recently announced it would not pay for 'hospital errors' or preventable illnesses, like hospital-acquired infections, according to the NYT article "Medicare Says It Won’t Cover Hospital Errors".

Interestingly, Michigan has been ahead of the curve in terms of forcing changes in hospitals there, which has saved lives and money. And the hospitals there improved their rates without employing new technology.

Michigan hospitals have been extremely successful in reducing bloodstream infections related to such catheters, researchers reported recently in The New England Journal of Medicine. The hospitals did not use expensive new technology, but systematically followed well-established infection-control practices, like covering doctors and patients from head to toe with sterile gowns and sheets while the catheters were inserted.

Hospital executives said these techniques had saved 1,700 lives and $246 million by reducing infection rates in intensive care units since 2004.

Some of the complications for which Medicare will not pay, under the new policy, are caused by common strains of staphylococcus bacteria.

Titans of Information Age aiming to transform healthcare

2007-08-14T16:27:00.000-05:00

The NYT article "Google and Microsoft Look to Change Health Care," run in the 14 August 2007 issue, talks about how the two giants are trying to integrate info technologies into healthcare. The key difference is that Google is approaching the consumer exclusively while Microsoft seems to be offering something to both sides of the fence, providers (e.g., hospitals and physicians) and consumers.

Some interesting tidbits from the article.

“What’s behind this is the mass consumerization of health information,” said Dr. David J. Brailer, the former health information technology coordinator in the Bush administration, who now heads a firm that invests in health ventures.

"A Harris poll, published last month [July 2007], found that 52 percent of adults sometimes or frequently go to the Web for health information, up from 29 percent in 2001." Furthermore, "58 percent of people who look online for health information discussed what they found with their doctors in the last year."

“The doctor is becoming a knowledge navigator,” [John D. Halamka, a doctor and the chief information officer of the Harvard Medical School] said. “In the future, health care will be a much more collaborative process between patients and doctors.”

"There are plenty of competitors these days in online health records and information from start-ups like Revolution Health, headed by AOL’s founder, Stephen M. Case, and thriving profit-makers led by WebMD."

"Indeed, it is the market reach and deep pockets that Google and Microsoft can bring to consumer health information that intrigues medical experts, and has lured recruits. Dr. Roni Zeiger, a graduate of Stanford’s School of Medicine, a medical informatics researcher and a former primary care doctor, joined Google last year. The 36-year-old, who still sees patients some evenings and weekends at a nearby clinic, said, 'At Google, I can use my expertise and knowledge to potentially help millions of people each day.'"

I have written about Microsoft's forays into healthcare here and here.

Google Health has been fleshed out apparently. Here are some screen shots. And here's how the article described it:

"A presentation of screen images from the prototype — which two people who received it showed to a reporter — then has 17 other Web pages including a “health profile” for medications, conditions and allergies; a personalized “health guide” for suggested treatments, drug interactions and diet and exercise regimens; pages for receiving reminder messages to get prescription refills or visit a doctor; and directories of nearby doctors."

CDC: number of doctors visits jump

2007-07-03T22:11:00.000-05:00

The CDC reported this past week that the number of patient visits to primary care medicine and surgical doctors' offices jumped by 20% between 1995 and 2005.

From the Reuters' article 'Survey finds U.S. hospital, doctor visits balloon':

"It was only a few years ago that we released that the total number of visits had reached 1 billion. And now we are up to 1.2 billion," Catharine Burt of the CDC's National Center for Health Statistics said in a telephone interview.

"That's a 20 percent increase in the just the last five years -- a huge number," said Burt. "I can tell you that the number of hospitals and physicians has not increased 20 percent."

The reason is clear -- Americans are getting older. "When you reach 50 things start going wrong, just little by little, and you keep going back to the doctors," Burt said.

Big Business trying to fix healthcare

2007-06-30T16:56:00.001-05:00

A February post from the blog 'Fixin' Healthcare' struck me because I have come to the same conclusion over the last couple years: Big Business will change healthcare in many ways, and more so than government will, and all to reduce costs.

One such change is changing the focus to prevention from treatment.

This notion is echoed by a recent article in "Businesses Help Workers to Lose Weight". This article is about the many small businesses that are pushing the wellness industry into the mainstream.

As Mike Huckabee, the former Arkansas governor I call the 'healthy living' governor because of his forceful promotion of obesity-fighting policies, said, "The truth is CEOs are the ones that have to address [the many problems in the healthcare system]."

Hey pharmtender!

2007-06-30T16:49:00.000-05:00

The NY Times piece "Old Drugs In, New Ones Out" is about an interesting development in drug R&D: combining old drugs that are off-patent and using this new product to treat a disease not treated by the original two.

There seem to be 3 reasons behind this new type of drug development: it's tough to discover new drugs that do work and are also safe, many drugs are coming 'off-patent', and information technology advancements have made it possible to try "several thousand [combinations] of medicines a day" affordably.

One of the companies profiled is CombinatoRx:

At its laboratory here, researchers and robots systematically pair about 2,000 generic drugs with one another, with 2 million different combinations possible. Each is tested on human cells. If a drug pair inhibits the cells’ production of inflammatory proteins, for example, that might be reason to explore whether the combination might work against arthritis.

Mr. Borisy describes it as a “dumb, brute-force, empirical approach” that assumes current knowledge of disease is too limited to predict in advance what combinations might work. The company does, though, give priority to testing pairs it believes have the best chance of working.

Eight of the company’s randomly arranged marriages, including drugs for cancer, arthritis and diabetes, have moved into clinical trials — an unusually high number for a company that is only seven years old. Other companies are taking more calculated approaches. Orexigen, in creating its obesity drug Contrave, took a treatment used for drug and alcohol addiction and combined it with an antidepressant sometimes used to help people quit smoking.

Alzheimer's

2007-06-11T21:07:00.000-05:00

“I think this is going to be the disease, and maybe one of the biggest health care political issues of my generation,” says Robert Essner, 59, Wyeth’s professorial chief executive. “It’s hard for anyone to envision how to provide health care in the United States if you’re going to have to deal with the burden. You just start to add up the cost, 20 years from now as my generation gets old — it’s phenomenal.”

This is from "Taking On Alzheimer’s" in the NY Times on how lots of money is being spent by drug companies to develop medicines to blunt the progress or even cure the disease, which because of the aging population will become a larger problem in the near-future.

“There is money to be saved, but it is not going to be cheap”

2007-06-11T20:47:00.000-05:00

So says David M. Cutler, a health economist at Harvard University, as quoted in the NY Times article "Who Pays for Efficiency?"

Indeed, the quest to save dollars in the nation’s $2.1 trillion annual health care bill is becoming a lucrative market of its own. Thousands of companies, large and small, are pitching cost-saving ideas that range from electronic patient records to new medical devices.

It’s not all marketing hype. Experts in health policy agree that there is a real opportunity to curb health spending, which last year was the equivalent of $7,000 for every man, woman and child in the country. Studies predict a gain of as much as 30 percent in efficiency, mostly through reducing unnecessary tests and prescriptions, paperwork and medical mistakes.

Such streamlining would not cut the nation’s total medical spending, as long as there is a growing aging population with ever-increasing health needs. But certain measures are expected to help keep costs from spiraling.

One theme of the article is that incentives are 'screwed up'. For example, reformers and corporations push primary care doctors to computerize their patient records by buying computers and an electronic medical systems. So who reaps the benefit from all this streamlining of some processes?

Insurance companies, mostly. In fact the doctors featured in the article have not seen an increase in their income, although their practice now does with three less workers. So where is the incentive for other primary care doctors to computerize their practices?

Money is the big incentive driving trends in healthcare, and this is seem in many examples. Sure less open heart surgeries are done with the advent of angioplasty and stents, but many more of those procedures are done than the number of less open heart surgeries.

“The trigger for intervention is lower and the pool of treatable patients is larger,” said Dr. John D. Birkmeyer, director of surgical outcomes research at the University of Michigan and a co-author of the journal article. “These are institutions with an incentive to increase the supply of surgically treatable disease. It’s a matter of if you build it, they will come.”

As the article states, entreprenuers are ready to help solve problems like complications from the mainstream use of new procedures like stenting. But their solutions are often costly.

Dr. Dean Ornish (a graduate of my school!) said pushing technology to treat and manage disease is the wrong approach to reducing healthcare costs. Instead, says the proponent of preventive care, let's focus on "low-tech approaches".

More than 90 percent of heart disease, Dr. Ornish insists, is preventable.

Over the years, Dr. Ornish has led several projects showing that fundamental changes in diet, exercise and stress management can stop and even reverse heart disease.

Preventive programs cost money upfront, but can cut overall treatment costs to insurers by 30 percent or more, yet few insurers pay for preventive care.

A third of people with health coverage switch insurers every year, so insurers reason that their investment in preventive health measures could become another company’s gain.

That attitude may be changing, though. Last year, Medicare agreed to cover a dietary program designed by Dr. Ornish.

Still, high technology reigns because there is so much venture capital investing in high tech (which tends to reap higher rewards, the thinking goes) like new medical devices, and because people in general want to feel that everything is being done when their lives are on the line -- and are usually willing to pay (or have their insurers pay) for it.

Interesting comments on WSJ's post on retail clinics

2007-05-27T15:33:00.000-05:00

I recently wrote about retail clinics regarding Illinois considering tightening regulation of them. Here's a WSJ Health Blog post about these clinics in general, and the comments I found most interesting were:

My prediction is that after a certain amount of time and the certain demise of many of the ckinics, the remainder will actually begin to have physicians as the staff. Prices will rise but will still remain relatively affordable. And doctors offices will respond by offering similar services since there is no barrier to competition.

Makes sense. After all, the supply of willing NPs are limited versus the number of primary care docs.

My wife and I have both used the medical service Target provides for our flu shots. There were no lines and the cost was half of what our phycian would have charged. Perhaps these services are similar to those provided by stores like 7 - 11. We still shop at Safeway, but 7 - 11 is more convenient on occasion. I think we should encourage service differentiation well matched to service needs.

A recogonition that retail clinics offer a better value than doctors' offices for services like vaccines.

While the quality of care and physician-patient relationship may be compromised or non-existent in this type of setting, these retail clinics may be a great solution for keeping non-emergency healthcare needs out of the ER during evenings and the weekend.

Don't know if I agree with this one, but being in the ER and seeing a few common complaints not belonging in the ER every day I certainly hope it comes true.

Another problem with these quick in-store clinics is many patients with apparently simple problems, the kinds the clinics treat, actually are not so simple.

Quite true! I see many cases in the ER, such as cuts that actually are abscesses tied to a person's unmanaged diabetes that also aren't ER cases per se but require a more advanced look at the person's health.

I believe that web based communication between doctor and patient will be more useful than Minute Clinics.

...
I believe that innovations in IT will make Minute Clinics obsolete. If a doctor knows his patient, he can do more in less time and at lower cost via communication with the patient over web site or telephone than the Minute Clinic can.

Oncoming generations of doctors and other healthcare workers will definitely make better use of Internet technologies to improve patient care.

The reality is anyone who has looked closely at this model will quickly determine that they cannot even break even (and one malpractice lawsuit and they are history). The rush to open these centers is the “dot com” of the healthcare. The real draw is the traffic these stores get after the visit.

Are they breaking even already?

Of course they [retail clinic nurses] are going to miss some diagnoses. Of course they’re going to overprescribe antibiotics. However, doesn’t that happen in the ER anyway? The complaint from hospitals, hospital based physicians is the prices are high because they see non emergencies in the ER. Wouldn’t it be nice if there was a place you could go after 5 in the evening or on the weekend, that you didn’t have to wait 4 hours, that didn’t cost a few hundred dollars and get at least seen and/or treatment? I’ve been seen by NPs and PAs and receive the same level of care, maybe even better as they tend to spend a little more time with patients.

A good point to consider if you're torn between visiting the ER, where I have seen most patients wait 8+ hours to see us, and a retail clinic where for cheaper you can see a nurse almost immediately in comparison.

What these clinics will not do is exert any real downward pressure on the medical cost trend in the US. 80% of our costs are driven by the 20% of Americans with chronic complex medical conditions. Treating these efficiently and effectively is a long term commitment requiring continuity between patients and providers, not well suited for drive-in/drive-out episodic care delivery models.

This is a good point to those who believe retail clinics will drive down the cost of overall healthcare. It won't, although I could see it dropping down the costs of basic healthcare (flu vaccines, treatment for minor infections and bites, getting your stitches out, get refills on prescriptions, yearly physical exams, etc.).

Try No. 3: Entrepreneurism fills in the gaps

2007-05-27T15:18:00.000-05:00

In the title above, I refer to Atul Gawande's essay where he concludes at the end that there are two possibilities to the future of the US healthcare system.

Ventures such as retail clinics (e.g., MinuteClinic, RediClinic), clinics focused on managing one disease (Diabetes America), online comparison sites mandated by states and founded as private enterprise (PricePoint, HealthGrades.com), and a host of others are filling in gaps between what people want and what the healthcare system currently provides.

And as long as there are gaps in healthcare, I have faith that social and capital entreprenuers, as it is said about Nature when it is hemmed in or temporarily tamed, will continue to always find a way.

Illinois docs feel threatened by retail clinics

2007-05-23T16:25:00.000-05:00

The Financial Times article "Wal-Mart health clinics divide US medics" describes how the state of Illinois is considering to enhance the regulation of retail clinics. This is due to pressure from its medical association, which no doubt feels that primary care doctors' livelihood is threatened.

[But a]dvocates say the clinics will improve access to healthcare and reduce costs; that they will reduce more expensive visits to hospital emergency rooms; and that they will catch some illnesses before they become serious and costly. As a result, physicians will have more time for complex cases.

...

Dr Rodney Osborn, president of the Illinois State Medical Society, said: “This is a brand new animal. That’s why we believe legislation is important to guarantee patient safety ... They’re not putting these things in to provide healthcare; these people are businessmen.”

If retail clinics make better sense to patients and their long-term health and will even save a part of the healthcare system (the ER) money, doesn't the complaints of these doctors appear more self-interested and less patient-centered? And aren't doctor practices businesses too?

Dr Arnold Milstein, chief physician at Mercer health consultancy, says doctors are playing on patient fears to thwart change.

“[Doctors] wrap themselves in the holy garb of quality ... completely ignoring the facts that all the research shows current care stinks,” Dr Milstein says. “The weaknesses that are endemic in the current healthcare system are being trotted out to block innovation and change.”

Nature's healing touch

2007-05-06T15:22:00.000-05:00

I only write because in the space of a few days there were articles regarding health and three natural substances (though processed into products): dark chocolate, honey and coffee.

The Reuters piece on dark chocoloate was more about the boom in sales but mentioned the antioxidant flavonols found in cocoa and their cardioprotective effect (here is a recent study supporting the claim).

The AFP piece on honey's ability to kill bacteria and thus prevent, in this case, the amputation of an ulcerated foot belonging to a diabetic person. A physician using so-called honey therapy has launched a study to gather more support for the claim. (This study concludes that honey inhibited growth of several bacteria species.)

(Aside: Unfortunately honey bees have been dying off rather mysteriously.)

The Reuters piece on coffee's health benefits touts its ability to ward off type 2 diabetes (according to this 2002 Lancet article) and perhaps some cancers, according to a panel including a public health professor at Harvard. This was tempered by evidence that coffee can increase incidence of leukemia and stomach cancer. So, like most things in life, moderation is key.

Manipulating Hollywood

2007-04-29T08:54:00.000-05:00

A recent Time piece on Harvard School of Public Health's campaign to persuade Hollywood filmmakers to take out smoking or to make smoking look unglamorous (where smoking is a necessary part of the script) was eye opening.

I never knew that Hollywood was persuaded once before to take up a public health issue. It bought into the designated driver campaign to reduce drunken driving accidents. And the campaign worked because it reaches basic human nature. As written in Time magazine:

"If there's one thing health experts know, it's that you don't influence behavior by telling people what to do. You do it by exposing them to enough cases of people behaving well that it creates a new norm. What made the designated-driver concept catch on in the 1980s was partly that Harvard and the ad agencies it worked with persuaded TV networks to slip the idea into their shows. There's a reason a designated-driver poster appeared in the bar on Cheers, and it's not because it made the jokes funnier."

Harvard which led that campaign believes there were obvious benefits to influencing the 'superpeers' of TV. "'The idea appeared in 160 prime-time episodes over four years,' says Jay Winsten, HSPH's associate dean. 'Drunk-driving fatalities fell 25% over the next three years.'"

The idea is elucidated by Robert Cialdini in his influential (for lack of a better word) book 'Influence': as more important or influential people do (or don't do) something, the more of mass public are persuaded to join in doing (or not doing) that same thing. The same idea explains why the 'superpeer', the composite person portrayed by films and other media, is able to influence teenagers' drug and sexual behavior.

As the article details, the campaign is working in Hollywood, albeit slowly. It's also building momentum as other organizations devoted to health and public safety join in.

"As Harvard closes in from one side, a dozen health groups including the American Medical Association are calling for reduction of smoking in movies and on TV, and 41 state attorneys general have signed a letter seeking public-service ads at the beginning of any DVD that includes smoking. Like smokers, studios may conclude that quitting the habit is not just a lot healthier but also a lot smarter."

Lesson: To change people's behavior, enlist people like Scarlett Johansson!

