Thursday, February 26, 2015

The Latest Health Wonk Review Is Up!

Happy Anniversary to the Health Business Blog. And what better way to celebrate the occasion than by hosting the Health Wonk Review.  David Williams' linked summary has the best of brainy health policy wonkery from around the web.


Monday, February 23, 2015

The Third Wave, Informatics, Quantum Mechanics and Health Care Reform

Schrödinger's cat
While the Population Health Blog continues to mull the promise vs. reality of Alvin Toffler's book on The Third Wave "Information" Age, it's been struck by the observation that any Wave's ideals are often applied to institutions.

It's a classic chicken vs. egg self-reinforcing feedback loop. For example, during the Second Wave, the industrial mindset gave rise to bureaucracies

Which prompts the PHB to wonder if the electronic health record (EHR) was the inevitable result of the Third Information Wave, or its intrusive invention?

Whither Biology in Health Care's Third Information Wave?

Yet, at the same time, the physician PHB has been struck by the emergence of biology-laced health reform jargon.  It's not unusual to read or hear that care delivery should have "organic" features (e.g., here and here) and resemble "ecosystems" (here and here).  Indeed, the intellectual underpinnings for integration is eerily close to complex 'living" entity, with a whole that is more than the sum of its semi-autonomous parts.  Think more organism than organization.

Biology: Not Incompatible but Synergistic

And before you assume that the healthcare paradigm of binary silicon-based electronics is  incompatible with complex carbon-based life forms, recall that DNA has been recast as a computer, and life has been defined as a DNA software system. Is networked machine intelligence in a large regional delivery system all that different than the chromosomes and enzymes that enable me to type this blog?

It seems that the "biology" of information technology" is not cognitive dissonance, but a perfect, if ironic, window into where health care is headed.

Enter Statistics

And since software is ultimately about information, "medical informatics" has - by definition - moved front and center. Assuming it is patient-centric," success in our Third Information Age is less about collecting patient anecdotes than their associated data: assembling and using of means, standard deviations, p < .05 significance, associations, predictors, regressions, known-unknowns, unknown-unknown Black Swans, artificial intelligence and "big data" inputs. Little wonder, then, that the informatics underpinnings of "population health" are increasingly being used by policymakers and has captured the attention of the entities such as the Institute of Medicine, and The White House.

Statistics on Steroids: Quantum Mechanics and What We Don't Know

Quantum mechanics is bubbling up into popular media (from photography to leadership). Health care - from the atomic level  of molecular biology to the societal level of public health - has not been immune.

Mix quantum mechanics with some Triple Aim, and Heisenberg's "Uncertainty" over position vs. momentum tells us that the more intense the statistical measurement of health care quality and cost, the greater the complexity, impreciseness and chaos. 

If so, it may be that the best that health system architects will ever be able to do is define the range of probabilities, risk and uncertainty that underlie cost, quality and care. 

Which leads the PHB to......

Risk as the Coin of the Healthcare Realm

Insurers are masters at measuring and monetizing (and, when necessary, avoiding) health risks. They understand the inherent uncertainties of health care. In the PHB's estimation, the quantum sophistication of the Information Age is going to lead the next level: managing uncertainty.

The Bottom Line: Outcomes vs. Risk Management

As health informatics and analytics grow, health care's imprecision will become better defined. We'll understand that not every patient with diabetes will be known to have diabetes, not every patient known to have diabetes will have a test for diabetes and collecting all individual tests for diabetes will never tell us what's really going on for the universe of diabetes.  The idea that we can use the health system to attain 100% measurement or perfection is about as real as the quantum state of Schrödinger's cat.

OK, What About the Real World?

While quantum mechanics already has some real world applications, it's too early to predict how risk, uncertainties and probabilities will factor into the future of health reform.  But the PHB confidently predicts that patient outcomes will be less a function of diabetes control, rehospitalization rates, medication compliance or satisfaction. 

Instead, it will be about understanding the determinants of a lower risk of diabetes complications, a lower chance of rehospitalization, a greater likelihood of medication compliance and a higher probability of satisfaction.  Quantum mechanics tells us that when measurement causes these well-managed probabilities to "collapse" out of their "quantum" state, the measurements will look better.

All that remains is determining the best combination of buyers, payers, insurers, providers and government necessary to achieve that.

