Topol's Healthcare in American - At a Crossroads of Innovation and Ossification

I recently read Eric Topol’s Creative Destruction of Medicine: How the Digital Revolution Will Create Better Health Care.  I highly recommend it.  Dr. Topol’s main premise is that innovative deconstruction of people (patients) into their more base components- (their DNA, RNA and proteins), will help us design better, more personalized treatments for a host of diseases.  

This relates to the science of pharmacogenetics, how our genetics individualize our respond to drugs.  This is in contradistinction to the current pharma model- treat as many people as possible even if the benefits are modest for most.  

Unfortunately, as Topol points out, medicine as an institution, and physicians in particular, have not kept pace.  The system is relatively ossified.  Through a combination of bureaucracy and tradition, medical education has not changed substantially since the last great paradigm shift, Flexner Report, in 1910.  In the face of an information explosion, the subjects I studied in medical school 25 years ago were similar to those my father learned 50 years ago.  Unless something drastic happens my daughter, currently a pre-med, is likely to have a similar curriculum.  This results is a type of healthcare delivery focused on the hospital, not the clinic, emphasizing the heroic not the chronic.  In part, this mismatch has lead to the US spending almost twice what other nations spend for healthcare with no perceptible benefit.  This is not sustainable.  Of course today’s medical students and residents are more likely to Google for answers than open a book.  Physicians no longer have to be walking encyclopedias.  However , the system continues to value test taking over personality.  I personally believe the best test takers do not make the best providers- just the opposite.   

The book regrettably gives short rife to telemedicine and opportunities for collaboration.  With the information explosion, no single provider can have all the answers.  More granular data will only exacerbate this problem.  Healthcare is moving from a one on one sport to more of a team game.  In order to have a sustainable delivery system, each provider will have a role to play to fully realize the value of new, personalized therapies.  Telemedicine can be leveraged to bring the healthcare pyramid, stratified expertise, to the bedside.  Most people think of this as expensive, limited technology.  However, browser based solutions allow telemedicine to be done over devices in your pocket.  Teams can be brought together to enable the right care at the right time.

Overall, I agree with Topol’s primary assessments- granular data will allow more effective, personalized treatments, and that the current educational and care delivery models are ill prepared for these disruptive innovations.  However, ultimately personalized medicine will be a combination of technology and choice.  No therapy, no matter how elegant, is without risk.  The past few decades have taught us that just because we can do something, even extend life, doesn’t mean we should.  The role of the provider and the team will be to understand the patient, their desires and act as a translator in this brave new world of personalized medicine.   

One of the best read ideas of 2012 that's going to ignored...Time to close speciality training

A friend of mine, Dave Fiorella, published one of the most widely read paper in the radiology literature this year.  

Should neurointerventional fellowship training be suspended indefinitely? -- Fiorella et al. 4 (5): 315 -- Journal of NeuroInterventional Surgery

He argues that the world has enough of his own subspecialty, neuro interventional surgery (NIS), and that training programs should voluntarily close.  You may not have heard of NIS.  These physicians care for a small group of patients that typically need blood vessels in their brain opened or closed.  Examples include stroke patients (blocked vessels need to be opened) and aneurysms (diseased vessels need to be closed). People like Dave do their work by running a small tube, a catheter, from the groin up to the head and then inject things through these tubes to open or close the vessels-pretty cool stuff!  and a huge advance from 25 years ago.  Before NIS, neurosurgeons would open your skull, do their work, and close you up.  And now, Dave says we have enough.  Why?

After training (which included NIS) my first job was at a good, but smaller community hospital outside Seattle.  In part, I was hired to build a stroke program and grow neurosurgical services.  However, these skills require constant practice, and 6 months at this hospital I had only done a handful of cases.  As far as the professional requirements were concerned, I was competent to do these procedures.  However, deep down I wasn't so sure. Within 18 months I gave up doing these procedures, preferring to send patients to the university up the street.  