Should doctors be taught nutition?

2007-04-28T14:32:00.000-05:00

"The public-health community has come to recognize it can’t hope to address obesity and diabetes without addressing the farm bill."

A thought-provoking quote from Michael Pollan's (of 'The Omnivore's Dilemma' fame) essay on how US farm legislation subsidizes -- and thus promotes -- the growth of corn, soy and rice, crops that allow for mass production of cheap food lacking nutrition and filled with calories (e.g., the twinkie) and thus directly (following the chain of events) lead to increase rates of obesity.

Healthcare workers can't overcome the legislative incentives. In other words they can't directly change what most farms raise. But they can promote diets more conducive to healthy living and less conducive to gaining unnecessary weight. That was my 'takeaway' from the essay.

I've often thought that med school (as well as dental school) needs to teach its students about nutrition. Not just what deficiencies in vitamins lead to (conditions we don't see often in this country like marasmus, goiter, scurvy and kwashiokor), but rather how taking in certain molecules are linked to better cardiovascular and mental health (like omega-3 fatty acid is) or how particular eating habits prevent cancer (as does eating a diet heavy in vegetables and fruits).

And schools ought not only teach these things, they ought to show these associations are in fact scientifically supported if not proven and encourage students to give these 'health tips' to patients when they are working in the outpatient or clinics setting. This would get the message out more effectively, and help the system convert to a more preventive health orientation.

Of course some will charge that there are nutritionists to do this type of promotion. I agree. They certainly do good. But if doctors aren't singing the same tune and are oblivious to what people ought to be eating to prevent becoming obese, then the message becomes diluted or weak.

So I'm not saying docs should be nutrition to replace nutritionist. Rather, I'm saying that docs ought to learn it so that everyone on the healthcare team is on the same page, and so patients are being taught from all sides what is good for the body.

Two articles on marketplace forces & the future of healthcare

2007-04-22T19:21:00.000-05:00

An essay by Jonathan Cohn (who just published "'Sick: The Untold Story of America's Health Care Crisis - and the People Who Pay the Price") appeared in the NY Times back on April 1st. "What's the One Thing Big Business and the Left Have in Common?" is about the surprising alliance between big companies like Safeway and Wal-Mart and labor unions and Democrats.

In particular, the essay details the journey taken by Democratic Senator Ron Wyden of Oregon and Steve Burd, the hard-nosed CEO of Safeway. Especially interesting is Mr. Burd's story of how he became interested in wellness and preventive medicine because of his family's health history, and how he tried ingraining the habits he learned into his employees.

"Burd says the results were impressive: in 2006, the first year of full implementation, employees who enrolled in the newer plans, with the greater individual cost-sharing, had their personal health-care bills drop by 20 to 30 percent, while the company's health bill for those employees shrank by 11 percent. (It is unclear what happened to the costs of people who stayed in the old plan.)"

A long time ago I told a group of friends that if the United States implements universal healthcare, it will be because of big business. Of course this sounds counter-intuitive. But it isn't since many companies spend more on their people's health than on anything else, and thus lowering healthcare costs is a corporate issue. This essay deflty elaborates on how some corporations want universal healthcare to look like (think Mitt Romney's "individual mandate" that requires every citizen to own a health insurance policy).

(The piece came to me thanks to my pal Vik R.)

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The Economist this week updates us on the retail health clinic in "McClinics". The growing popularity of the business model among consumers is based on the problems of how doctors' offices and ERs run.

"IN NO other industry is the relationship between the consumer and the provider as unbalanced as in health care,” says Joseph Maloney of Health Stop, a pioneering retail health-care chain. In a recent case study on his firm prepared by Regina Herzlinger of Harvard Business School, Dr Maloney observed that the typical patient frequently waits a week for an appointment, then an hour longer at the doctor's office or, worse yet, is forced to go to an emergency treatment centre. As Dr Maloney summarised, “Any dry-cleaner that operated this way would be put out of business.”

The article proclaims that the boom in the concept has just started, and is driven because it offers two things: convenience and low price. And Dr. Maloney says that a third reason that would compel more consumers to get their healthcare at these 'minute clinics' is consistency.

School does what it can to reduce childhood obesity

2007-04-14T14:35:00.000-05:00

The tale of a Wyoming school district's proactive policies on reducing childhood obesity is detailed in the WSJ article "In Obesity Wars, A New Backlash" (sorry, subscription needed). The 'new backlash' comes from teachers (because soda machines are banned from schools including the teachers' lounge), parents (some are acutely sensitive to their kids being called fat by school) and kids.

However, the main proponent of the Healthy School Task Force policies at the school district, Dr. David Fall (a pediatrician who also serves on the school board), says that "the importance of the program 'outweighs any temporary hurt feelings'." Also he says there hasn't been public opposition to his committee's policies outside of a few negative comments, putting the backlash in a new perspective. Here's one person who's glad the school is helping him lose weight.

More power to Dr. Fall and his task force I say. Why? Because obesity is a medical issue. Obesity is associated with higher risk of heart disease and diabetes in adulthood, period. Are high blood pressure and high blood sugar bad? Yes, for these conditions impair the quality and the quantity of life. We think nothing of promoting those habits that reduce hypertension and hyperglycemia. Ergo, obesity is bad too and should be prevented.

Furthermore, as the doctor in the article says, kids who are obese are more likely to be unhappy; this study in a 2003 issue of 'Nature' journal adds to the body of evidence asserting that obesity causes mental health problems like depression.

School is the best place to teach kids how to be healthy and to help obese kids lose weight and improve their prospects for good health in the future.

Kids spend more time in school than anywhere outside of the home. School is where kids learn about all kinds of subjects deemed important by society like writing, reading, mathematics, history, natural science and so on. Why should health not also be taught? I can't think of a good reason not to teach kids those things that are scientifically proven to be good for the body (e.g., eating more fruits and vegetables is linked to increased longevity, eating less saturated and trans fats is linked to lower levels of cholesterol, etc.).

Plus at school kids gain habits that stay with them for life, like how to be social and work with others, how to read and how to write and how to learn. That's undeniable. Thus if healthy habits can be picked up by kids at school and if such habits will stay with the kids for a lifetime, should schools not do what they can to better ensure healthy habits are promoted at school? Yes.

I was all for taking fatty foods and sugary drinks out of school as Texas' agricultural commissioner did years ago (old post) and I am all for teaching exercise and techniques to reduce stress (after all chronic psychological stress is linked to eating more and obesity) because good diet and physical exercise means better health for these kids as they become adults. Go Dr. Fall and his team in Gillette, Wyoming!

Hospital invests further into retail clinics

2007-04-11T13:55:00.000-05:00

The Houston Chroincle reports today that Hermann Hospital has invested more deeply into retail clinic company RediClinic, which operates clinics inside HEB stores here in Texas.

The hospital believes retail clinics can be profitable because patients would be sent with conditions too complicated to be dealt by NPs in a retail setting or referred to Hermann doctors for long-term management.

Since RediClinic got its start about two years ago, Memorial Hermann-affiliated doctors have provided oversight for the nurse practitioners who provide care inside retail stores, said Mischer, who previously served as the chief executive of Hermann Hospital for two years.

"Their taking an economic interest in the company evolved over that period of time," he said.
Memorial Hermann Chief Executive Dan Wolterman said Tuesday that the foot traffic into the retail stores was part of what attracted him to RediClinic.

I believe this is really smart of Hermann.

And it is completely opposite of the reaction of a group of tired pediatric residents who last fall complained about these clinics and how they would force many of them to keep longer hours or odd hours and compete with them on price. I sympathize with the pediatricians and their concern over how retail clinics would affect their careers.

But I cannot sympathize with the pediatric residents' position. These retail clinics aren't a bad thing at all if operated properly.

They promote preventive care, which means people who go there will less likely become acute sick. And if retail clinics succeed on a large scale, this will relieve pressure off overworked and understaffed ERs. Furthermore this will save taxpayer funds which could be used to provide other services or could be returned to taxpayers. So retail clinics will make possible preventive care which will save society money. Seems like a win-win situation for the consumer-patient, the hospital and the taxpayer.

(I wrote about the growing industry twice already, once in April and once again in September.)

Where there's a will, there's a wii!

2007-04-03T22:21:00.000-05:00

In addition to vending machines and fast food at school, video games have been the scapegoat of childhood obesity. This is intuitive since in general video games require players to sit in front of the screen and compel no physical activity. And too many kids, as the cliche goes, spend hours playing video games.

There's probably some truth in that commonly held perception. However, the Nintendo Wii has changed the way video games are played and may, as a by-product, compel physical activity so strenuous as to help overweight children lose weight.

This was the gist of a recent WSJ article on the Wii entitled "A Wii Workout: When Videogames Hurt".

The new console has been wildly successful, selling out at stores and winning high marks from critics and game buffs. But as players spend more time with the Wii, some are noticing that hours waving the game's controller around can add up to fairly intense exertion -- resulting in aches and pains common in more familiar forms of exercise. They're reporting aching backs, sore shoulders -- even something some have dubbed "Wii elbow."

In one study printed in Pediatrics this past year, Dr. Lorraine Lanningham-Foster and her team found that playing one physical activity oriented video game in particular, "Dance Dance Revolution," helped lean kids burn more calories than spending the same amount of time on a treadmill while watching TV.

So the idea of physical activity oriented video games helping overweight kids lose weight, based on the observations that many kids don't like to get physical activity outside or their parents feel it is unsafe for them to and that kids seem to get involved deeply in video game play, is promising, as is the idea of using video games to give all kids in general a chance to develop physical exercise habits.

I'm currently helping with a project to create a 'wiimnasium' -- an exercise facility of physical activity based video games -- at the local children's hospital. Stay tuned.

Going to the bazaar for medical services

2007-04-02T23:48:00.000-05:00

"Bargaining Down That CT Scan Is Suddenly Possible" in the 27 Feb 2007 NY Times gives an interesting peek into a new business: helping consumers who must pay for procedures bargain down the prices of those procedures.

Companies like MyMedicalControl.com find the rates insurance companies pay hospitals for procedures and use those prices as baselines when they bargain on behalf of consumers. What is the payoff for the company? A "35 percent collection fee" off of what is saved, apparently.

And the payoff for the consumer? Lower medical bills. According to the article, "[f]rom a typical claim of $1,100, Mr. Cahill said, the company shaves an average of $232." That's substantial.

Another company called Vimo.com uses federal Medicare data to arrive to its estimates for procedure prices and points to one reason this business is even possible: better access to data via the Internet.

Recent legislation from state governments provide another reason. "Rudimentary information is increasingly available to consumers. Thirty-two states now require that hospitals provide pricing information to the public."

There are critics who charge that improved price transparency won't help reduce overall healthcare costs. I'm not sure what to make of it, but for the many people who must pay out of pocket because of lack of insurance or because they use a Health Savings Account, it seems increased price transparency and the business services that have sprung as a result of this does help protect the wallet.

And as the article points out, this service is likely to grow fast. Why? Because more healthcare costs are coming straight from -- for better or worse -- more people who are obviously more sensitive to costs and have less power than insurance companies in making sure they are paying a fair price.

What about cognitive errors?!

2007-03-28T16:50:00.000-05:00

The latest issue of Time has a review of Dr. Jerome Groopman’s new book “How Doctors Think” which presents the four categories of cognitive errors that doctors make in thinking about their patients’ problems.

Much has been made about “technical errors,” such as mixed up lab orders, and how they contribute to up to 98,000 deaths among American hospital patients each year, and thus the errors of our decision-making, the “cognitive errors,” are totally overlooked.

These errors, Groopman claims, have graver consequences. He learned that about 80% of medical mistakes are the result of predictable mental traps, or cognitive errors, that bedevil all human beings. Only 20% are due to technical mishaps -- mixed-up test results, hard-to-decipher handwriting and the like.

So what are the four cognitive errors doctors make that can harm their patients? Using stereotypes instead of facts to inform decisions, being influenced by having “seen something like this,” a bias toward action over thought and negative emotional reactions to certain patients.

I believe it's hard for physicians to change these types of errors. We should be aware of them and do our best to overcome these mental traps. However, as the neuroscientist Antonio Damasio asserts (and which too many economists were blind to because of their faith in rational motives as the end-all be-all explanation for why we buy what we do), emotion plays a central role in cognition and decision-making.

And human nature, because it relies heavily on emotion and cannot shortcircuit emotion's influence on reasoning and logic, will force physicians to fall back on these errors despite the best of efforts. (I’m making the case for most doctors, as I’m sure there are some exceptions to the rule.)

So I say instead of trying to change fundamental human nature, let's create tools to overcome it. Patients’ health must not suffer because of human folly if it can be overcome. And it can. Technology after all is used to reduce technical errors, so why should it not be used to reduce cognitive errors too?

It seems to be happening under the radar, actually. I wrote about the Isabel computer diagnostic tool before. Of course, more must be done to spur the adoption of these tools as well as to develop new ones. This seems like a big opportunity for entrepreneurs!

The VA may be ahead of the technology curve, but...

2007-03-23T01:34:00.000-05:00

I have written about the VA hospitals in the past, impressed by the use of EMR/EHR systems. It's a sign of progressiveness.

However, every so often one is reminded that technological advacement does not a better service make by itself if money and quality people are lacking. The news about the poor conditions of the Walter Read barrack opened investigations into military hospitals. One VA hospital here in Texas (luckily not Houston's) was shown to provide very poor care over & over again.

The patients range from terminally ill Vietnam-era veterans seeking cancer treatment, to a decorated Marine wounded in Northern Iraq who is now dealing with post-traumatic stress disorder and drug addiction.

Their complaints begin with the long wait just to be admitted to the hospital, but they don’t stop there. Once in the system, they describe an uncaring and unresponsive staff unwilling to provide even the most basic care. The most serious allegations suggest misdiagnoses, if not malpractice.

This is an excerpt from "Investigation Reveals VA Hospital Conditions" by Ginger Allen for Dallas' CBS station.

Preventive Medicine using Imaging but at a High Price

2007-03-16T19:17:00.000-05:00

Two days ago I had the privelege of shadowing a great endocrinologist in Austin. It was at his clinic that I was introduced to the idea of doing both ultrasound imaging and fine needle biopsy of the thyroid in-house.

What was far more interesting to me -- because it doesn't fall within "endocrinology" (e.g., diabetes/pancreas, thyroid and reproductive organs) -- was that the clinic sonographers can also take an ultrasound image of the carotid arteries and then tell you if there is too much thickening of the intima and media, the inner two most layers of the carotid artery, and thus determine one's risk of ischemic stroke.

Called CIMT (for Carotid Intima Media Test), this is a non-invasive procedure that takes less than 3 minutes. And the cost? $299, though the clinic is currently running a special for $199. Does insurance cover this screening test? No.

And there is another non-invasive imaging test called this review article.) Cost at the heart hospital in Austin? $199.

I believe focusing on preventive medicine is important for preserving or enhancing a patient's quality of life and for lessening the cost burdens on our healthcare systems as a large portion of complications can be averted.

However, in these cases the barrier is high cost. Only a small segment of Austinites can afford to get screened for the health of their carotid and coronary arteries. Which means for the most people this kind of preventive medicine is unavailable.

Still, this is a step in the right direction. And with most technology costs, it will fall in time so that more can afford it.

Time will also tell if these preventive measures help reduce stroke and heart attacks. If they are found to be effective and also become cheaper, then insurance companies and the government will more likely cover them in the future to the benefit of most Americans.

However, in time the promise of these imaging-based screening tools can prove false, as a recent study showed with CT screening for lung cancer. As one NY Times article judged it, based on the article published in JAMA in March 2007:

Lung cancer screening with CT scans does not appear to save lives and exposes people to serious risks of injury and even death from needless surgery, researchers are reporting today.

None of this is to say that we shouldn't keep trying to find effective screening tools that will prevent disease and death. We should, by all means. All this does is puts the promises of new untested screening tools in perspective.

Tablet PCs (finally!) for healthcare

2007-03-13T19:18:00.000-05:00

In searching for news on Catalis, about which I wrote my last post, I learned about another Austin company that exists in the health IT field: Motion Computing. Led by a former Dell exec, Motion has redesigned the tablet PC specifically for doctors, nurses and other healthcare workers.

Their tablet PC is called the Motion C5 and seems to be -- according to this Austin American-Statesman article -- either endorsed or designed with the help of both Intel and UCSF's medical faculty. Features of the C5, as quoted in the article, are:

The book-size device comes with a built-in bar-code scanner for tracking patients and medications, a video and still camera for documenting patient problems, and radio frequency identification tracking technology.

It has the ability to store, access and update patient records wirelessly from anywhere in a hospital. It also is spill-resistant and easy to disinfect.

Executives say the device will help nurses cut down on paperwork, freeing them to spend more time with patients. It also is designed to reduce medical errors and improve efficiency in hospitals.

It is, according to the CEO Scott Eckert, the only tablet PC that currently packages all those features in one computer. This seems a boon to healthcare workers. However, in the short-term there will be the usual source of resistance: the difficulty of teaching old dogs new tricks. And the C5 is competing in a tough field, tough not because of competition but due to lack of demand.

A few years ago, after Microsoft Corp. introduced the operating system for Windows-based tablet computers, some analysts predicted as many as 14 million of the devices would be sold by 2009.