It starts with the risk.  Complex health systems that adapt to that fundamental paradigm shift will win.

Image from Wikipedia

Monday, February 16, 2015

mHealth Apps to Monitor Recently Discharged Patients

After knee surgery: how do you
monitor this patient at home?
The "this paper" link in the original post directed readers to the wrong web site.  It's been corrected and the PHB apologizes for the error)

While the Population Health Blog is tantalized by the prospect of healthcare consumers using mHealth apps to lower costs, increase quality and improve care, it wanted to better understand their real-world value propositions. 

Are app-empowered patients less likely to use the emergency room?

Do they have a higher survival rate? 

Do they have higher levels of satisfaction?

In other words, where's the beef?

That's when this paper caught the PHB's search engine eye. It's a report on using an app to monitor post-operative patients at home.

This was a "feasibility study" involving a Canadian cohort of home-based post-operative patients who had gone through either reconstructive breast or knee (anterior cruciate repair) surgery. In order to qualify, patients had to be between age 18 years and 75 years, not using tobacco and able to speak English.  Once the app was activated, patient were asked about pain, their recovery and satisfaction (using a 1 to 4 scale).  They also used the app to take pictures of the surgical site. 

To maintain confidentiality, there were no patient identifiers linked to any images and a "locked down" subscriber identify module (SIM) was used. Data was encrypted on the server and the device.

Three surgeons participated and were responsible for reviewing their patients' data on a daily basis.  The app flagged any measure that was unexpectedly out of range for expedited review.

Instruction on use of the app took between 30 and 45 minutes. Patients were loaned a smartphone or a tablet, along with an instructional booklet.  At the end of the 30 day period, the smartphone or tablet had to be returned.

38 breast patients were approached at 33 agreed to participate.  40 orthopedic patients were approached and 32 agreed to participate.


The mean number of log-ins over the 30 days ranged from 19 to 24, with greater use in the first half of the month. Over 2000 photos were generated. Based on the pain and recovery scales, two early infections were identified and one was treated over the phone with antibiotics with subsequent improvement. On a 1 to 4 scale, the overall level of satisfaction was 2.7 to 3.9.

The PHB's take?

It would appear that the science on using apps to address specific outcomes in narrowly defined populations is still in its infancy.  While the Triple-Aim potential of mHealth is high, we're just beginning to understand how an app would work in the real world, say.... monitoring the outpatient status of recently discharged surgery patients.

That's why this particular study was interesting. It would appear handhelds or tablets can be used in the post-operative setting, that patient satisfaction is high and that, with symptom monitoring and imaging, an early wound infection can be identified and managed early.

Naturally, it'll take a study involving a control group to better understand the true value of an app like this.  Based on this feasibility study, the PHB is looking forward to reading about it in the not too distant future.

Image from Wikipedia

Thursday, February 12, 2015

The Latest Health Wonk Review Is Up

Peggy Salvatore at the Health System Ed blog hosts the latest version that's been aptly titled the Valentine Edition of the Health Wonk Review: For Health Policy Lovers Everywhere. The aw shucks PHB is there with other blogging luminaries who are embracing topics that run from the cells of women to health-worker strikes.

Tuesday, February 10, 2015

The End of Power Health Care?

Corporate titans enjoying
the good old days.
While Moses Naim's The End of Power devotes only a few pages to medicine, it's still provocative and worthwhile reading for anyone involved in the delivery of health care.

As the Population Health Blog understands it, the book's central thesis is that traditional "power" is being disrupted by the three modern trends of "more," "mobility" and "mentality."

We live in an unprecedented era of more (relative) widespread wealth, have an astonishing ability to move goods, services, information and ourselves around the globe (mobility) and are far less likely to adopt the cultural and intellectual assumptions and norms of established society (mentality).

Despite the depressing narrative of the "elite 1%," the irony is that governments and corporations have far less ability to command and control the 99%. This has big implications for world affairs, democracy and U.S. power.


Big themes like this naturally prompt the excitable Population Health Blog to speculate about the implications of Naim's more-mobility-mentality for health reform in the United States.

It should be no wonder that policymakers, politicians, academics and regulators are promoting a large and concentrated i.e. powerful version of healthcare delivery.  These cognoscenti argue that huge integrated delivery systems, accountable care organizations and regional providers can "rationalize" health care with standardized protocols, less variation, efficient service lines, alignmment of incentives, optimum capital deployment and assumption of insurance risk.