A coiled aneurysm.  The big ball is the aneurysm.  
Imagine pushing a wire into a basketball, replacing air  with wire.

My experience is similar to many physicians.  There simple aren't enough patients needing high end procedures to go around.  As a result, skills and quality suffer.  Unfortunately, hospitals want to compete.  Every center wants to be a stroke center or a chest pain center, a (you fill in) center of excellence.  In part this is done for branding, in part this is done for contracting.  Insurers want to simplify the process and get all the services they need from a few hospital partners.  The big loser here is the patient.  Many studies have documented a relationship between volume and outcomes (https://leapfroghospitalsurvey.org/web/wp-content/uploads/2012/03/Fact_Sheet_EBHR.pdf).

You or a loved one may need these services.  A physician will come to talk to you about the risks (you could die), benefits (the procedure may help you), and options (they hopefully mention other treatment alternatives, but they may not mention that you can go down the street to another facility).  Your outcome will be tied to the experience and volume the physician has done.

If there were fewer NIS physicians, there would be more cases/practitioner and better outcomes.  But the likelihood of programs are going to voluntarily shut down- that's not going to happen as long as hospitals are hiring.  There is a way out of this dilemma.

At the consumer level, you should ask the hard questions.  Doctor, how many of these have you done of these, when was the last time you did one of these?  Is there anyone else who has done more of these procedures in a 20 mile radius?  At the payer level, there should be a a requirement for a certain experience before paying a provider, and then there should be recertification, a certain number of on going cases to keep getting paid.  Ultimately, the payer should ask for outcomes from the provider, information about how their patients are doing 3, 6 and 12 months after the procedure.  

In short, Dave is right.  Practice makes perfect.  There just needs to be a business model supporting the desired (patient) outcome.

Why I use LinkedIn, and hope you do too....in the New Year, build your "hubness"

I am a Jew married to a Catholic.  Neither of us practice.  Next year we'll be married 25 years.  We have 3 children, all whom I am proud to call a friend.  But, I have this nagging feeling.  At the end, I'll get to the gate and be brought before (Jesus, Budda, Mohammed) who will ask why am I deserving.  Or at a minimum, with my last breath, I want to reflect on a life well lived.  That's why today I use LinkedIn.  Most people look at Linkedin and see a job board on the web or a professional Facebook.  I see something else: an accelerator of human potential.

Several years ago I read Malcolm Gladwell's Tipping Point.  He talks about the spread of ideas and how if you are lucky enough to meet a hub, the chance of your idea spreading to the next person, the right person, goes up exponentially.  At that moment, I realized that I wasn't getting any faster, or better looking and that senility was fast approaching. Though in spite of this inevitability, I knew that I could actively pursue my "hubness"… that I could become a connector.  When I met new connections I could learn about these people, what they were interested in, what they aspired to do, and file that information away until the day when I met their puzzle piece, the person who completed them.  Together, the two people could go on to accelerate human potential.

Fast forward to 2003: along comes Linkedin.  I had found the perfect tool.  Ii told me what people were doing, what they cared about, and when they changed paths.  It is the perfect tool for finding the missing puzzle pieces.

If you look at your world there are probably 20 people you see on a daily basis.  There is another 100 whom you like, respect and perhaps see every other year.  The is a larger circle beyond that, with some affiliation, but perhaps they have particular skills or knowledge.  With LinkedIn these secondary and tertiary circles become your world.

Today, I may spend as much time collaborating with people in my network as I do with people in my building.  I actively go through my network once a month, introducing people in my network simply because they should know each other.  Their pieces may fit, they may not, but I hope the world is a better place because of it. Of course in all honesty, I am the big winner.  I hear about interesting things people do, and sometimes join in the projects I helped catalyze.

Just imagine if each of us made it a New Year's resolution to build our “hubness”; to look for ways to bring strangers together so that they might call each other a colleague.  LinkedIn, or at least the process it enables, is one of the most powerful tools we have...we just need to use it correctly.