Today, the projection is closer to 3.5 million, according to Roger Kay, a computer industry analyst who runs Endpoint Technologies Associates Inc.

Still, the article notes that one strong area of demand for tablet PCs is the healthcare industry. In fact Motion makes a large portion of their revenue by selling tablet PCs to healthcare workers. And at $2,200, it's in the same price range as high-end desktops (which hospitals and practices often buy) and laptops.

A Different Kind of Electronic Health Record

2007-03-13T18:56:00.000-05:00

My friend Karthik, who's in Health/Info Sciences, told me to check out an Austin-based company called Catalis. It's not just another company with an EHR product, but a company making a graphical-based EHR product.

The graphical-based part is what makes it stand out in a crowded field based on my experience using many different kinds of EHR systems (the VA's VISTA, a McKesson-made system and a GE product called Centricity) for over a year now as a med student.

Catalis does a nice job of showing off the features of its EHR software. (Caveat: I don't know if these features are unique to Catalis' software versus other EHR systems software.) The three I found most compelling -- and most represent a step up from EHR systems I've used -- are:

1. You can document such problems as fracture sites graphically instead of (or in addition to) textually.

2. Typing is replaced by handwriting, which means docs won't have to learn new habits when it comes to charting.

3. The EHR system will warn you if a drug you prescribe is contraindicated, something I lobbied McKesson to do with a couple emails -- and to no avail I might add (although the company did start having monographs linked to drugs in patient charts after I emailed them).

Apparently this isn't just on the drawing board, according to the press release where a few doctors endorse Catalis' EHR software.

Microsoft purchases health information search engine

2007-02-28T17:58:00.000-05:00

The name of that engine (and company) is Medstory. (A graphic explanation of what the engine does is below, from the engine's homepage.)

And here's a brief NY Times article on the search engine (text below), its unique approach to search, and Microsoft's (as well as others') desire to enter the consumer health information industry. If Microsoft was just testing the waters with an earlier acquisition (here's my post on it) last year, then it seems to have dived into the uncharted waters.

---

February 27, 2007

Microsoft to Buy Health Information Search Engine
By Steve Lohr

Microsoft’s drive into the health care market is just getting under way, but the company signaled yesterday that one important ingredient in its plan will be a specialized search engine tailored to deliver useful medical information to consumers.

Microsoft is buying Medstory Inc., a small start-up in Foster City, Calif. Its search software applies artificial intelligence techniques to medical and health information in medical journals, government documents and on the Internet.
The terms of the Medstory acquisition were not disclosed.

The Medstory purchase, said Peter Neupert, vice president for health strategy at Microsoft, was a first step in a broader company strategy to assemble technologies that would “improve the consumer experience in health care.”
“Clearly,” Mr. Neupert said, “search is a critical part of that better end-to-end experience for consumers.”

The acquisition follows Microsoft’s purchase last year of Azyxxi, a clinical health care software system that retrieves and quickly displays patient information from many sources, including scanned documents, X-rays, M.R.I. scans and ultrasound images.

The Microsoft move comes at a time of increased investment in online health ventures, rising traffic at consumer health sites on the Web and profits at the most popular sites. Last month, a venture firm headed by Stephen M. Case, the former chief executive of America Online, introduced an ambitious new consumer health site, RevolutionHealth.com.

WebMD, the leading health-related site, last week reported strong quarterly profit of $8.9 million on revenue of $80.6 million, surpassing Wall Street’s expectations. The stock price of WebMD — an Internet pioneer in health information that struggled for years — has surged in the last year.

In health-related search, Healthline Networks, a start-up in San Francisco, reports rising traffic on its Web site and a growing string of deals to provide the search engine for sites of other companies, including Merck and PacifiCare. At Google, Adam Bosworth, a vice president for engineering, is leading the effort to develop a health-information offering.

These companies and others are seeking ways to build businesses on the Internet that profit from what is called consumer-driven health care. The notion is that shifts in demographics, economics, technology and policy will inevitably mean that individuals will want to, and be forced to, make more health care decisions themselves.

Aging baby boomers, accustomed to personal choice and to technology, tend to want a say in their treatment decisions. And the Internet is already an important source of health information. Eight million people in the United States go online for health information every day, according to a study last year by the Pew Internet and American Life Project, a nonprofit group.

Financially, the pressure by Medicare and private health insurers to hold down costs and shift more of the burden to individuals, analysts say, will force people to make more health care spending choices.

In Medstory, Microsoft is acquiring “some of the best deep technology” in the emerging field of medical search, said Esther Dyson, an industry analyst who is also an investor in Medstory. That technology, Ms. Dyson said, is “not so much a search engine, but an ontology engine,” with a capability to find and identify concepts in health and not just sort through words and Web links.

The longer-range goal, Mr. Neupert said, is to link personal information like age, sex, drug regimens, family history and even genetic markers to search. The ideal is that search results are tailored individually, identifying treatments, drug interactions and medical journal articles of interest.

“Health search could be way more relevant,” he said. “You don’t need to see thousands of results. What you want to know is, what does this mean to me personally?”

Dr. Alain T. Rappaport, the founder and chief executive of Medstory, said he was impressed by the importance Microsoft placed on “intelligent search” in health care and by the promise that Microsoft’s global reach and resources could accelerate the spread of the technology his team developed.

Microsoft had talked to Healthline recently about using its health search service, said West Shell III, the chief executive of Healthline. “This means Microsoft has decided to go it alone,” Mr. Shell said.

Depressed? Try some Omega-3 fatty acids

2007-02-28T17:42:00.000-05:00

Last year when I was on my child psychiatry rotation, I had to present a paper on treatment. In my research I learned that Omega 3 fatty acids have been shown to lower rates of violent behavior in an English prison, as reported in this long Guardian article under the heading "Prison trial".

This has led some people to indict the lack of Omega 3 fatty acids in the modern diet as the reason for a general increase in violence. I don't know if I buy it, but here's one explanation of the theory. (The Sydney Morning Herald piece also supplied the graphic you see below.)

Using a new health information search engine today, I search "Omega 3 fatty acids" to see the latest medical study articles on it, and this is what I found in the Journal of Clinical Psychiatry. It concludes:

"Meta-analyses of randomized controlled trials demonstrate a statistically significant benefit in unipolar and bipolar depression (p = .02). The results were highly heterogeneous, indicating that it is important to examine the characteristics of each individual study to note the differences in design and execution. There is less evidence of benefit in schizophrenia."

This is neat, since it means that Omega 3 fatty acids could be a powerful multi-purpose drug as it has been shown to have cardioprotective effects as well (here's a post on that from some time ago).

A new and better way to vaccinate kids against the flu

2007-02-21T00:35:00.000-05:00

From the NY Times Febrary 20th op/ed piece.

Less Flu, Less Squalling

FluMist vaccine, a nasal spray that has never quite caught on in the marketplace, turns out to do a better job of protecting young children than a standard flu shot. This is a double blessing: better protection, and without those dreaded needles that send children into crying fits and turn parents into mush.

The good news came from a study involving some 7,800 children 6 months to 5 years old. The results, published last week in The New England Journal of Medicine, were striking. The children given FluMist came down with 55 percent fewer cases of the flu than did those given the standard shot. The only cautionary note was that in children younger than 1 year, and in older children with a history of wheezing illness, there were slightly more hospitalizations in the FluMist group.

The results could open the way for the Food and Drug Administration to approve the use of FluMist in young children. Currently, it is approved for healthy people 5 to 49 years old who aren’t pregnant. One big barrier that has slowed its use, the fact that it had to be stored in a freezer, was removed last month with F.D.A. approval of a version that can be stored in refrigerators, just as the injectable vaccines are. That should make it easier for schools, pharmacies and doctors to use the spray.

More widespread and effective vaccination of children would also be a boon for parents. Children are notorious Typhoid Marys who spread the virus in day care centers and schools and take it home. Anything that protects children should make everyone feel better.

The NEJM abstract.

Flumist website.

And if you didn't get the "Typhoid Mary" reference, you can get it here.

A novel way to treat malaria

2007-01-20T11:42:00.000-05:00

Each year 200-300 million people worldwide are infected by malaria, and 1 million children die. This is why many, most notably Bill Gates, have put their money, efforts and time into finding ways to fight malaria. (It is also why, when I asked for donations for tsunami relief two years ago, one old friend lashed out at me saying money would be better spent fighting malaria.)

There was an interesting AP article on the east African jumping spider, Evarcha culicivora.

A jumping spider in East Africa is known to crave mosquitoes engorged with blood. Now scientists find the spider prefers a particular type of them—mosquitoes infested with the deadly malaria parasite. These predatory spiders could help control the lethal disease, scientists say.

...

In past research, the scientists discovered E. culicivora consistently preferred female mosquitoes that had recently finished a blood meal. The spiders targeted bloodsuckers over non-biting midges (by far the dominant mosquito-sized insect in these habitats), male mosquitoes (which do not suck blood), and female mosquitoes that were fed sugar.

Talk about biological warfare. I wonder if this species could somehow be encouraged to grow in numbers to contain the number of mosquitos that spread malaria.

Greatest medical innovation in last 160 years?

2007-01-20T11:34:00.000-05:00

Sanitation.

That's right. Here is an AP article that elaborates on the results of the BMJ poll.

Sanitation "greatest medical milestone since 1840"
Thu Jan 18, 9:27 AM ET

Sanitation was voted the most important medical milestone in the past century and a half on Thursday in a poll conducted by a leading medical journal.

Improved sewage disposal and clean water supply systems, which have reduced diseases such as cholera, was the overwhelming favorite of 11,341 people worldwide who voted in the survey conducted by the British Medical Journal.

It surpassed antibiotics, the discovery of DNA, and anesthesia, which were among the top five milestones in the poll. Participants were asked what they thought was the biggest medical advance since the journal was established in 1840.

"I'm delighted that sanitation is recognized by so many people as such an important milestone," said Professor Johan Mackenbach, of Erasmus University Medical Center in Rotterdam who championed the sanitation choice.

"The general lesson which still holds is that passive protection against health hazards is often the best way to improve population health," he added.

"Clearly, sanitation still plays a vital role in improving public health now and in the future," he said.

Other important milestones recommended for the top prize included the development of imaging techniques, the contraceptive pill, immunology and computers.

London was one of first cities of modern times to seriously tackle the problem of poor sanitation after a British doctor, John Snow, discovered in 1854 that cholera was water-borne and not air-borne as had previously being thought.

Bringing clinics closer to where people work

2007-01-14T22:33:00.000-05:00

The NY Times covered a growing trend in primary care -- clinics are opening up in large work facilities, or close to them, and often have all the services one can find at a community clinic as well as a pharmacy.

Frustrated by runaway health costs, the nation’s largest employers are moving rapidly to open more primary care medical centers in their offices and factories as a way to offer convenient service and free or low-cost health care. Within the last two years, companies including Toyota, Sprint Nextel, Florida Power and Light, Credit Suisse and Pepsi Bottling Group have opened or expanded on-site clinics. And many employers are adding or planning to add even more clinics, which were experimented with about 30 years ago but fell out of favor amid questions about their cost-effectiveness.

Today a new wave of clinics is opening, driven largely by a motive that was less of a factor in the past: employers’ desires to reduce their health insurance premiums by taking care of workers before they need to see outside doctors. More than 100 of the nation’s 1,000 largest employers now offer on-site primary care or preventive health services — a number forecast to exceed 250 by the end of the year, according to David Beech, a health benefits consultant. Corporate America’s new in-house medical offices go well beyond traditional occupational health clinics that hundreds of factories have long maintained for job-related injuries and worker’s compensation cases. Employees can now stop by for check-ups, allergy and flu shots, pregnancy tests or routine monitoring for chronic diseases like diabetes and asthma.

This isn't new. It was an experiment that failed in most cases in the 1970s. But that was before "health insurance premiums have soared and many companies have run up big bills at emergency rooms and urgent care centers."

And so, "the corporate clinic has made a comeback. For employees, on-site clinics can mean faster medical attention and lower out-of-pocket costs, since visits are usually free or carry only a small co-payment. Some workers may fret about the privacy of their medical records, but employers say they treat the information carefully and responsibly. Some companies hire outside providers to run the clinics, thus offering an additional privacy firewall."

Employers are hosting these clinics because it means more productivity and lower costs.

For employers, on-site clinics can mean gains in worker productivity and lower health-insurance outlays. “A clinic serving a couple thousand employees can probably save $1.5 million to $2 million a year,” said Mr. Beech, a health care specialist at the Watson Wyatt benefits consulting firm. “Right away, it’s easy to see reduced referrals to hospital emergency rooms and specialist physicians, and a shift away from hospital outpatient doctors to the clinic.” The biggest primary care clinic so far opened Jan. 2 in Texas, when Toyota workers and their families started using a $9 million, 20,000-square-foot medical center alongside a new truck assembly plant in San Antonio.

Unlike most of the new medical offices — which are staffed by nurse practitioners and in some cases a part-time doctor — Toyota’s San Antonio health center has two-full time doctors, a part-time physician, a blood-test lab and an X-ray center. It is “a clinic on steroids,” Mr. Beech said. And yet, even smaller operations, like the one with nurses, a physician’s assistant and a part-time doctor at the midtown Manhattan offices of the investment firm Credit Suisse are drawing praise from many employees.

John Probert, a 42-year-old Credit Suisse foreign exchange trader, recently took a few minutes from his 10-and-a-half-hour work day to pick up a prescription for a throat remedy at the firm’s clinic. He had it filled at a nearby pharmacy. “My throat was just killing me,” Mr. Probert said. The next day one of the clinic’s two nurses, Allison Ain, called to see how he was faring. “I told her I was feeling much better,” he said. “It’s nice to have a human on the other end of the phone that actually cares.”

And he liked the fact that his medical care did not take much of his time. “Instead of doing it on a Saturday,” Mr. Probert said, “you can just hop over next door and get back on the trading floor.” Pepsi Bottling, another sponsor of clinics, is trying to meet the basic health care needs of its 33,000 workers at 46 plants and 264 distribution centers around the country. The company currently has 15 clinics and plans to open 15 more over the next couple of years, according to David Kasiarz, the vice president for compensation and benefits.

The rest of the article "Company Clinics Cut Health Costs" by Milt Freudenheim which ran on January 14th, 2007 is below.

Pepsi Bottling employees are not charged for the services, which include not only allergy shots and prescriptions, but advice on weight loss and smoking cessation. “We think health affects business performance,” Mr. Kasiarz said. “Our drivers and sales people define how customers look at Pepsi Bottling. We need to keep them on the street; we need to keep them well and happy.” The nurses and physician’s assistants who run the Pepsi Bottling clinics are employed by a unit of Johns Hopkins University. “It is important that this is considered independent, ” Mr. Kasiarz said.

Although many companies still run their own clinics, a growing number have been hiring independent vendors. CHD Meridian, a unit of I-Trax, is the largest clinic-outsourcing company; others include Whole Health Management, Comprehensive Health Services and IMC HealthCare. All say they have pending orders from employers for new clinics that will offer primary care and other services. “There has been an evolution in this industry,” said Stuart Clark, executive vice president of Comprehensive Health Services, which operates dozens of traditional on-site clinics. “As the workplace becomes safer through training and safety engineering, our customers have opened access to their clinics for nonwork-related issues like flu shots, chronic disease, weight management and smoking.”

Andrew Scibelli, health benefits manager at Florida Power and Light, said his company estimated that it got back $1.50 for every $1 spent at its three on-site health centers, which are run by Whole Health. That estimate, he said, is based on what the services would cost if provided by doctors under the company’s health insurance, along with a calculation of the value of an employee’s time spent visiting an outside doctor. General Motors, despite continuing its traditional clinics, has put its emphasis on working with local doctors and hospitals to improve the quality of health care in communities like Flint, Mich., where G.M. retirees and their families vastly outnumber the company’s active work force.

Other companies have eliminated primary-care clinics, either because they did not consider them cost-effective or for other reasons. Ford Motor, which used to offer basic health care in the 1950s at its big Rouge plant in Dearborn, Mich., now says it believes that most employees prefer to go to their own doctor for primary care. But the foreign-based auto makers in this country, including Nissan and BMW, which do not have union-negotiated benefits or large numbers of retirees, are embracing the on-site health trend for their work forces. Comprehensive Health Services recently announced plans to provide clinic services at three existing Nissan plants and the company’s new North American headquarters in Franklin, Tenn.

Toyota currently has on-site pharmacies or prescription drug services at 11 plants in the United States. The new San Antonio clinic is meant to serve the 2,000 Toyota employees and 2,100 people working for suppliers as well as their families. The doctors, who will be employees of the contractor CHD Meridian, will emphasize preventive care, said Dan Sieger, a Toyota spokesman.

“We are really excited about this,” he said. Big health insurers say they are closely watching the proliferating clinics, which could potentially pose a competitive threat. A vendor company that runs on-site clinics, for example, could steer patients to its own programs for disease management, say, or smoking cessation, instead of equivalent ones offered by the patient’s health insurer.

Cigna, which runs clinics for its own employees in Bloomfield, Conn., Philadelphia and Phoenix, sees its role as a “partner with both the employer and the clinic provider” to make sure an employee’s doctor is fully aware of the patient’s medical history and health needs, said Tom Richards, a Cigna senior vice president. Brad Fluegel, an Aetna vice president, said the company was talking to its large customers about ways to dovetail its own “wellness” and chronic disease management programs with the companies’ expanding on-site programs.