Mr. Naim cautions that the power-play may not succeed. The PHB extrapolates:

1. While pundits can argue whether the Affordable Care Act's insurance options are as good as they should be, we're devoting a lot of wealth toward health care. More individuals have higher levels of resources to put into their care than they've ever had before. And they know it.

2. While that wealth is being tempered by out-of-pocket expenses, network exclusions, service limitations and other trade-offs, consumers still have relatively abundant choices on not only when, but where to see that doctor, have that surgery or take that pill.  By the way, information is not only cheaper (thanks to the internet) but no longer monopolized by the health professions. 

3. Whether it's a one-on-one recommendation to have a procedure or a proposal to build a new hospital wing, gone are the days when a professional expert's opinion was automatically accepted. Stakeholders are demanding evidence, seeking justification, asking for alternatives and are relishing the "gotcha" moments.

Where do these healthcare versions of more-mobility-mentality take us? Greater access to resources means higher expectations. Mobility means consumers will use exercise choice to cross country, state or even national borders to access care when they choose to do so.  And mentality translates into higher levels of individual consumerism.

Instead of protocols with less variation, patients will want the care to be personalized. Service lines will be judged less on efficiency than on local notions of value. Provider incentives based on "outcomes" and "upside risk" will have zero value proposition for their wealthy, mobile and skeptical customers.  Capital won't necessarily flow toward non-performing assets and year-end savings won't materialize just because policymakers wish it so.

Accountable care organizations and integrated delivery systems will still have huge competitive advantages. That being said, their chances competing successly against smaller competitors and access to capital will be increased if

1) their protocols are flexible,

2) variation is not only welcome but warranted,

3) patients have a good reason to choose their service lines,

4) incentives are broadened, and

5) this new and different level of complicated risk is realistically priced.

And that's assuming that the health provider policymakers, politicians, academics, regulators and CEOs realize that they're not quite in charge anymore.

Wednesday, February 4, 2015

Maintenance of Certification (MOC) Update: A Health Reform Lesson

The 1967 Corvair. A non-PHB version
Long ago, when the Population Health Blog was courting the future PHB spouse, our unspoken understanding was that if the PHB liked its unsafe-at-any-speed 1967 Corvair, it could keep its unsafe-at-any-speed Corvair.

The sweet perfume of our relationship more than made up for the odor of car exhaust, unsightly blemishes, noisy rattles and rusted floorboards.

Cracking the windows, touches of spray paint, the AM radio volume knob and care where you placed your feet also helped.

It wasn't until courtship turned to relationship that the spouse's true thinking began to manifest itself.

That's why, years later, the PHB was unsurprised by President Obama's disavowal of his you-can-keep-your-health-plan assurances. Substitute Federal minimal essential benefit requirements, narrow networks and unaffordable premiums for spousal safety demands, mocking eye-rolling and intrusive hints about the merits of a new car, and readers should understand the PHB's acquiescence.

So the PHB shrugged off the notification that its life-long American Board of Internal Medicine (ABIM) specialty credential wasn't really a life-long credential.  

Enter maintenance of certification or "MOC."

More background can be found here, but, briefly, the sweet perfume of accomplishment was overcome by the MOC stink of intrusive, unproven as well as expensive documentation, education and testing renewal requirements.

Thousands of the PHB's physician colleagues were less submissive about the matter in print and on-line. There were also competitive threats, lawsuits, online petitions, and websites. The American Medical Association weighed in. And then state medical societies, which have a vital interest in serving their membership, began to sound the alarm.

And it paid off. 

While the PHB would have predicted that the academics populating the ABIM leadership were about as likely as Mr. Obama or the PHB spouse to change their minds, they've issued a "we got it wrong and sincerely apologize" announcement. 

As a result, many of their documentation requirements are on hold, the test is being revamped, fees are being reduced and the education options are being broadened.

Good for the ABIM and good for the practice of internal medicine.

This kind of mea culpa is a good first step in engaging the opposition and is likely to turn many critics into allies. More importantly, this is a great example of the impact of grass roots activism and the advocacy of organized medicine.

If this can happen in this corner health care, perhaps there are other areas of health reform where a well placed apology might be a good first step.