Shoe boxes should be for shoes, not medical records

If you ask a person coping with a chronic illness for their medical records, they may take out a shoebox with a neatly organized papers and CDs.  They hope the next doctor or nurse will open the box, look inside and help them.  This almost never happens.

What's in your box?

There is simply no time for providers to put this information into a meaningful story.  The provider tends to reorder labs, and begin from scratch.  

Patients and providers agree this is absurd.  Records should be immediately at the time of care.  This would enable better, more cost effective care.  Industry has spent decades trying to solve this problem, but it is a work in progress.

Centralized versus decentralized records.

In part, this failure reflects American healthcare's focus on the doctor and the hospital rather than the patient.  There is an expectation that others will care for us, rather than engage us.  Medical record solutions tend to pass centrally from patient, to doctor, to EMR, to a central clearing house (sometimes called an health information exchange, HIE).  

HIE, centralized healthcare records

HIEs sound like a great idea.  If the patient goes to 2 facilities or 2 different doctors, records would magically be collected and viewable by all participating facilities.  Unfortunately, HIEs are more concept than reality.  HIEs require high level collaboration from competing healthcare systems.  Further, there is first adopter risk.   Imagine buying the first fax- who would you send to? 

An alternative solution would centered around the patient.  In this case, the patient acts to collect data about themselves.  But rather than the shoe box, the information is organized so that others use it effectively. 

Google and Microsoft in fact took this approach and spent billions to create PHRs- this has largely been a failed effort  

Google Health shut down after several years

The medical apps industry is another approach.  Apps allow the people to collect all sorts of data about themselves (weight, blood pressure, physical activity) People can look at the information themselves or  present it to their practitioner.  As yet, industry has not achieve significant adoption or investor value.  

Both apps and PHR currently reach the wrong market. Apps and PHR tend to be used by the "super fit," the people trying to obtain that last little bit of potential immortality.  Although the super fit are a market, they are not the market insurers and providers are trying to reach.  The people who need PHR and apps, the sick, tend not to use them.  These people are typically older and less tech savvy, they tend to be less focused on their "wellness."  

Portal or PHR?

Hospitals are currently implementing portals, web based tools for patients and providers to see medical records. Healthcare systems view portal as an evolving service expectation, a chance to build customer loyalty.  However, this strategy is limited.  Portal is an extension of the hospital EMR.  Current portals do not aggregate records across the continuum or enable the patient to collect information about themselves.  

Would it be better if hospitals provided PHR?  This could be a card given to patients leading all providers, those from the hospital and their competitors, a web site where they could view and enter enter information for the patient.  Rather than centralize the information via an exchange, this would decentralize efforts around the patient.  At a minimum, this would allow providers to note that the patient received care and there are records to share.  Better would be an upload of records to the PHR; this is already possible via an accepted standard (CCD).  This would not replace EMR (which provide necessary documentation, scheduling and billing) but instead supplement care documentation.

Decentralized, Collaborative PHR records could supplement EMRs.
Providers across the continuum  could add to the record for the patient.
Most PHR ask the patient to do all the work currently

Compassionate Capitalism- towards a sustainable business model for collaborative healthcare records 

As mentioned earlier, centralized health exchanges, with a centralized business models, have largely failed.  The return on investment ratio for the early adopters has not enabled wide spread adoption.  However, decentralizing the offering may have unique benefits for a healthcare system.  Registration in a system showing patients their hospital records, occurrences or records from other providers  as well as chance to record their own observations is value, something patients can't get or can't maintain (eg...the Microsoft and Google offerings) on their own.  Building brand through patient value equates to loyalty. Further, collaboration across the continuum, provides the necessary infrastructure for value based  cost effective care delivery.  This is not rocket science, but rather a repurposing of existing market tools.