“There might be even greater savings if a clinic can steer people to lower-cost places for treatment — efficient, high-quality providers — and generic drugs” Mr. Fluegel said. A pharmacy is one of the new features planned by Qualcomm, the wireless technology company based in San Diego. The company, which has operated a heavily used free clinic for its 8,000 workers in San Diego since 1998, is now nearly tripling the space to 4,000 square feet, extending visiting hours and hiring Whole Health.

Qualcomm says it sees the clinics and related health services as a way to retain the loyalty of employees — particularly its thousands of engineers. But of course, for Qualcomm and other big companies, cost considerations are always a primary concern. “Employers are so frustrated with health costs that they are looking for any solution,” said Dee W. Edington, director of the Health Management Research Center at the University of Michigan. “One option is to find ways to take care of people before they get sick.”

Robot in labor!

2007-01-05T09:25:00.000-05:00

In South Korea, because of a shortage of pregnant women relative to the number of medical students, robots are being used to teach students how to bring babies into the world according to the AP article "Robot mother helps South Koreans prepare for birth."

Kyunghee University Medical Center in Seoul is the first institution in South Korea to use Noelle, a life-sized robot, and her "newborn" to give obstetric students experience.

"With this simulator training tool, we can conduct not only normal deliveries, but also complicated deliveries such as breech births, Caesarean deliveries," Professor Jung Eui told Reuters Television. "Students can practice in a very realistic situation with this mannequin."
Students regularly crowd around Noelle as she gives "birth." They take turns at monitoring her vital signs and at pulling the "baby" out of her body.

The newborn, also a robot, is equipped with lights on its hands and cheeks to indicate its health -- blue lights mean problems while pink lights signal all is ok.

What was interesting is that this robot must be in use in the US:

Noelle was purchased for $20,000 from Miami-based Gaumard Scientific Co. Inc. in the United States. She was manufactured in 2000 and over 400 units have been sold in the United States.

Brain exercises could help keep the Mind sharp

2006-12-28T09:57:00.000-05:00

From the NY Times oped piece "Exercise Your Aging Brain":

If you’re worried that your mental powers will decline as you age, a new study offers hope that a relatively brief flurry of brain exercises can slow the mind’s deterioration.

The study, whose findings were published last week in the Journal of the American Medical Association, involved 2,800 men and women in six American cities. All were healthy, 65 and older, and living independently. Most participants were given 10 sessions of training to improve a particular mental skill. A memory group learned strategies for remembering word lists and textual material. A reasoning group learned how to find the pattern in a letter or word series. And a third group was trained to identify an object on a computer screen at increasingly brief exposures.

When tested five years later, these participants had less of a decline in the skill they were trained in than did a control group that received no cognitive training. The payoff from mental exercise seemed far greater than we are accustomed to getting for physical exercise — as if 10 workouts at the gym were enough to keep you fit five years later.
Researchers have yet to find compelling evidence that the retention of mental skills significantly improved the ability to tackle everyday tasks, like handling money or following instructions on a medicine bottle. But there are encouraging hints in the data that brain exercises may well help, a critical factor in determining whether elderly Americans can live independently.

If further studies show that mental exercises can improve everyday functioning, doctors may need to prescribe such training, senior centers may want to set up “brain gyms,” and aging Americans would be wise to do brain-stretching activities. For this purpose, even the Medicare prescription drug program, which critics deem too confusing for many older people to navigate, could prove an unexpected blessing. Spend 10 hours mastering its intricacies today and you could be a lot sharper than your compatriots five years from now.

Here's a related NY Times article "As Minds Age, What’s Next? Brain Calisthenics" that goes in-depth and takes a more critical view of the studies that show some improvment in cognition in elders who do brain exercises (e.g., the seniors can play the games better after playing sessions of them, but they cannot transfer the increased cognitive skills to everyday tasks.)

It also mentions the growing brain exercise industry, replete with Nintendo's "Brain Age" video game, websites HappyNeuron.com and MyBrainTrainer.com, two insurance companies pushing brain health using software, training camps and education -- MetLife and Humana, organizations like the Alzheimer's Association and AARP conducting workshops and providing tips, and living centers like Epoch Senior Living in Providence, RI and Emeritus Assisted Living providing brain fitness exercises to their residents.

Science is not sure yet, but across the country, brain health programs are springing up, offering the possibility of a cognitive fountain of youth.

From “brain gyms” on the Internet to “brain-healthy” foods and activities at assisted living centers, the programs are aimed at baby boomers anxious about entering their golden years and at their parents trying to stave off memory loss or dementia.

“This is going to be one of the hottest topics in the next five years — it’s going to be huge,” said Nancy Ceridwyn, co-director of special projects for the American Society on Aging. “The challenge we have is it’s going to be a lot like the anti-aging industry: how much science is there behind this?”

Med school notes in Libya is like med school notes in Texas

2006-12-10T23:41:00.000-05:00

Seriously, I was looking at some of these notes made as PowerPoint slides and saved as pdf files at a Libyan school, and felt that this could be notes that I download from my school's blackboard system.

It's amazing how universal medical knowledge has become, and how English is the lengua franca of medicine, and also how uniform medical education is around the world.

Medicaid tries to work with incentives

2006-12-03T22:21:00.000-05:00

Ignoring doctors’ orders may now start exacting a new price among West Virginia’s Medicaid recipients. Under a reorganized schedule of aid, the state, hoping for savings over time, plans to reward “responsible” patients with significant extra benefits or — as critics describe it — punish those who do not join weight-loss or antismoking programs, or who miss too many appointments, by denying important services.

The incentive effort, the first of its kind, received quick approval last summer from the Bush administration, which is encouraging states to experiment with “personal responsibility” as a chief principle of their Medicaid programs. Idaho and Kentucky are also planning reward programs, though more modest ones, for healthful behavior.

In a pilot phase starting in three rural counties over the next few months, many West Virginia Medicaid patients will be asked to sign a pledge “to do my best to stay healthy,” to attend “health improvement programs as directed,” to have routine checkups and screenings, to keep appointments, to take medicine as prescribed and to go to emergency rooms only for real emergencies.

This is from the article "Medicaid Plan Prods Patients Toward Health" in the December 1st issue of the NY Times.

Big Business pushes for e-health records

2006-11-29T17:12:00.000-05:00

Big Employers Plan Electronic Health Records
By GARY MCWILLIAMSNovember 29, 2006; Page B1

Several big employers are about to deliver an electronic jolt to the U.S. health-care system.
Next week, Intel Corp., Wal-Mart Stores Inc., British Petroleum and others will disclose a plan to provide digital health records to their employees and to store them in a multimillion-dollar-data warehouse linking hospitals, doctors and pharmacies. Their goal: to cut costs by having consumers coordinate their own health care among doctors and hospitals.

Craig R. Barrett, Intel's chairman, calls portable electronic records "the building-block to modify the U.S. health industry" into a more responsive and cost-conscious system. "I frankly don't think that the industry is capable of modifying itself," he says.

Next week, the companies will announce their collaboration on a records standard to kick-start the plan. Later, about 10 employers are expected to chip in $1.5 million each to construct a data warehouse to store and update the e-records. Once in place, the combination would allow consumers and insurers to evaluate price and performance data from millions of employees. Eliminating duplicate tests and erroneous or lost information would also slash administrative overhead, which is estimated to account for 40% of medical costs. And electronic prescriptions alone could help prevent the 98,000 serious illnesses or deaths that result annually from prescription mistakes.

Doctors could also use the records to measure which treatments worked best for chronically ill groups of patients. In addition, once their records are online, employees could order prescriptions and calculate their out-of-pocket medical costs using software that understands their health plans.

Patient medical records -- often hand-written -- are currently strewn among doctors' offices and hospitals. Computerizing them has long been supported by hospital and doctors' groups, but has foundered on technical and cost grounds. Now, only about 10% of U.S. doctors have a completely electronic record-keeping system.

Coalition members believe that giving consumers control over their own records would help get around the technical and cost issues. But the idea of portable medical records and a massive repository still faces hurdles. Privacy advocates worry that digital records will be misused by employers and insurers to deny jobs or health-care coverage. The watchdog group Patient Privacy Rights Foundation urges employees to shun the approach until there are adequate protections. "The system is leaking information," says Chairwoman Deborah C. Peel, a practicing psychiatrist. "Once out there, it's like a Paris Hilton sex video. It's [there] for the millennium."

The coalition expects to apply a combination of market pressure and incentives to get doctors and hospitals on board. The employers will insist that health-care providers adopt electronic records and prescribing as a condition of future business. Retailer Wal-Mart will apply its purchasing power to get bar codes on products intended for hospitals and clinics. All expect employees to pick doctors willing to use and update their records, though employee compliance is voluntary. According to the companies, the records will be the property of the employees, and the data will be mined by insurers and others only after the patients' identity is stripped off.

"We're trying to bring all the right people to the table and show them what can be done," says Linda M. Dillman, the Wal-Mart executive vice president in charge of the company's budding health-care initiative. A late comer to the health-care debate, Wal-Mart has been criticized for its employee health plans, and it has sought out allies among medical societies and health-care advocates.

Intel and Wal-Mart came together on the initiative last summer at the suggestion of the Centers for Disease Control and Prevention. Each had been meeting separately with the federal agency to discuss its efforts. Wal-Mart's Ms. Dillman describes the linkup as a bit of unexpected luck. "There is only so much you can do internally. To make a difference, you have to reach outside your own four walls," she says.

Both companies' businesses could benefit from the initiative's success. Intel sells chips that power prescription-writing hand-held PCs as well as giant file servers. Wal-Mart, the third-largest pharmacy chain, will soon have 60 "miniclinics" dispensing basic health-care services, and it is rapidly expanding the business.

Wal-Mart and Intel also share a common enemy: benefit costs. Intel figures its health-care spending will be as much as a fifth of its research and development costs by 2009. Wal-Mart says the costs for its 1.3 million U.S. employees, if unchecked, will climb $1 billion annually for the next five years.

While health care in the U.S. has remained paper-based and fragmented. Danish hospitals, pharmacies and general practitioners communicate via a secure, government-supplied network. Danes can go online to book medical appointments, renew prescriptions, view diagnoses and query their doctors.

At the heart of the Intel-Wal-Mart approach is the belief that if price and quality measures apply market pressures, technology can duplicate the integration that government-run health-care systems like the Danish one achieve. The final pieces to the puzzle -- pricing and performance information -- only recently started appearing online. The government posts pricing information using the fees charged to Medicaid. Groups including Hospital Quality Alliance, Ambulatory Quality Alliance and the Wisconsin Collaborative for Healthcare Quality rate hospitals and doctor groups on quality.

"The evidence is beginning to show that what gets measured and reported publicly gets improved faster," says Christopher Queram, president of Wisconsin Collaborative for Healthcare Quality, which began rating southeast Wisconsin hospitals and doctors in 2003.

"If this works, for the first time people and companies will be able to get a sense of how their doctors are doing so they can steer to or from them," says Sheldon Greenfield, director of the health-policy research center at the University of California, Irvine. Costs will fall when consumers can see "other doctors are achieving the same outcomes at lower cost. That's going to eventually affect us," he says.

Suitable quality measures for certain illnesses, such as depression and heart disease, aren't currently available, says Dr. Greenfield. But in other areas, such as diabetes, there are widely accepted ways to measure quality -- and match it to pricing.

The Intel-Wal-Mart plan to offer employees medical records and automatically update those records with hospital, doctor and pharmacy detail "is very ambitious," says Dr. Greenfield, an adviser to Care Focused Procurement LLC., a nonprofit putting together an HMO claims database. "We love the patient as the agent."

"It has always seemed unusual to me that the medical record is seen as the property of the medical system," adds Donald Berwick, chief executive of the Institute for Health Care Improvement, Cambridge, Mass. Tests are duplicated and information lost in the handoff between physicians or clinics. "The best integrator in the end is the patient," Dr. Berwick says.

Write to Gary McWilliams at gary.mcwilliams@wsj.com

Robot doctor

2006-11-23T09:47:00.000-05:00

Here's video (yes video!) on a robot controlled by a doctor in UCLA's medical center. It visits patients to see them by the bedside (see them for the human doctors using them, that is) and collects medical data, sending it to wherever the doctors are.

This is the video report, which looks like a promotional product. Thanks to my friend Mandar for sending it my way.

Pagers for patients in the ER...

2006-11-20T22:45:00.000-05:00

That's just one of the innovations being implemented by ERs in some hospitals to reduce the typical (outrageously) long waiting times.

Patients are now color-coded and fast-tracked on an elaborate computer system, with the wait time from door-to-doctor cut from eight hours to just 23 minutes.

From NBC Nightly News' "Hospitals work to improve ER wait times."

Silicon chips bytes obesity

2006-11-15T15:24:00.000-05:00

From the 6 Nov. 2006 Businessweek article on Texas Instruments, "To See Where Tech Is Headed, Watch TI:"

Some TI chips are finding unusual uses. One low-power processor originally designed to read meters electronically for a German utility found a home at biotech company IntraPace Inc. in Menlo Park, Calif. IntraPace decided to use the TI chip in a pill to treat chronic obesity. Once patients swallow the pill, which is set for clinical trials next year, the chip sends out electrical impulses that make them feel satiated. "TI has such a breadth of technologies that for a medical-device guy like me, it's like being a kid in a candy store," says IntraPace Chairman Mir A. Imran.

Here's what the CEOs of American auto cos. wants

2006-11-14T23:48:00.000-05:00

I've told some friends before that the big business will dictate how healthcare will work in this country sooner or later. Here's what I mean.

From the Nov. 13 AP article "Bush to meet with auto industry CEOs:"

"We're not going into this meeting seeking specific relief for our industry," said GM spokesman Greg Martin. "We understand that we have to win in the marketplace but there are issues of national importance like health care and trade that affect the competitive balance."

All three automakers spend more on health care per vehicle than steel, which adds about $1,000 to the cost of a car built by the Big Three. GM, the nation's largest private provider of health care, spent $5.3 billion on health care last year for 1.1 million employees, retirees and their dependents.

Wagoner urged Congress last summer to provide a "vigorous and robust" prescription drug market, develop national health information technology and focus on high-cost, catastrophic cases among a small number of patients.

The best medical information site in the world? The WWW.

2006-11-13T16:12:00.000-05:00

According to researchers quoted in the UK's Daily Mail article "Doctors using Google to diagnose illnesses," "almost six-in-10 difficult cases can be solved by using the world wide web as a diagnostic aid."

Misdiagnosis is still a common occurrence in the medical profession despite all the tools available such as the blood tests and state of the art scanning equipment.

Studies of autopsies have shown doctors seriously misdiagnose fatal illnesses about 20 per cent of the time.

So millions of patients are being treated for the wrong disease. And the more astonishing fact may be that the rate has not really changed since the 1930s.

So a team at the Princess Alexandra Hospital in Brisbane identified 26 difficult diagnostic cases published in the New England Journal of Medicine last year, including obscure conditions such as Cushing's syndrome and Creutzfeldt-Jakob disease.

They selected three to five search terms from each case and did a Google search while blind to the correct diagnoses. Google gives users quick access to more than three billion medical articles.

The researchers then selected and recorded the three diagnoses that were ranked most prominently and appeared to fit the symptoms and signs, and compared the results with the correct diagnoses as published in the journal.

Google searches found the correct diagnosis in 15 (58 per cent) of cases. Respiratory and sleep physician Dr Hangwi Tang, who led the study, said: "Doctors adept at using the internet use Google to help them diagnose difficult cases.

The research team's leader, Dr. Hangwi Tang, endorses "googling" difficult-to-diagnose diseases and states that clinicians should be trained in how to use search engines to improve their practice of medicine.

The comments are really interesting, running the whole gamut of responses.

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

2006-10-31T21:12:00.000-05:00

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?

2006-10-26T19:55:00.000-05:00

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

2006-10-25T13:59:00.000-05:00

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

2006-10-18T19:08:00.000-05:00

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?

2006-10-18T18:24:00.000-05:00

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

2006-10-10T21:23:00.000-05:00

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

2006-10-10T21:19:00.000-05:00

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"

2006-10-05T12:30:00.000-05:00

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?

2006-10-04T08:56:00.000-05:00

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.

2006-10-04T08:33:00.000-05:00

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

2006-10-03T22:28:00.000-05:00

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

2006-10-01T22:42:00.000-05:00

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.

Finding out how to cause bacteria to dye

2006-09-30T10:32:00.000-05:00

A new book by Thomas Hager titled "The Demon Under The Microscope" is reviewed in today's WSJ ("Medicine's First Miracle Drug" by Paul McHugh). It's a description of how the first miralce drug was discovered. All along I thought this was penicillin, but the drug here -- sulfa drugs -- actually came first.
From the the 1870s, thanks to the work of scientists Louis Pasteur, Joseph Lister and Robert Koch, the germ theory (that germs cause infections and disease) was becoming accepted, but nobody had a clue of how to prevent or stop germs. At the turn of the century, a German scientist named Paul Ehrlich "proposed that chemical compounds -- "magic bullets" -- must exist with a selective capacity to kill germs in the body. After all, he noted, certain dyes selectively stained bacteria. Why couldn't certain dyes be made to kill them, too?"