The magnanimous PHB is also happy to admit that, in retrospect, the spouse was right about the Corvair. At one point, highway snow was blowing up into the passenger compartment.  At 60 miles an hour.  Seriously.

Since then, it has gotten to like and keep lots of other stuff.  It makes having to pay so much for its own heath insurance a little more tolerable.

Image from Wikipedia

Monday, February 2, 2015

CMS and Health Reform: More of the Same

Whoa, with breathless media coverage like this (dramatically change! ambitious!) you'd think that the Feds had just announced something important about health reform. 

After reading the CMS press release, a CMS blog post and this article in the New England Journal, the Population Health Blog has concluded that it's more of the same. 

As the PHB understands it, Medicare's January 26 announcement is that it will build on three ongoing reforms:

1. Financial incentives to expand "alternative payment" methodologies to 30% of all reimbursement by 2016 and to 50% by 2018.  These include accountable care organization arrangements, monthly fees to Patient Centered Medical Homes and use of bundled payments.  In addition, 85% of fee-for-service payments that are still in place will be linked to quality by 2015, with an increase to 90% by 2018.

2. Promoting "provider integration." That apparently means a new forum called the Transforming Clinical Practice Initiative, with a first yet-to-be-planned meeting in March of 2015.  In addition, CMS will continue to rely on its Partnership for Patients and the Patient Centered Outcomes Research Institute.

3. Information technology (IT) including more promotion of electronic records, meaningful use, interoperability and universal information technology standards.


The cynical PHB is not impressed. The Obama Administration was using, is using and will continue to use faux announcements to advance its reforms.  What's more, when it reads the CMS pabulum, it's riddled with the same top-down mainframe rhetoric on realigning care, moving from volume to value, accountability, alternative payment models, serving populations, building a better system, increasing coordination, convening meetings, promoting information technology etc. There are no new details here.

The PHB will share three insights, however:

1. CMS, Ms. Burwell and their White House handlers lost an opportunity to reach out to the Republicans about the sustainable growth rate and leveraging that to build on multiple areas of agreement to jumpstart bipartisan reform.  Doing so could have accelerated the forward momentum of value-quality-cost-based reforms beyond the 2016 elections.

2. That being said, health care providers need to increase their familiarity with the opportunities as well as perils of payment reform as well as the very real barriers to fixed payment schemes.

3. The announcements are a reminder how CMS is still fixated on the EHR, while the real innovation is occurring in handhelds and their associated applications.  The PHB figures that its not about the providers and their desktop electronic records, but about patients and their smart phones. As these devices continue to grow in speed, power and sophistication, providers who figure out how to use the iPlatform to leverage self-care, communication and decision support will thrive.....

With or without Medicare's incentives, promotion or IT policies.

Image from Wikipedia

Tuesday, January 27, 2015

Either You Give Your Patients a mHealth App, or They'll Get One Themselves

That's what the Population Health Blog learned after reading this research paper by Bauer and colleagues that recently appeared in the Journal of the America Board of Family Medicine.

It also confirmed that chronic care management apps are a business opportunity.

What was the research and what did it show?

All adult patients receiving care at six clinics in a northwest U.S. primary care network during a two week window of time (June 2013) were anonymously surveyed about their use of mHealth.

Depending on the clinic, 22% to 62% of the patients were insured by Medicaid.  More demographic info can be found here.

1363 surveys were distributed and 918 (67%) were completed. 

91% had a mobile phone and more than half (55%) owned a smart phone.

Among the smart phone owners, 70% had used "mHealth." 57% had downloaded at least one app. Of these, 69% used it less than 3 times a month, while 11% used it on a daily basis.

There was no association of mHealth participation with health literacy, chronic conditions or depression. Use was more prevalent among persons less than age 45.

One third used "general" health apps, while one quarter used fitness, diet or weight-loss apps. Only 3% used it for chronic disease management.

The authors asked respondents to use a 1-5 scale to rate the desirability of various app features. Appointment reminders came in first, followed by medication reminders and general health information.

10% learned about this from their physicians and only 31% "prioritized" their physician's involvement.

The PHB's summary:

Smart phone and app use may be more prevalent in the northwest, which may make the findings of this survey less generalizable to the rest of the United States.  With that caveat, approximately 40% of the patients sitting in the average primary care clinic waiting room are mHealth users and about 20% are using health apps. And what do patients most prize in their apps?  Reminders about appointments and medications.