Then a group of German physician-scientists who believed in the truth of Ehrlich's theory, perhaps for lack of a better alternative theory, began working during the post-WWI period at the "dye conglomerate IG Farben."

Year after year the team infected mice with streptococci, the bacteria responsible for so many deadly infections in humans. The researchers then treated the mice with various dyes but had to watch as thousands upon thousands of them died despite such treatment. Nothing seemed to work. The 1920s turned into the '30s, and still Domagk and his team held to Ehrlich's idea. There was simply no better idea around.

Then one of the old hands at IG Farben mentioned that he could get dyes to stick to wool and to fade less by attaching molecular side-chains containing sulfur to them. Maybe what worked for wool would work for bacteria by making the dye adhere to the bacteria long enough to kill it.
Sulfanilamide, called sulfa by the chemists who synthesized it around 1900, sat on all dyers' shelves, the proprietary patents having long expired. In October 1932 Domagk began using dyes with sulfa attachments and promptly his mice began to survive -- indeed many started "jumping up and down very lively," he noted. At first the investigators couldn't believe the results. But repeated experiments showed again and again that sulfa-augmented dyes protected the mice from infection.

In February 1935, after a variety of trials on humans, Domagk announced to the medical world his discovery of the drug he called Prontosil. It was a common nitrogen-based azo dye with a sulfa side-chain, and it cured bacterial infections. The news spread quickly.

It's amazing that such a simple theory, that is not intuitive and certainly unconventional (even today people would find it hard to believe that a dye can kill bacteria), worked. What's even more amazing is the serendipity involved, for it wasn't the dye that did the deed.
The German scientists -- all of them Ehrlich disciples -- thought that the power to cure infection rested in the dye, with the sulfa side-chain merely holding the killer dye to the bacteria. The scientists at the Pasteur Institute, though, showed that the sulfa side-chain alone worked against infection just as well as the Prontosil compound. In fact, the dye fraction of the compound was useless. You could have Ehrlich's magic bullet without Ehrlich's big idea! This bombshell rendered the German patents worthless. The life-saver "drug" turned out to be a simple, unpatentable chemical available in bulk everywhere.

Still, the lesson of this story (as in so many, especially in medical science) is that being determined about and working hard for a goal may yield big results, even if it's not due to the belief you had behind the goal. "Gerhard Domagk was embarrassed that he missed the final analytic step, allowing the French to carry the day. But without his dedication to Ehrlich's idea, no one -- German or French -- would have used sulfa in a medicine, let alone fought infections with it. Domagk deservedly won the Nobel Prize in 1939."

Technology, technicians, and shortages

2006-09-29T09:31:00.000-05:00

Just last night I was having dinner with a couple med school buddies when one proposed that a technician can do a colonscope procedure as well as a GI doctor. He meant the preparing, inserting and scoping around of a person's lower GI tract. One doesn't need an MD-level training to do that he said.

My other friend disagreed: the countless times a GI fellow scopes patients leads to a high level of skill. While the first friend agreed that a physician does need to observe, interpret what they see from the scope and determine a management & treatment plan, he was still convinced that the physical labor can be done for much cheaper, saving patients and more so insurers money on this procedure.

I said this would not come to pass unless there was a crushing shortage of GI docs and too many patients needing to be scoped. Then pressures would compel some solution, which I think is a GI technician who would do scopes, leaving the truly medical aspects of the colonoscopy to the physician.

And then I saw this article in the 26 June 2006 Businessweek titled "The Doctor Is (Plugged) In." It's not as much about new technology allowing doctors to monitor patients remotely as it is how the problem of a shortage of ICU physicians and nurses is being resolved using technology.
The eICU technology, sold by Baltimore's Visicu Inc., lets hospitals leverage the scarce resources of specially trained intensive-care doctors and nurses. A single physician and nurse can support bedside caregivers for more than 100 patients at once. "We classify it as transformational because of what it represents," says Gartner Inc. analyst Vi Shaffer. "How do you do better with less, and how do you improve care when intensive-care specialists and nurses are scarce?"

Both Big Business and the specialty association are behind using technology to deal with specialist shortages.

The Leapfrog Group, a consortium of big employers, says 54,000 people a year could be saved if every U.S. ICU case were co-managed by a specialist. That's impossible without technology: It would take 25,000 specialists to staff
ICUs, and only 6,000 are available. "I've watched eICUs take off just in the past year," says Phillip Dellinger, past president of the Society of Critical Care Medicine. "It inherently makes sense."

Only 7% of American ICU beds are monitored using such technology, and the obvious limiting factor is cost. And this going to remain the limiting factor until prices begin to descend to more affordable levels, despite: "Sentara's Hochman says the system paid for its initial cost ($1.6 million) within six months."

At a time when organizations want to cut the "fat," meaning in one regard cut our layers of management, the eICU adds layers.

Indeed, the real advantage to the eICU is the change it allows in hospital management. Under Sentara's old system, a patient was admitted to a hospital by a nonspecialist doctor. That doctor made rounds in the morning, then went back to the office. For the rest of the day nurses handled whatever came up, alerting doctors when things got urgent.
The eICU system adds two more layers of patient management. An in-hospital team uses shared data to conduct its own daily case reviews. At Norfolk General, Medical Director for Quality of Critical Care William A. Brock rides a Segway through corridors as he directs a dozen doctors, nurses, pharmacists, and other professionals in reviewing each case in Sentara's cardiac ICU, ordering tests, and offering advice to admitting physicians. And from noon to 7 a.m., the eICU team offers specialized support to bedside nurses, who manage cases while patients' personal doctors do other work.

Despite high costs and increasing the layers of patient management, the payoff is there.

In two ICUs, deaths fell 27% the first year Sentara had the system up,
according to a study in the journal Critical Care Medicine. Based on death rates before and after the technology was rolled out systemwide, Sentara estimates that its eICU has saved 460 patients who would have died in traditional care. And the cost per ICU case also fell, by nearly $3,000, or 25%...
Much of the savings came from a dramatic plunge in complications such as hospital-acquired pneumonia and bloodstream infections, which occur more often when patients aren't monitored by experts who understand the meaning of subtle changes in their condition. If not treated immediately, they result in more tests, more treatments, and longer stays in intensive care, which costs about three times as much as the rest of the hospital. The system cut almost a day off the average ICU stay, from 4.4 days to 3.6.

I think it's just a matter of time until every ICU in the country is wired up this way. And it's not just new companies pushing the technology -- it's also patients demanding it. Hospitals may soon have to "factor in a question posed by Charlotte Pipes's sister-in-law, Janet Eiler: 'Patients' families are going to ask: "Why don't you have this?"'"

Quality of healthcare in the US improves

2006-09-28T12:55:00.000-05:00

Or so goes the title of an AP article on the findings of National Committee for Quality Assurance, which accredits and certifies insurers.

For patients in private insurance plans, there was improvement in 35 of 42 measurements, including such categories as cervical cancer screening, colorectal cancer screening and the controlling of high blood pressure in hypertension patients.

Still, most insurers do not report objective healthcare data that would help build a more accurate picture of what's really going on.

One in four Americans are enrolled in health plans that collect and report data on the quality of care. However, more than 100 million Americans are enrolled in plans that report no objective quality data, the report said.

"This past decade has demonstrated the benefits of measurement, reporting and accountability, but three out of four people don't enjoy those benefits today," said Margaret E. O'Kane, the president of the National Committee for Quality Assurance. "It's time to ask, 'Why not?'"

What's a smart public health policy? Smoking bans.

2006-09-26T12:33:00.000-05:00

The American Heart Association asserts that smoking bans in workplaces and in public buildings (here) and says it has more support from a study done in Pueblo, Colorado, where bans have “sparked a steep decline in heart attacks,” as reported in this AP article.

In the 18 months after a no-smoking ordinance took effect in Pueblo in 2003, hospital admissions for heart attacks for city residents dropped 27 percent, according to the study led by Dr. Carl Bartecchi, a clinical professor of medicine at the University of Colorado School of Medicine in Denver.

"Heart attack hospitalizations did not change significantly for residents of surrounding Pueblo County or in the comparison city of Colorado Springs, neither of which have non-smoking ordinances…"

…

The association said this was further evidence of the damage wrought by secondhand smoke.

"The decline in the number of heart attack hospitalizations within the first year and a half after the non-smoking ban that was observed in this study is most likely due to a decrease in the effect of secondhand smoke as a triggering factor for heart attacks," it said.

And I thought the biggest benefit of the smoking bans was that my clothes wouldn’t stink of cigarette butts when coming home from a night out.

(This reminds me of a student who won a prize in my history of medicine class last year who, after reviewing Roman public health measures like aqueducts, concluded that public health measures does more to improve the quality of human life and on a broader scale than medical measures.)

Putting money where the mouth is...

2006-09-25T23:11:00.000-05:00

There's an interesting trend in health insurance to cover dental care for a certain group of people during a certain time in their lives. Why? Well because a "number of studies suggest that early prevention and treatment of gum disease may result in significantly improved outcomes for pregnancy, heart disease and diabetes, often leading to substantial medical-cost savings."

Cigna Corp.'s Oral Health Integration Program, implemented earlier this year, covers additional deep cleanings known as scaling and root planing during pregnancy at no extra cost, or an additional regular cleaning (over the usual two a year) for pregnant women who don't require scaling and root planing. A similar benefit is available for patients in Cigna's diabetes and cardiac-care disease-management programs.

So far the biggest beneficiaries of this trend are pregnant women, as Aetna and smaller insurers are paying for commonplace items like antibiotic mouthwash.

"'We can save medical costs by getting people to have dental care at the right time in their lives,' says Glenn Melenyk, dental consultant at Blue Cross Blue Shield of Michigan in Detroit." BCBS has in fact signed up big corporations like Ford Motors -- companies that have been complaining about the rising costs of healthcare -- because they believe this preventive approach to healthcare will save them money in the long run.

(This comes from the 19 Sept. 2006 WSJ article "Health Plans Expand Dental Benefits" -- subscription required)

Primary care medicine - what'll save it?

2006-09-25T17:34:00.000-05:00

Some people in medicine, like many of our professors, gripe about how we need more primary care doctors. Even the media cites how had it will be to see your local doctor when this impending shortage emerges, even though such predictions made by the AMA have been wrong in the past.

While I don't entirely believe in a primary care physician shortage because there's plenty of foreign medical graduates who fill the open residency slots every year, and despite conceding that there might be truth in the conclusion of a Dartmouth study that less doctors per capita may do the local populace some good, I assert that there is an ever-decreasing interest in primary care specialities (internal medicine, pediatrics, obstetrics/gynecology & family medicine) among students at my school.

Why? Because of pure and simple economics. Primary care doesn't pay as much as other specialties. So many, weighed down by the burden of student debt, are compelled to seek better paying options. And others just want to make plenty of money, which is hard to do in a primary care field because of the lack of insurance reimbursements, governmental & private, for the non-procedural kind of work these doctors do.

According to responses to a recent WSJ article, some feel that Medicare's bueracratically determined payments is to blame. "The physician shortage you describe in "Is There a Doctor in the House" (The Journal Report, Aug. 21) will worsen and spread as Americans age and as physicians increasingly opt out of Medicare to free themselves of Medicare's fee structure and tortuous regulations."

That same writer offers a plan for patients to get primary care in coming days when there'll be a shortage of such doctors, one different than the usual "tell Congress to stop the cuts in Medicare payments!":

Choose a physician who has opted out of Medicare. By opting out, a physician chooses to work directly for her patients and forgo Medicare reimbursement. Such physicians have fewer patients, more time and a strong financial incentive to deliver excellent care. Such an arrangement is better for doctors and patients and saves Medicare money.

Will this new (but really old actually) direct pay-for-service model take off?

$4 for a month's supply of generics

2006-09-25T14:25:00.000-05:00

Wal-Mart's announcement last week was big. Big enough to influence the prices of drugstores downward by 7-9% on that day.

I asked a family friend who's a CVS pharmacist today in passing what he thought about Wal-Mart's plan. He said that his company isn't worried, largely because he believes they won't be able to sustain it. A pharmacist will fill about 10 prescriptions per hour and charge about $40 per hour in salary. So at $4 per prescription, they won't be making much margin. Or so his argument was.

Furthermore, pharmacists won't work more than they're accustomed to -- and so there won't be higher volume of sales to offset the loss in margins. And many consumers will value convenience over price since it will now take hours in his mind for a Wal-Mart shopper to get her prescription filled.

But even he admitted he doesn't know exactly how things will play out, and conceded that if Wal-Mart is successful, then the market (i.e., his company and others) will have to adjust.

It will be fun to watch on the sidelines if the innovations Wal-Mart has used to lower prices on many goods not just in its stores but across the board will allow the company to sustain generics and their current system of dispensing medicines -- or if they'll have to give up, or even come up with new innovations to keep the low prices rolling.

Gaps in unbiased medical information can be painful

2006-09-24T23:49:00.000-05:00

This NY Times essay by Jerry Avorn titled "The Sting of Ignorance" presents the problem of information gaps in healthcare that instead of re-interpreting what he wrote I'm just printing his essay in its entirety below.

LATE on a summer afternoon not long ago, the water at Lucy Vincent Beach on Martha’s Vineyard was warm, and the toxic jellyfish that had plagued bathers weeks earlier had floated out to sea. Body-surfing in on my last wave, I suddenly felt as if someone had whacked my leg with a lead pipe studded with nails. On the 1-to-10 pain scale we use with patients, I would have called it a 14. When I rubbed the area with my hand, my whole palm stung. Apparently those toxic jellyfish hadn’t all left.

A crowd of passers-by gathered to offer tips from the tainted well of conventional wisdom. “Use ammonia.” “Rub in some meat tenderizer.” “Apply vinegar.”

Soon a small army of bronzed youths in official-looking tank tops arrived carrying enormous medical kits. One poured sterile water on the sting area; another rubbed it with an ice pack. A third worked an alcohol-based anesthetic into the wound. Each treatment made the pain worse.

Eventually our group attracted the attention of a nurse strolling down the beach. A year-round Vineyard resident, she had seen her share of vacation-related medical emergencies. “You’ve removed the tentacle, haven’t you?” she asked matter-of-factly. No one, including the medical-professor patient, had thought of this. She took a piece of gauze and pulled off a slimy, transparent string laced with neurotoxins. It had continued to send those toxins into my leg for the first 20 minutes of my care. They are particularly activated, I would later learn, by distilled water, by mechanical pressure (as from an ice pack), and by alcohol-based topical medicines — all the treatments I had so earnestly been given.

Now the pain began to abate. I drove home and reached for three of the most useful medicines I know: aspirin, acetaminophen (Tylenol) and the Internet. As the first two began to take effect, the third revealed a study published in February in The Medical Journal of Australia.

The clever Aussies (whose beaches are also infested by toxic jellyfish) had conducted a clinical trial that randomly assigned sting victims to application of hot water (to deactivate the poison) or icepacks. The trial was stopped halfway through because the hot-water group did so much better that it would have been unethical to continue. I didn’t discover this through any proprietary medical search engines. I used Google and Wikipedia, and it took about two minutes.

Coincidentally, much of my work is about defining which medications work best for which conditions, and how to close the gap between that knowledge and the care patients typically receive. My research group constantly comes across effective treatments that are underused, and poor-choice drugs that are widely prescribed. Even when good clinical trial data on a regimen or medicine exist, no coherent system ensures that the message gets out to doctors and patients. As a result, many treatment choices are driven by habit, old information or glitzy promotional campaigns.

My aquatic encounter was a small example of what millions of patients confront daily, in much more serious circumstances. The nation faces two yawning medical information gaps. First, we need more studies comparing treatments to each other, as that simple Australian trial did. Drug companies don’t usually do such tests, preferring to evaluate their new products by comparing them to placebos. (The drugs usually win.)

The National Institutes of Health, facing its first real-dollar budget cut in generations, isn’t likely to expand its mandate in this direction. But what about the insurers, private and governmental, who pay such a large share of the nation’s $220 billion annual drug bill? They could support such studies with the rounding error of their annual budgets — and then save billions if the findings were put into practice.

The second problem is that much of the knowledge we do have is not communicated to the people who need it. Drug companies are adept at barraging doctors and patients with slick messages touting their most expensive products — even if they are no better than older, more affordable standbys. Maybe if Merck held the patent on hot water, my well-intentioned beach squad would have known all about the Australian study. But that’s a poor way to ensure that patients receive the right care.

We need an unbiased, efficient system to get the word out to practitioners on what works best. My colleagues and I have done pro bono research aimed at developing such an approach. Because the drug industry is so adept at changing beliefs and practices, we’ve taken a few leaves from its book.

In a program financed by the Commonwealth of Pennsylvania, called the Independent Drug Information Service, we scan the medical literature for the best evidence on how to treat a given medical problem (like high cholesterol or arthritis), boil it down into user-friendly packets of information, and then send nurses and pharmacists out to doctors’ offices to recommend optimal treatments. The information we provide is unbiased and noncommercial, and we don’t offer free trips to golf resorts. The resulting savings from more cost-effective prescribing could more than cover the costs of programs like this.

The approach has been adopted in several Canadian provinces, and Australia runs a continent-sized program to update its primary care doctors (though I don’t know if it addresses jellyfish injuries). The government covers expenses, but scientific content is determined by nonprofit professional organizations. Their recommendations are transmitted in person by “outreach educators,” in concise newsletters, and electronically to doctors, health workers and patients.

If the Vineyard beach first responders had known of the latest research results, they wouldn’t have done everything they could to transfer toxin from the jellyfish tentacle to my leg. All of us need access to current, noncommercial medical information. Besides helping to contain our runaway medication expenditures, programs of this kind could prevent a lot of needless suffering — by patients and doctors alike.

(I bolded certain lines to emphasize the main points.)

How one state fights childhood obesity

2006-09-24T23:36:00.000-05:00

When I write about "healthcare innovations," I use the broadest definition of the word 'healthcare.' That's why I write about the innovative way the state of Arkansas has been dealing with obesity as reported in the NY Times.

Gov. Huckabee and his government has been trying to make a healthier lifestyle a more attractive choice. "Many of his policies include incentives like exercise breaks for state employees. He has expanded state insurance coverage to cover obesity treatment."

However, he has used his power to restrict choices too.

The policy that has brought the most attention to the governor, however, was not his initiative. In the spring of 2003, Herschel W. Cleveland, then the Arkansas House speaker, introduced a bill to remove vending machines from elementary schools and send home the body mass index report cards.

The bill passed easily, but the public generally did not notice until Mr. Huckabee had become the health governor. The news made national headlines and brought vehement objections from parents concerned about government intrusion and fragile young egos, recalled the sponsor, State Representative Jay Bradford, a Democrat...

Plus in the South, eating fried foods filled with fat is considered a birthright.

Mr. Huckabee knows what he is up against, namely all-you-can-eat buffets, cheese grits and a local ice cream flavor called Woo Pig Chewy. One of his own family dogs is named Sonic, after the fast-food chain whose cherry limeades are favored by his wife, Janet.

“It’s not just your culture,” he said, speaking in his office in the Capitol building. “It’s your comfort.”

And the state's policis have done little to change waist sizes so far, since "in three years of recording children’s body mass index and reporting it to parents, the number of children at risk of obesity has decreased — by half of 1 percent."

Still, he believes he can -- through smart, and sometimes forceful and quite unpopular policies -- change hearts and minds. "But Mr. Huckabee insists that a lifestyle revolution can happen, citing four behaviors that have been reshaped over the years by concerted government effort: littering, seatbelt use, smoking and drunken driving."

Is it too hard to figure out what incentives change doctors' habits?

2006-09-24T22:26:00.000-05:00

The answer is probably yes. The authors of the book Freakonomics wrote a NY Times Magazine piece on how L.A.'s Cedars-Sinai Medical Center got its doctors -- who had the worst rate among hospital staff of cleaning their hands before attending to patients -- to change their ways.

The concept that doctors washing their hands regularly would saves patients' lives was established in 1847 when Dr. Semmelweis found:

The mortality rate in the doctors’ clinic was nearly triple the rate in the midwives’ clinic. Why the huge discrepancy? The doctors, it turned out, often came to deliveries straight from the autopsy ward, promptly infecting mother and child with whatever germs their most recent cadaver happened to carry. Once Semmelweis had these doctors wash their hands with an antiseptic solution, the mortality rate plummeted.

But still today, the Semmelweis Rule is hard to enforce. Why? "[f]or starters, doctors are very busy. And a sink isn’t always handy... [and] even with Purell dispensers mounted on a wall, ... doctors didn’t always use them." In addition there are psychological reasons: there's "a perception deficit" (in an Australian study, "doctors self-reported their hand-washing rate at 73 percent, whereas when these same doctors were observed, their actual rate was a paltry 9 percent") and there's “[t]he ego [that] can kick in after you have been in practice a while."

According to the writers, the incentives "were not quite aligned with the hospital’s."

At first the hospital team assigned to the task sent emails and faxes, and put posters up. But none of it worked. So the team moved onto rewarding those docs who complied with the Semmelweis rule.

They started a Hand Hygiene Safety Posse that roamed the wards and let it be known that this posse preferred using carrots to sticks: rather than searching for doctors who weren’t compliant, they’d try to “catch” a doctor who was washing up, giving him a $10 Starbucks card as reward. You might think that the highest earners in a hospital wouldn’t much care about a $10 incentive — “but none of them turned down the card,” Silka says.

When the nurse spies reported back the latest data, it was clear that the hospital’s efforts were working — but not nearly enough. Compliance had risen to about 80 percent from 65 percent, but the Joint Commission required 90 percent compliance.

Eventually, the entire staff was compliant! But how? Well, one day "after [a group of doctors] finished their lunch, Murthy [the hospital epidemiologist] handed each of them an agar plate — a sterile petri dish loaded with a spongy layer of agar. 'I would love to culture your hand,' she told them."

They pressed their palms into the plates, and Murthy sent them to the lab to be cultured and photographed. The resulting images... “were disgusting and striking, with gobs of colonies of bacteria.”

The administration then decided to harness the power of such a disgusting image. One photograph was made into a screen saver that haunted every computer in Cedars-Sinai. Whatever reasons the doctors may have had for not complying in the past, they vanished in the face of such vivid evidence. “With people who have been in practice 25 or 30 or 40 years, it’s hard to change their behavior,” Leon Bender says. “But when you present them with good data, they change their behavior very rapidly.” Some forms of data, of course, are more compelling than others, and in this case an image was worth 1,000 statistical tables. Hand-hygiene compliance shot up to nearly 100 percent and, according to the hospital, it has pretty much remained there ever since.

The writers state this tale demonstrates how playing around with and using the right incentives can effectively change old habits. But "it also highlights how much effort can be required to solve a simple problem — and, in this case, the problem is but one of many."

Playing around with incentives, then, may be too much work. And technology could possibly help making it easier not so much to change people's mind and habits but to circumvent them. Which is why the writers conlude their piece by mentioning that Craig Feied, a "physician and technologist who is designing a federally financed 'hospital of the future,' is working with a technology company that infuses hospital equipment with silver ion particles, which serve as an antimicrobial shield."

You can teach an old doc new tricks, but it requires a lot of time and effort and a new way of looking at things called incentives.

Retail clinics becoming accepted by major insurers

2006-09-03T09:48:00.000-05:00

The rapid rise in retail store clinics was something I wrote about in April. It started out as an all-cash business model, removing the third-payer out of the equation. But getting insurers to pay for services must have been too attractive a proposition to keep them out of the equation for long.

From the "Aetna, Humana reach agreement with InterFit" article printed on Sept. 1 in the Houston Chronicle:

"As we continue to increase the convenience and strive to increase the access through our convenient-care clinics, this is an important step, to add partnerships" with health insurance companies and others, [company spokesman] Hall said. "It gives patients another option for payment."

InterFit's RediClinic is only the second provider of its kind with which Aetna has contracted, Aetna spokeswoman Rachelle Cunningham said Friday.

Earlier this year, the insurer signed a contract with Minneapolis-based MinuteClinic.

To me this seems like the new clinic model is on the road toward mainstream acceptance.

Is collaboration the key to innovation today?

2006-08-26T10:35:00.001-05:00

"The Medici Effect," mentioned in my last entry, is about the fruits of collaboration. The author asserts that collaboration between seemingly unconnected disciplines is key to being truly innovative (i.e., coming with new ideas) today.

One anecdote he writes is about a team of Brown University scientists that created a way for a monkey to use not his hands but his brain to control a mouse cursor on a computer screen.

This story is especially compelling not just because of what the team of scientists discovered, but because it was the result of a deliberate effort to find an intersection of disciplines. The group... consisted of mathematicians, medical doctors, neuroscientists, and computer scientists...

This was no accident. Professor Leon Cooper, who pioneered the brain science research efforts at Brown University, made a special point of bringing together a wide range of disciplines to understand the human mind. (12)

This team was featured in a recent NY Times article, as mentioned by the author in a blog entry.

Such interdisciplinary collaboration is becoming more common, and not just in the science lab. A story in the WSJ earlier this year followed a capitalist who brings patent lawyers together with doctors, surgeons and scientists to brainstorm concepts. They get written down, and those that are applicable and profitable get written up as possible patents. Everyone gets compensated for their contribution if it becomes a product or service. (Unfortunately, I can't find the article.)

Coming back to the science world, there's the Institute for Systems Biology in Seattle, profiled by BusinessWeek in "Deconstructing Disease" whose vision is of "health care in which physicians predict who will develop certain diseases, and then tailor individual drug regimens to cure them." The institute was pioneered by Dr. Leroy Hood, considered the "godfather" of systems biology.

To understand the disease process, Hood believes, scientists must decode the complex biochemical pathways created by the more than 50,000 proteins that genes produce -- and link what they learn to the whole system. Only then can doctors figure out how to interfere with a pathway to cure or even prevent an illness.

This sums up how systems biology tackles the understanding of pathology. The relevant aspect of Dr. Hood's story is that he is "known for taking a cross-disciplinary approach to tackling diseases... [He has brought together] 180 specialists in biology, chemistry, math, and physics [to] work together to unlock a range of medical mysteries, from how cancer develops to how the immune system forms in childhood," according to the institute's website.

One doesn't have to be on an interdisciplinary team to find connections between seemingly unconnected things. Sometimes it can happen within someone's mind. In a section on success and failures in "The Medici Effect" is a story of a young medical student named Deborah Prothrow-Stith (now a public health professor at Harvard) who overcame many obstacles, especially from inside the medical establishment, to convince people that violence can and ought to be prevented.

The more [she] thought about it, the more she realized that physicians often got involved with prevention of harm by attempting to change patient behavior. She and other physicians pushed people to wear seatbelts, to eat right, to exercise, to avoid risky sexual behavior, and to avoid many other lifestyle hazards. But at the time they didn't do anything to prevent violence.

Is the interdisciplinary approach is ideal for ideation? Seems like it. After all, as a late 19th century conservationist John Muir once put it, "When one tugs at a single thing in nature, he finds it attached to the rest of the world."

A new health drink?

2006-08-21T12:52:00.000-05:00

Well, it's not new really. What is new is how health researchers see coffee. Recent studies praise a cup of java for its many beneficial health effects, according to the NYT article "Coffee as a Health Drink? Studies Find Some Benefits."

Take a landmark study in JAMA last year which claimed habitual coffee drinking is associated with reduced risk of developing Type 2 Diabetes.

Coffee contains antioxidants that help control the cell damage that can contribute to the development of the disease. It is also a source of chlorogenic acid, which has been shown in animal experiments to reduce glucose concentrations.

Caffeine, perhaps coffee’s most famous component, seems to have little to do with it; studies that looked at decaffeinated coffee alone found the same degree of risk reduction.

Larger quantities of coffee seem to be especially helpful in diabetes prevention. In a report that combined statistical data from many studies, researchers found that people who drank four to six cups of coffee a day had a 28 percent reduced risk compared with people who drank two or fewer. Those who drank more than six had a 35 percent risk reduction.

Another study finds an association between coffee consumption and reduced cardiovascular disease.

The findings, which appeared in May in The American Journal of Clinical Nutrition, suggest that antioxidants in coffee may dampen inflammation, reducing the risk of disorders related to it, like cardiovascular disease. Several compounds in coffee may contribute to its antioxidant capacity, including phenols, volatile aroma compounds and oxazoles that are efficiently absorbed.

In another analysis, published in July in the same journal, researchers found that a typical serving of coffee contains more antioxidants than typical servings of grape juice, blueberries, raspberries and oranges.

“We were surprised to learn that coffee quantitatively is the major contributor of antioxidants in the diet both in Norway and in the U.S.A.,” said Rune Blomhoff, the senior author of both studies and a professor of nutrition at the University of Oslo.

These same anti-inflammatory properties may explain why coffee appears to decrease the risk of alcohol-related cirrhosis and liver cancer. This effect was first observed in 1992. Recent studies, published in June in The Archives of Internal Medicine, confirmed the finding.

Of course, drinking coffee isn't all good. A prevailing belief is that caffeine decreases bloodflow (and thus oxygen delivery) to the heart via coronary artery vasoconstriction, and can elevate blood pressure too by vasoconstricting other arteries in the body.

There are many studies (1, 2, 3) , in these same journals, that point to the detrimental effects of coffee. And who can overlook the toll coffee takes on one's teeth?

Is becoming an expert counterproductive to becoming innovative

2006-08-20T00:57:00.000-05:00

In the book "The Medici Effect" by Frans Johansson, about how the best applicable innovations arise from the intersection of disciplines, there is an anecdote about a guy with no medical background who creates a technique to discover cancer, as told by one venture capitalist cited by the author.

Paul Maeder is also a very well educated man. He earned his undergraduate degree at Princeton University, his master's in mechanical engineering at Stanford, and his MBA at Harvard Business School. With all of these degrees, you would think he places an extraordinarily high value on education. But only seconds into our conversation he started listing individuals and groups who have radically innovated because they did not have formal training... (50)

The idea that the lack of formal training is a good thing isn't far-fetched. Many great scientific innovators, people like Einstein, Edison, Franklin, and da Vinci, lacked formal education in the fields they excelled in. (I wonder if the same applies to innovation in the arts or other fields.)

"Take this guy Stan Lapidus," he told me one day. "He doesn't have an M.D. or a Ph.D., but he has come up with an amazing way of analyzing stool samples for colon cancer pathology. Put it in a blender, mix, and you can spot cancer with hardly any false positives. It's really an amazing invention. Now, why did he think of this? Because he's not a doc."

Mr. Johansson says the capitalist doens't think education is a bad idea. "But he clearly sees it as potentially limiting creativity."

Through school, mentors, and organizational cultures, education tends to focus on what a particular field has seen as valid. If, for instance, you wish to be a great medical doctor, there are rules that must be mastered. A good education will teach you these rules. You learn what past experts and thinkers concluded and use their experiences to build your own expertise. You do this to learn what works. Expertise in a particular field could suffer if too much time were spent questioning basic assumptions. The price for such an approach, however, is that one more easily becomes wedded to a particular way of doing things. As a result, associative barriers are erected, making intesectional ideas less likely.

Food for thought.

A novel way of thinking about grapefruit juice

2006-08-17T18:26:00.000-05:00

It's now common knowledge that one should stay away from grapefruit juice if taking certain medications like cholestrol-lowering statins. This is because compounds in the fruit inhibit a liver enzyme responsible for normal metabolism of these drugs. It thus slows the excretion of these drugs, which is dangeous if one is unaware of his drug levels and keeps ingesting the drug at his prescribe dosage, leading to overdose.

More details are given in this Wikipedia article, which come largely from a 1997 Journal of Clinical Investigation paper on how grapefruit juice slows down the breakdown of a calcium channel blocker.

So then, grapefruits slows down parts of the liver and thus prolongs the concentrations of some drugs in the bloodstream. Bad? Yes, for some people died because of the overdosing effect. But is there any good too?

Perhaps yes. Here's a short letter to the editor in the July 29th issue of Science News demonstrating some novel thinking on this matter:

It would seem to me that instead of looking to minimize the effect of grapefruit juice in slowing the metabolism and elimination of drugs, one could cut drug dosages by taking advantage of it ("Nabbed: Culprit of grapefruit juice-drug interaction," SN 5/20/06 p. 317). Grapefruit juice costs less than any drug and has far fewer side effects. This could only benefit the patient by lowering drug exposure and costs.

Pretty neat idea, using something that affects physiology in a seemingly adverse way to improve health instead but with an economic benefit.

The idea is untested of course, and as an UNC researcher points out in his rebuttal, nobody knows how grapefruit juice exactly affects metabolism, or what dosages would be effective and safe. Still, kudos to the letter writer for being creative in the realm of medicine. Creativity is about roaming into the unknown, unconstrained by conventional views and even logic sometimes, which is what the writer did.

Early detection can help, but is it worth it for everybody?

2006-08-14T15:13:00.000-05:00

Featured in the March 27, 2006 Businessweek article "Beyond the Annual Physical" is an Austin company, Biophysical Corp., that caters to Americans who want to be fully tested for everything that could be possibly wrong with their health. The B-week writer calls them "medical worriers."

The company's hallmark service is "a $3,400 blood test named the Biophysical250 that screens for 250 possible diseases, at least 150 more than most standard physicals." The vast majority of insurance plans do not cover the costs. So how does it work?

The company sends a nurse to your home to draw two tablespoons of blood, then the samples get shipped to Austin to test for everything from the mundane -- cholesterol and blood sugar levels, infection -- to the downright scary, such as dozens of proteins and enzymes that could indicate the presence of cancers, autoimmune diseases, or weird genetic anomalies. The test screens for 39 markers for heart disease alone.

Smartly perhaps, and in line with current medical thinking, the company "does not... screen for diseases about which nothing can be done -- Alzheimer's and Parkinson's, for example." And admittedly, this battery of tests isn't necessary according to the writer's own doctor and even the writer himself in the final analysis: "All in all, Biophysical250 is a nice affirmation if you're fairly certain you're in good health, and an early warning system if you're not."

Interestingly, this extremely thorough physical isn't confined to medical startups. Well-regarded institutions like Mayo Clinic offer similar services called "executive physicals," which are more costly. The added value is that the physician takes a detail history.