What's more, most of this is occurring without the benefit of their providers' participation.

Last but not least, apps have not penetrated the chronic disease population.

The PHB's take?

1) If all those patients with smart phones are going to download apps, they might as well download ones that - at a minimum - are endorsed by their providers. Optimally, they should complement their providers' services.  Used right, they might be able meet their patient's desires for coordinated appointments and increased medication compliance. 

Providers and patients would benefit from better quality and lower costs.

2) And patients with chronic conditions have yet to discover apps.  That may be a function of age, but it may also be a function of the conspicuous silence of their providers as well as the failure of the currently available apps to meet their potential customers' desires. 

That spells opportunity.  Recall the adage of the two shoe salespersons who were sent to Africa.  The more pessimistic of the two found that none of the natives were using shoes and decided to return home.  The optimist likewise found that no one was using shoes, but he called back to the home office and asked for help.

The market for chronic care apps needs help.

Image from Wikipedia

Thursday, January 22, 2015

Could mHealth Apps Be a Reprise of the EHR? The Need for Clinician Input

While the Population Health Blog continues to delight in the emerging science of "mHealth" as a newly minted start-up Chief Medical Officer, it ran across this interesting article on risk and patient safety.

Authors Thomas Lewis and Jeremy Wyatt worry that "apps" can lead to patient harm. 

They posit that the likelihood of harm is mainly a function of 1) the nature of the mistake itself (miscalculating a body mass index is far less problematic than miscalculating a drug dose) and 2) its severity (overdosing on a cupcake versus a narcotic).  When you include other "inherent and external variables," including the display, the user interface, network issues, information storage, informational complexity and the number of patients using it, the risks can grow from a simple case of developer embarrassment to catastrophic patient loss of life.

In response, they propose that app developers think about  this "two dimensional app space" that relies on a risk assessment coupled to a staggered regulation model.  That regulation can range from simple clinical self assessment to a more complex and formal approval process.

What's clear to the PHB is that hidebound mainframe entities like the Food and Drug Administration are no match for the app "ecosystem".  Rather than try to formulate a one-size-fits-all "not function as intended" model like this, maybe it should triage its oversight using the Lewis and Wyatt framework.

In addition, the PHB agrees with Lewis and Wyatt that safety is also a function of clinician input.  Docs and nurses can assess possible mistakes, their downside severity and the impact of all those variables.

The PHB couldn't have put it better:

".... many app developers have little or no formal medical training and do not involve clinicians in the development process and may therefore be unaware of patient safety issues raised by inappropriate app content or functioning."

Without the insights of seasoned real-world doctors and nurses, apps could end up with the same safety issues that are plaguing electronic health records, many of which were also developed with little regard to physician or nurse input

In other words, just because it's a "health" app doesn't mean its necessarily so.

Image from Wikipedia

Monday, January 19, 2015

The PHB is Back

The Population Health Blog received a gratifying number of "Where'd ya go?" reader posts, emails.  Thank you......

It didn't need a handgun to know it wasn't going anywhere.

Rather, the PHB recharged over the holidays, continued to build its Twitter followership and, best of all, was busy with medSolis.

It's paid off. We've closed 2014 with a solid product, two customers, one investor and more than a dozen employees. Looking ahead to 2015, it's gonna need shades.

Speaking of a bright future, it recently got to surf the JP Morgan Health Care Conference ecosystem, described by CNBC as the "biggest health care investing event of the year." In addition to some promising additional investor leads, the PHB came away with two memories:

1) San Francisco's Union Square is usually populated by a pleasant mix of tourists, shoppers and natives. During the conference, however, it was thick with (mostly white male) suits, most of whom were staring off into space while pressing the latest handheld technology against the side of their heads. They moved very little.  The PHB knows this because it watched them very closely.

2) Overcome by the bursts of electromagnetism, the PHB retreated and sought out quiet time in those oases formally known as "hotel lobbies." They too were packed with suits, but they were excitedly clustered around open lap tops or lustfully stroking some piece of monitoring gadgetry. Open seats and cheap coffee were nowhere to be found.

And what has it learned in the last two months? In addition to discovering that the PHB spouse doesn't believe $400 San Francisco hotel rooms are a "biggest health care investing week" bargain, the PHB also confirmed that the most promising population health technology solutions are simple and scalable.

More on that in a future post.