"We do run the standard evidence-based tests, but we also listen very carefully to the patient and pursue any clues they may give," says Dr. Deborah J. Rhodes, director of Mayo's program. She gives the example of a 37-year-old man who mentioned in passing that he recently noticed one testicle seemed smaller. This common asymmetry would have barely been noted, except that the patient said it was a recent change. As a result, Rhodes ordered a test for testicular cancer and discovered that the man had the very earliest stages of the disease, catching it long before it would have been found in a physical exam.

Is this kind of extreme physical necessary to maintain good health? Probably not, as the writer points out, for the majority of us. But as quoted in a Scientific American June 2006 article titled "Early detection can lead to better outcomes," and actually seen on Biophysical Corp's site:

Millions of adults—even those who appear healthy—live with undetected illnesses. In the U.S. alone, 1.4 million people will be diagnosed with cancer this year. Another 17 million will suffer an adverse cardiovascular event. The good news is that the sooner specific diseases and medical conditions are detected, the sooner—and more effectively—they can be treated.

There is real value in a test that could detect an early-stage cancer or new-onset (and subacute, meaning no symptoms) diabetes, as this could help a person not only increase her chances of surviving, but also of living with a better quality of life in most cases (e.g., preventing kidney and eye disease in diabetics and curing cancers by resection before it metastasizes). Still, is there value for everyone if most people do not have such disease that are in the early stages of development? I'm not so sure.

And in the end, this jury isn't convinced one way or the other quite yet about the value of these comprehensive physical lab exams.

Ayurvedic tourism & the AOL founder's healthcare revoltution

2006-08-12T20:33:00.000-05:00

"In the Land of Four-Star Asceticism" is a NYT travel article about health resorts in the south Indian state Kerala where visitors, mostly German tourists and Lonely Planet types, take the "the humble oath of four-star asceticism" to immerse in ayurveda, "the 3,500-year-old herb-based healing tradition that still flourishes in the daily life of India." So what is that humble oath?

...to forsake all known forms of vacation decadence (rice gruel for dinner, anyone?), to give up meat, alcohol, caffeine, leather accessories, naps, sunbathing, swimming and mindless frivolity in order to purify and balance your whacked-out Western body and soul...

Why people would pay money to live like ascetics and get "detoxed" by unscientifically proven therapies is part of an interesting trend that I call the "wholesome trend," which has many aspects. Among them are care oriented around the whole person -- mind, body & spirit -- and not just one part, ingestion of wholesome (i.e., natural or organic) foods & herbs, wholesome (non-artificial, as in medications & surgical) interventions like yoga & acupuncture.

These resorts, centuries old, have detected that trend (rather their investors have) and have thus rebranded themselves to appeal to Westerners with deep pockets. The one featured here, the Kalari Kovilakom, "markets itself as combining 'the indulgence of a palace with the austerity of an ashram.'"

Is this just another Eastern fad? AOL founder Steve Case doesn't believe so. According to a recent Honolulu Advertiser article on him.

Case, who last year started a company focusing on healthcare and luxury resorts, tells his audience that the U.S. is ripe for a transformation.

"The objective of this movement must be to make healthier, more sustainable lifestyles available to every American," says Case, 48, who's wearing an open-collar shirt and khakis. "If we achieve that, we will effectuate nothing short of a revolution in this country."

The founder of Revolution LLC is making big promises. He's done it before. In 2000, as chief executive officer of America Online Inc., Case pitched the acquisition of Time Warner Inc. to his shareholders, saying it would create new ways for people to shop and communicate.

And according to an older Washington Post article, Case is "bet[ting] that activities once associated with a new-age lifestyle are going mainstream."

Case was right more than a decade ago with Internet use, confined at the time to academics, going maintream, and he took advantage of a widely undetected demand among ordinary Americans to get onto the WWW.

So perhaps he's right about the "wholesomeness trend," about the desire for middle and upper-class Americans to live more "holistically" and to pay more to do so. And perhaps Case's new company, and the rebranding of ayurvedic health resorts in India, are based on a bigger trend, one labeled the "experience economy" by a 1999 book of the same name. (Dan Pink writes about it here.)

If so, then entrepreneurs & investors beware. An experience economy thrives in times of economic wealth, but when that economic wealth is being sapped, like now largely thanks to higher oil prices, interest rate hikes and inflationary pressures, people tend to stop spending on experiences and become more price and value-conscious.

This is the gist of this past week Slate's Daniel Gross article, "The Rising Cost of Living Well," detailing the falling fortunes (and stock prices) of companies like Starbucks and Whole Foods, companies steeply entrenched in the experience economy (and the wholesome one too).

It will be interesting to see if companies that service people's desire to live more wholesomely can still thrive during economic recessions, because then the trend is truly deeper than a superficial new-age desire.

Despite controversy, steady progess

2006-08-04T11:00:00.000-05:00

This is the point of writer Deborah Blum's August 1st essay "A Pox on Stem Cell Research."

How is the research to advance from hopeful to helpful when national policy inhibits the work from being done? Discouraged proponents have suggested that the president’s decision, which was applauded by conservative religious groups, has the potential to keep American science locked in the past.

The past, however, seems to encourage a more optimistic outlook. Medical progress has stirred religious and moral objections throughout history — objections that were overcome as the benefits of medical advances became overwhelmingly obvious.

After detailing some instances of when medical advances, initially perceived as an affront to God, was widely accepted, the essay delves into the story of Dr. Edward Jenner, who introduced inoculation to prevent infections from the deadly smallpox -- admist objections from religious leaders and even fellow doctors.

He designed a procedure using fluid from cowpox lesions to inoculate against smallpox. His approach was untested, but Jenner believed it offered the potential to become “essentially beneficial to mankind.”

The religious authorities of Jenner’s day viewed smallpox inoculation as an affront to God and man. A widely published British sermon was titled “The Dangerous and Sinful Practice of Inoculation.” American clergy warned that inoculation usurped God’s power to decide the beginning and end of life. Only hypocrites would undergo the procedure and still pray to God, one theologian declared.

Jenner responded with a risky demonstration of his idea. In 1796, the doctor persuaded his own servant to allow the man’s 8-year-old son to be inoculated with cowpox material; two months later, Jenner exposed the child to smallpox.

The experiment was a success...

Why despite antagonizing moral and even expert opinion has the healthcare innovation -- the inoculation for prevention of infectious disease -- been so widely practiced since?

Not by hyping the potential of his ideas, as some stem cell supporters occasionally have done, but by doggedly gathering more evidence based on more inoculations. Fueled by his success, the practice spread, and smallpox rates plummeted. In time, the life-saving merits of inoculation eventually overwhelmed all doubt; the evidence, Jenner wrote, became “too manifest to admit of controversy.”

The writer's premonition is "stem cells — especially the amazingly versatile cells evident in early human development — have the potential to hold off our own ministers of death. And history suggests that’s a proposition too powerful to remain shackled by the moral strictures of the moment."

Antibodies galore!

2006-08-01T19:47:00.000-05:00

It seems like lab-designed antibodies that block effects of hormones, receptors and neurotransmitters are becoming a hot concept.

I wrote in passing about an antibody designed by Pfizer that blocks nicotine receptors, preventing on a molecular level the chemical nicotine from binding onto its receptors on brain cell membranes, and thus preventing on a human level the craving for the "nicotine effect" from smoking cigarettes.

There's a new antibody therapy aimed at obesity that's not close to testing in humans, but is apparently successful in stopping lab mice from getting fat. Read more about it in the Reuters article "Scientists take step toward obesity vaccine." Ghrelin is the hormone that this experimental antibody targets.

For more on antibodies, go to this Wikipedia article.

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

2006-07-29T14:08:00.000-05:00

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

2006-07-28T23:21:00.000-05:00

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

2006-07-24T19:30:00.000-05:00

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

2006-07-24T01:42:00.000-05:00

"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

2006-07-23T14:00:00.000-05:00

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

2006-07-22T11:37:00.000-05:00

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

2006-07-22T11:10:00.000-05:00

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…

2006-07-22T11:01:00.000-05:00

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

2006-07-21T14:51:00.000-05:00

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

2006-07-17T17:29:00.000-05:00

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?

2006-07-15T12:30:00.000-05:00

“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

2006-07-13T16:55:00.000-05:00

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

2006-07-09T16:20:00.000-05:00

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

2006-07-09T16:06:00.000-05:00

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

2006-07-04T16:09:00.000-05:00

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

2006-07-02T17:34:00.000-05:00

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?

"Healthcare outsourcing" is picking up among Americans

2006-06-30T15:15:00.000-05:00

In its May 29th issue, Time magazine ran a full-length article dubbed "Outsourcing Your Heart: Elective surgery in India? Medical tourism is booming, and U.S. companies trying to contain health-care costs are starting to take notice."

The entire article is readable on Time's site (just click the link above), so I'll just post some of the highlights:

With this surgical sojourn, his first trip outside the U.S., Miller joined the swelling ranks of medical tourists. As word has spread about the high-quality care and cut-rate surgery available in such countries as India, Thailand, Singapore and Malaysia, a growing stream of uninsured and underinsured Americans are boarding planes not for the typical face-lift or tummy tuck but for discount hip replacements and sophisticated heart surgeries. Bumrungrad alone, according to CEO Curtis Schroeder, saw its stream of American patients climb to 55,000 last year, a 30% rise. Three-quarters of them flew in from the U.S.; 83% came for noncosmetic treatments. Meanwhile, India's trade in international patients is increasing at the same rate.

That's a lot more Americans than I expected flying to Asia for surgery through just one company. And that 83% figure surprised me since I had thought most surgeries done on Westerners abroad were cosmetic.

It's one that could put greater competitive pressure on U.S. hospitals as some of their most lucrative patients are siphoned off. Elective surgeries are key moneymakers for hospitals, and even a small drop-off can cut deep into their profits.

Hospitals, like so many industries, is feeling heat from the "flattened world," a Tom Freidman term for globalization. And as if there weren't tremendous domestic cost pressures already. Put another way, "'This has the potential of doing to the U.S. health-care system what the Japanese auto industry did to American carmakers,' says Princeton University healthcare economist Uwe Reinhardt." Dr. Reinhardt (official webpage) is a big supporter of commercialized healthcare, as this blog entry states.

What may accelerate the trend is that some pioneering U.S. corporations, swamped by rising health-care costs, are taking a serious look at medical outsourcing. Blue Ridge Paper Products of Canton, N.C., a manufacturing company, may soon offer employees outsourcing as a health-care option. The carrot? The patient would get to pocket some of the firm's substantial savings...

The calculus behind this interest isn't complicated. Many major employers in the U.S. are self-insured, which means they pick up the tab for much of their employees' medical care. That's why three major corporations that collectively cover 240,000 lives asked Dr. Arnold Milstein, national healthcare "thought leader" at the consultancy Mercer Health & Benefits, to assess the best places to outsource elective surgeries. Procedures in Thailand and Malaysia, he found, cost only 20% to 25% as much as comparable ones in the U.S.; top-notch Indian hospitals sell such services at an even steeper discount.

Yet another instance of American companies being forced to find solutions to alleviate its own cost pressures from healthcare. And even some unique types of insurers are offering the option of "medical tourism":

United Group Programs (UGP) of Boca Raton, Fla., a third-party administrator that sells a low-premium, bare-bones form of coverage called a mini--medical plan, this month began promoting Bumrungrad Hospital as a preferred provider to its customers. Employees of self-insured businesses who use the more conventional plans designed by UGP will also have access to the Thai hospital. This means that UGP offers the option of partly or fully covered medical tourism to some 100,000 people, including those who could use it most.

Why all this interest in "healthcare outsourcing" inside the USA, home of the most advanced healthcare system(s) in the world? Well, just check out the cost savings (in this rather group but legible -- I hope -- chart in Time's pages).

What's interesting is what hospitals abroad wanting to court Westerners are doing: seeking JCAHO accreditation, staffing themselves with American-trained doctors, and making attached hotel and restaurant complexes.

And Asia isn't the only place where Westerners are going for healthcare. People go to Mexico for dental work, and Europeans are flying to northern Africa as reported in a previous post.

This is how the Time article ends:

Mohit Ghose of the trade group America's Health Insurance Plans says many have taken note of medical outsourcing but are scared off by the regulatory and legal uncertainties. Aaditya Mattoo, a World Bank economist who has published a study on the potential of medical outsourcing, suspects that pure institutional inertia has something to do with the lack of interest.

Yet as the medical-cost crisis deepens, the corporations who pay insurers are likely to find the lure of outsourcing as irresistible in health care as it is in software.

Hand-offs are dangerous, but fixable

2006-06-30T14:51:00.000-05:00

And I'm not talking football. It seems by the day, more hospitals are implementing simple innovations and thus reducing dangerous errors. A big reason why they're doing so is the push from the JCAHO, the body that accredits hospitals & regulates them.

The push continues. The JCAHO recently reported that communication breakdown is "the single largest source of medical error," and it's now "for the first time [establishing] standards for hand-off communications," the communication between outgoing & incoming staff.

The stakes are high, as hospitals that fail to comply with Joint Commission patient safety standards risk losing accreditation, which is often required for reimbursement from Medicare and private insurers.

Luckily, "a few hospitals and health-care quality groups have been ahead of the pack, borrowing communication strategies used in aviation and the military..." One such group is the Institute for Healthcare Improvement, which has been promoting a "communication model known as SBAR -- an acronym for Situation, Background, Assessment and Recommendation," which was developed for use in nuclear submarines. Kaiser & the VA are also ahead of the pack.

"A hand-off is a precision maneuver, but in medicine it has been left to happenstance," says Richard Frankel, a professor of medicine at Indiana University who is working on safety programs with the VA medical center in Indianapolis.

What's the danger in hand-off errors? Well, they run the gamut "from a patient getting a dose of a drug that was already administered on a previous shift, to doctors inappropriately reviving a patient because they aren't aware of a "do not resuscitate" order," says an internist at Yale University and the VA.

The most remarkable example of how communication models like SBAR can reduce fatalities and other medical injuries, as reported in the WSJ article "Hospitals Combat Errors at the 'Hand-Off': New Procedures Aim to Reduce Miscues as Nurses and Doctors Transfer Patients to Next Shift," is at OSF St. Joseph Medical Center.

John Whittington, patient safety officer at OSF St. Joseph Medical Center, says the SBAR "quick briefing" model can help overcome differing communication styles, such as nurses who give long, descriptive reports and doctors who say, "just give me the headlines," and don't want a nurse's opinion. OSF started training staffers to use the SBAR communication model in 2004, offering pocket cards and laminated "cheat sheets" posted at each phone.

At first, nurses and other staffers were hesitant to provide the "R" -- for recommendation -- to physicians, Dr. Whittington says, but doctors were asked to encourage staff to do so. By last year, the briefing format was used by more than 98% of nurses and the rate of adverse events -- defined as an unexpected medical problem that causes harm -- fell to 39.6 from 89.9 per 1,000 patient days, Dr. Whittington says.

It's amazing how powerful this small inexpensive change in the way things are done in the hospital truly is. You would think hospital leaders would be all over it. Think again.

"It does sound like this is something we should have been doing for the last 100 years, but one of the reasons errors are made during hand-offs is the longstanding culture of medicine," says Frank Mazza, vice president of medical affairs at Austin, Texas-based Seton Healthcare Network. Seton began using the SBAR model in its four labor-and-delivery units in January 2005, as part of an effort to eliminate complications for patients and make it easier for nurses to quickly brief each other and doctors.

Still, people inside hospitals are changing. And one of the catalysts of this change is technology, namely the electronic patient record system.

Brigham and Women's Hospital in Boston, for example, has used a computerized sign-out system for several years, and is developing a more-advanced version for the sickest patients in the ICU. David Bates, chief of the Division of General Medicine, says electronic systems are the only way to ensure the safe hand-off of large numbers of patients in a busy hospital, "so a standard set of information can get exchanged every time."

As part of its transition to electronic medical records, Kaiser has developed a Nurse Knowledge Exchange computer program, which allows departing nurses to create customized electronic reports on patients for the incoming nurses, such as lab results or medication changes. But the nurse coming on duty also makes bedside rounds with the outgoing nurse, and engages patients when possible in a discussion of treatments and progress.

It's awesome that a basic innovation in process, coupled with better info technology, are saving many more lives with little additional cost.

But jogging's so boring!

2006-06-26T01:40:00.000-05:00

It's safe to say most people know that regular exercise (coupled with good diet) prevents an array of chronic diseases. But there's a host of issues that make exercising easier said than done, from no time to lack of motivation. Well, this US News & World Report piece says these issues are simply excuses, and presents techniques to deal with them.

Primary care docs are getting ready for consumer-driven healthcare

2006-06-25T16:45:00.000-05:00

In a NYT piece titled "Market Forces Pushing Doctors to Be More Available" from June 24th, we learn that many primary care docs -- those who practice family medicine, pediatrics and internal medicine -- are gearing up for a more competitive, consumer-centric world.

It is not just a matter of moving to a small town. Ms. Kissell's doctor, Melissa Gerdes, is one of a rapidly growing number of physicians who have streamlined their schedules and added Internet services, among other steps, to better meet the needs of patients. For physicians like Dr. Gerdes, it is simply good business.

Those doctors know that as walk-in medical offices and retail-store clinics pose new competition, and as shrinking insurance benefits mean patients are paying more of their own bills, family care medicine is more than ever a consumer-service business. And it pays to keep the customer satisfied.

"It's about the patients — making people well and keeping them well," said Dr. Gerdes, 35, who has had her own practice for seven years.

The doctors' professional associations are urging their members to adopt new technologies to increase the ease for patients to see them and to reduce costs.

The academy is spending $8 million on consultants who visit doctors nationwide to suggest improvements in patient care. The advice is meant to "keep them from going to an in-store clinic," Ms. [Amanda Denning, a spokeswoman for the American Academy of Family Physicians] said, while also benefiting doctors by making office procedures more efficient.

Meanwhile, the 119,000-member American College Of Physicians is promoting "patient-centric care," which it made the focus of a policy paper this year, calling for more consumer-friendly scheduling, electronic medical records and electronic prescriptions, among other measures.

Coming back to the featured physician, Dr. Melissa Gerdes of Tyler, Texas, there are some interesting changes afoot in her clinic that depart from conventional care, at least the care I got my whole life, which included waiting days if not a week to see a doctor from when I called (except at the Baylor Clinic, which has same-day appointments), waiting "forever" in the waiting room and again in the patient room, and having to pick up a paper prescription and take it to the local drugstore to get medications.

In Dr. Gerdes's office, the innovations include daily clinics at lunchtime called QuickSick, in which patients who have phoned up that morning can come in for routine problems requiring immediate attention, like an upper respiratory infection, and are guaranteed they will be examined, treated and on their way within a half-hour.

After a nurse checks the patient's temperature and blood pressure and types the symptoms into a computer, the doctor follows up with a brief exam. If medication is warranted, Dr. Gerdes can e-mail a prescription that will be ready when the patient arrives at the pharmacy.

"I can see three patients with acute needs every 15 minutes," she said.

The charge is $52 to $60, which is coverable by insurance and similar to prices at many of the new clinics springing up in places like CVS pharmacies and retail chains like Wal-Mart.

What are the goals of these changes? Lower cost and more convenience, based on the two following quotes. "People will change physicians for differentials of $10 or $15 in a co-pay," said Dr. Anne B. Francis, a pediatrician in Rochester and spokeswoman for the American Academy of Pediatrics... "We try to cut down on the waiting time," [Dr. Larry S. Fields, American Academy of Family Physicians] added. "We need to be more conscious of patients' time."

Are patients catching onto these changes? For some doctors, yes.

Dr. Ellen Blye, an internist with a busy practice on the Upper West Side of Manhattan, said about one in 10 of her patients used the online scheduling system she leased from NexSched, a start-up in Marcellus, N.Y., near Syracuse.

Michael W. Davis, executive vice president of Himss Analytics, a health care technology consulting firm, said that NexSched and a handful of competitors were "just beginning to penetrate the market" and that fewer than 1 percent of physicians offices had installed the technology so far.

"The patients who use it, love it," Dr. Blye said. "They can see what is available and do it any time." Although she does not offer same-day scheduling, her patients "can often come right in, if they see that someone has canceled."

Dr. Blye said that electronic scheduling, together with electronic medical records — a system made by GE Healthcare — enabled her staff of two internists and two nurse practitioners to save on overhead by eliminating one clerical employee.

One change using the simplest of Internet technologies seems promising: e-mail consultations. I have been doing this with my primary care physician, and it's been great. Over email I can get questions answered about when I can come in to see him and what kind of tests they have and how much they'd cost. I've even shared an article or two on medical matters with him via e-mail.

The same computerization that makes online scheduling possible can also open the door to online consultations, which usually involve questions that patients ask about routine matters like diet or possible changes in the strength of a prescription drug. The patient can go online at any convenient time, and the doctor often replies the next morning. But because health plans only rarely pay for these e-visits, such services have been slower to catch on.

I wonder if these changes are purely defensive, which seems to be the case presented in this article, or if some forward-thinking, technology-saavy iconoclastic doctors are driving these changes forward. While the primary care associations have caught on, and seemingly are improving care to improve their patients' healthcare, the big medical association seems to be reacting to a perceived threat to its members' monopoly.

And for all the new openness that many doctors are adopting, some efforts seem mainly defensive moves against the retail clinics, which are typically operated by nurses. At its annual meeting this month, the American Medical Association called on the clinics to accept a list of principles that would limit their scope to simple services and ensure that a physician oversees the operations.

Even Dr. Gerdes seems to be reacting defensively, discussing with her clinic planning group "how we will respond when retail clinics come to Tyler and what we can do to improve access for the patient."

Still, patients quoted in the article express their satisfaction with the changes made by Dr. Gerdes, and so, whether compelled by the desire to remain in business in the more competitive, cutthroat world of medical care thanks to new forces in the marketplace or nobler patient-centric reasons, changes in conventional healthcare are coming without a doubt, and they will be good for patients.

My ideas, part 1

2006-06-24T12:21:00.000-05:00

During my neurology & psychiatry rotations the past few months, I had the habit of jotting down to-dos and thoughts into my Palm PDA. I also wrote ideas down, ideas that could improve healthcare or presented a problem that needed to be solved. Here's what I culled from mid-March until May, in chronological order:

1. Better manage hypoglycemia [or pathologically low blood glucose, a common effect in diabetics who take more medicine than needed] with a compliance tool to avoid stroke-like symptoms. (Esther Dyson, a noted "thinker" in the IT world, said whoever developed compliance tools for medications would be richly rewarded.)

2. Make diabetes care more humane and empower people with diabetes to live normal lives. One patient from a small Texas town was told by her endocrinologist that she ought not have a baby because her blood sugar was instable. This is untrue and bad medicine, and in her case prevented the woman from having her baby when she was younger [and being younger confers one definite advantage, lesser rates of birth defects].

3. If surgeons today use Da Vinci surgical robots to do mini-surgeries while they themselves are several feet from their patients and sometimes in different rooms while their staff wait at the patients' bedside, can't surgeons do this remotely?

4. Telemedicine allows doctors who don't need to conduct a thorough physical examination (think psychiatrists) -- or who have staff local to patients to do this for them -- to see patients far, far away from their own offices. Instead of focusing expensive incentives on bringing doctors and nurses to small towns and the countryside, let's build up telemedicine capabilities instead, which will be cheaper in the long-run and allow people more freedom to live where they'd like.

4. St. Luke's & Methodist, the two big Houston-area hospitals, use different Patient Management Records [PMR] systems vendors, McKesson and Hyperspace respectively. What happens if a patient is transferred between hospitals, or more likely if the patient comes to one hospital after having been hospitalized in another?

A layer of software could be constructed to draw patient data from both systems and displaying it on one interface, eliminating the need for re-entry of old data into each PMR system & improving medical persons' access to all the medical data out there on their patients. And this is a more feasible solution than getting all hospitals to buy from one vendor, or having them subscribe to a federal government invention.

That's it for now, future installments to follow.

Basic innovations saved 100K+ lives in US hospitals

2006-06-22T18:34:00.000-05:00

Almost every post here is on a new technology, a novel way of looking at things of doing them, but I have not been able to cite how much these "healthcare innovations" are truly changing the way people's health are cared for.

So it was a stroke of fortune that the WSJ reported on June 15th about how new practices adopted by hospitals have indeed cut down on errors and thus saved lives, which has been a major goal of the Institute of Medicine. In the AP article titled "Hospital Initiative to Cut Errors Finds About 122,300 Lives Saved," Donald Berwick (the Harvard professor who headed the initiaitive) said, "I think this campaign signals no less than a new standard of health care in America."

About 3,100 hospitals participated in the project, sharing mortality data and carrying out study-tested procedures that prevent infections and mistakes. "We in health care have never seen or experienced anything like this," said Dennis O'Leary, president of the Joint Commission on Accreditation of Healthcare Organizations.

The JCAHO is the national board that regulates hospitals.

Medical mistakes were the focus of a widely noted 1999 national report that estimated 44,000 to 98,000 Americans die each year as a result of errors and low-quality care. That year, Dr. Berwick -- president of the Institute for Healthcare Improvement, a Massachusetts-based nonprofit organization -- challenged health-care leaders to improve care quality and prevent mistakes.

In December 2004, he stepped up the challenge by announcing a "100,000 Lives Campaign." He set a June 14, 2006, deadline to sign up at least 2,000 U.S. hospitals in the effort and implement six types of changes.

Among the six changes were "rapid-response teams for emergency care of patients whose vital signs suddenly deteriorate [operating] around the clock to other units," "checks and rechecks of patient medications to protect against drug errors," and "preventing surgical-site infections by following certain guidelines, including giving patients antibiotics before their operations."

The effort was endorsed by federal health officials, health insurers, hospital industry leaders, the American Medical Association and others. The roughly 3,100 hospitals that signed up represented about 75% of the nation's acute-care beds. About 86% sent in mortality data. Roughly a third said they were implementing all six measures, and more than half committed to at least three, Dr. Berwick said.

This is great news because it shows simple systematic changes (as opposed to increasing the education of medical professional) can make a big difference, akin to the introduction of hand-washing in hospitals causing a dramatic decrease in the number of deaths and infections in hospitals.

Innovations do save lives, especially it seems the simplest low-cost ones.

Incentives to be healthy - is it all about the benjamins?

2006-06-17T10:48:00.000-05:00

Here are some of the incentives my medical school offers its students, faculty, researchers, staff & support people to stay healthy, as delievered in an email today.

The summer is a great time to get healthy. BCM has some exciting programs with nice financial incentives to help you get through Houston's sizzling months and come out in better shape:

Weight Watchers at Work: If you sign up for convenient Weight Watchers at Work classes during the summer, BCM will pay for 20% of your enrollment fee. It's normally $180 for the 15-week session, but now BCM will pay $36 and you pay only $144...

24 Hour Fitness: BCM has a special corporate rate with 24 Hour Fitness, and the gyms have reduced their family add-on fee to only $49...

Smoking cessation: Our EAP provider... will be providing four-session courses for BCM employees and students and their significant others... Each participant is encouraged to bring a buddy... The fee for the course is $125 per person. After completing all four classes, each participant (both BCM folks and their buddies) will be reimbursed $100.

It is funny to see this line at the end of the smoking cessation deal, in case you didn't realize it: This is a very good deal.

Do financial incentives change people's behavior? On the surface, and intuitively, the answer seems yes.

But the Douglas Rushkoff of a neat book called Get Back in the Box (about work & life in today's internet-based renaissance) disagrees. He frames the ineptness of the financial carrot stick in the world of work: "The more frequently you reinforce "good" behavior with cash, the more you disconnect employees from their own experience of the work itself... [shifting focus] from the task and onto the reward."

Is that a bad thing per se, or ineffective? Well, no. The writer himself backs off a bit from his strong assertion by writing there are people who need money desperately or want money in order to fill a psychological emptiness (think Maslow's hierarchy and about how the need of love & belonging is below self-actualization), and for these people money is most ideal motivator.

However, I think for an educated guy or girl who wants to quit smoking for health, even moral reasons, money is not as good a motivator to quit as making the process of quitting fun (which is the book's point: intrinsic rewards drive a person to work harder at something because that work is approached as play), painless or full of meaning.

In fact I know people who quit by spending more money -- a clear disincentive in the conventional sense -- because quitting simply meant so much to them.

And more obviously, kids are more interested in fun. For the average obese kid, what would compel him to lose weight, being given $500 to exercise 3 times a week for a year or making the experience fun? I think kids, who aren't as entrenched in the real world where money means so much, would rather have fun. In fact, a professor at my school says his dream is to combine elements of a gym and video games to get obese kids skinnier.

These are just some thoughts and anecdotes. I'll post more when I find some scientific evidence to back up these positions.

Web tools enable price comparison & push consumer-driven healthcare

2006-06-13T15:51:00.000-05:00

Insurance companies are begin to comply in earnest with a policy of greater price transparency, something the Bush administration has long been advocating as it pushes "consumer-driven healthcare." From the June 13th WSJ article Patients Get New Tools To Price Health Care:

Aetna Inc., which last year in the Cincinnati area became the first major insurer to reveal rates it negotiates with local physicians, is expanding that program to eight more areas. Other major insurers, including Cigna Corp., Humana Inc. and UnitedHealth Group Inc., are adding or expanding their own online pricing tools. And Medicare early this month posted online1 the ranges of what it pays hospitals for 30 common procedures and treatments, the first in a series of disclosures the agency says it will make. Several state governments and hospital associations, including in Florida, New Hampshire, Utah and New Mexico, are launching Web services that list hospital charges.

The information provided by these new tools comes with caveats, but the services do show that, in principle at least, comparison shopping can make a difference: While prices of simple services in doctors' offices are fairly consistent according to some online data, hospital costs often vary widely. For example, a Web-based pricing tool offered by Humana shows that at hospitals in a Humana network in southeast Wisconsin, a knee replacement ranges from a minimum of $16,900 at one hospital to a maximum of $34,050 at another, reflecting in part discounted rates that the insurer has negotiated with health-care providers.

What's behind the further push into this direction?

The new pricing services are popping up as consumers are being asked to shoulder an ever-greater proportion of their health-care costs. Employer-sponsored and other health plans are shifting more of the cost of health care to consumers by raising co-payments and cutting benefits. That dovetails with efforts by the Bush administration to promote so-called consumer-driven health care, mainly through high-deductible insurance policies paired with health savings accounts that offer financial incentives to shop wisely for care.

The problem for consumers has been finding the prices in order to make the comparisons. Until recently, doctors and hospitals had little incentive to disclose prices, since insurance would generally pick up the tab. When patients do seek cost information, health-care providers can be hard-pressed to explain the often-byzantine pricing systems. And the discounted rates that insurers negotiate with doctors and other providers are held close to the vest for competitive reasons.

There are certain limitations to the insurance companies' push for better price transparency. For one, they have limited price information to their enrollees, and then only in certain test cities. Also, [a]nd while some tools, including Aetna's and Cigna's, are adding information on quality of care, comparative data in that area are still hard to come by. So patients may simply opt for the costlier options in the absence of any other gauge of quality, even though one of the goals of consumer-driven health care is to lower costs.

"It's not like going to Wal-Mart and saying, 'I'm going to buy tuna fish now, it's cheaper,' " says Regina Herzlinger, a Harvard Business School professor who is an advocate of consumer-driven health care. "This is a more complex kind of decision."

An important factor in all this is the Internet. Web technologies allow consumers to see prices without having to call the doctor's office and ask what some consumers themselves may see as pesky questions. And besides, for the insured they have not been in the habit of asking for prices since all they pay is the co-pay (which is beginning to change as the insured are beginning to pay more -- and variable amounts -- for their healthcare. But the web presents its own problem.

The tools are mostly Web-based, so many patients won't have the resources to access them.

And a price listing isn't the end-all-be-all in medicine.

Charles Murray, a human-resources manager at a South Milwaukee, Wis., manufacturing firm, used Humana's hospital-cost tool before his knee replacement in March. The hospital he preferred turned out to be among the least expensive listed. Humana says the tool shows that a knee replacement at that hospital costs $18,150 to $19,650, taking into account discounts the insurer has negotiated with the hospital. When Mr. Murray received the bills, he says, the cost totaled $20,220 (though insurance did cover most of the costs). Costs can fall outside of the range for a variety of reasons, Humana says, for example if a patient stays in the hospital longer than others typically do.

Still the insurance companies press on, imagining having to provide price information readily soon.

Aetna says it didn't expect the program to cause tangible changes in its first year, but that as more consumers have plans with high deductibles, prices will become more important to them. "All of a sudden, they're going to demand the information, and if we're not ready for it, then we'd be very concerned," says Robin Downey, Aetna's head of product development.

And they're not limiting this to just medical care.

UnitedHealth Group early this year added a tool to its consumer Web site that lets enrollees in its dental plans nationwide look up the rates the insurer has negotiated with individual dentists for nearly 600 procedures, plus what they'll have to pay out of pocket. Some insurers, including UnitedHealth and Lumenos, a unit of WellPoint Inc., have online tools that let enrollees look up drug costs at specific pharmacies in their areas.

Perhaps another reason why insurance companies are changing their tune is because governments are beginning to demand it.

On the state level, in the past year and a half a number of bills on price transparency have been introduced in legislatures. Among laws that have passed, South Dakota requires hospitals to report annually their median charges for their 25 most common inpatient services. That information was posted online in early June, at hospitalpricing.sd.gov2. A Minnesota law requires the development of a public Web site on common hospital charges by Oct. 1.

The New Hampshire Hospital Association last month launched a site, www.nhpricepoint.org3, that provides average charges and lengths of stay for a variety of procedures at hospitals in the state. Similar sites are available in Wisconsin and Oregon, and the Utah and New Mexico associations plan to offer similar sites later this year. The Wisconsin site, www.wipricepoint.org4, had about 320,000 page views since it was launched in February 2005, according to Wisconsin's hospital association.

Florida's government late last year launched floridacomparecare.gov5, which provides individual hospitals' average charges and lengths of stay, plus some quality information. Another Florida site, myfloridarx.com6, provides retail prices at individual pharmacies for the 50 most-commonly used prescription drugs in the state.

Framing universal healthcare to get support from big business

2006-06-11T22:25:00.000-05:00

"Mrs. Clinton often frames the problem today as one of economics as much as social justice. She asserts that soaring health costs are weighing down American corporations and hindering their ability to compete in a global marketplace, against countries with government-financed health benefits or no expectation of health coverage at all."

From "Wounds Salved, Clinton Returns to Health Care" run on June 11th in the NY Times.