To survive, radiology should become a horizontal

The future of radiology is bright, but its not so clear for radiologists....Lawrence Muroff, RSNA 2012

I attended the recent RSNA in Chicago this year.  Each year 60,000 people come to talk and sell all things imaging.  However, after years of short sighted, self destructive life style based decisions, radiologists have now successfully commoditized their specialty.  Although imaging will remain central to care, reimbursement for these services will likely change to align with the ACO/CIO agenda.  It remains to be seen if the specialty can reinvent themselves moving forward. 

Image isn't everything.

Radiologists are obsessed with the image.  This is understandable.  No other the speciality takes ownership of the quality and safety related to image production.    However, this focus on constant image improvement has to some degree been at the expense of image value for the patient. In the new world of value based care, every provider, every speciality will be measured against the patient's ultimate outcome.  Traditionally, radiology's relationship with the patient ends with the dictation.  There is no follow up.  Did the study decrease morbidity or cost of care?  Were care decisions influenced by imaging findings.  Were there differences between general and specialist interpretations influencing outcome or utilization?  This type of information, eminently obtainable via patient registries or directed personal health records, would add relevance to discussions with the payers moving forward.

Radiology as a “horizontal”

Radiologists and the imaging vendors can continue to ignore the the changes going on around them, or perhaps it is time to think about “creative destruction” of imaging.  These is a phrase coined by Eric Topol reflecting the rest of healthcare. 

Today, radiologists are paid for the transaction, the dictation.  Tomorrow we are paid for patient value.  How can we cross the chasm to this new world?

There is some good news.  There are some unique aspects of imaging services.  Unlike almost any other field in healthcare, radiology is a horizontal.  As opposed to neurology, obstetrics, surgery, relatively siloed verticals of care, imaging is required for all areas of medicine.  Radiologists have a broad understand of care across the continuum and could help navigate the patients course, suggesting appropriate next steps to arrive at cost effective diagnosis.  

(Radiology circa 1965...the reading room was the center of the hospital)

I am not suggesting the imaging subspecialists generalize themselves, but rather imaging services as a department begin to think of themselves as part of the care team, requiring and synthesizing clinical information to offer appropriate next steps.  Vagaries such as “stroke” or pain should not be accepted as clinical history.  Comparison studies should be found.  After an imaging study, there should be ownership of the outcome so that radiologists can effectively participate in utilization management.

These changes will not happen over night.  Currently, the IT tools supporting this type of practice are not offered- but markets respond.  If there is an ask, there will be product.  This is also anathema to the current practice patterns- aka, the referent is always right.  

Currently, it is almost like there is a sense of the “end of days,” make as much as you can now because the end is coming.  The end isn’t coming.  Imaging is here to stay.  Change is coming.  We can chose to plan for it and align with value, or deal with an abrupt, painful transition

Back to the Future- The New Black Bag, an iPad

In the early 60's, my father started in medicine making house calls.

He would carry his black bag from home to home.  It had all he needed to make a diagnosis and get the patient on the road to recovery.  Now, 50 years later, no one can lift this black bag.  It is too heavy with options. Improvements in care have meant more options, so much to know that no single person can have all the right answers.

Overall, Americans have benefited from medical advances.  We are living longer than in the 1960's.  But, it has also had the perverse effect of fragmentation.  Take the example of my mom, a quadriplegic.  

At times her care sounds more like a text on physiology.  There is someone for the lungs, the kidneys and the neurologic system.  Yet, no one is responsible for her.  In part, this is too much for one person, there is not speciality called "quadraplegia" and all that goes with it.  In part, this is how healthcare is reimburse- money is paid for problems, rather than wellness.

However, I see hope on the horizon.  Like Hermione's magical bag in the Harry Potter series, we can give our providers all that they need as they travel from house to house, or at least room to room.  Collaborative technologies can deliver the community, rather than strictly the provider, to the bedside.  In this world, the black bag is replaced by an iPad or other PDA.  The specialist is available for advice, supporting and reassuring the patient and local provider alike.  This is our future.  We need to learn to scale our healthcare ecosystem, to not rely on the best available locally but rather the the best available from anywhere in sustainable ways.  New economic incentives are accelerating these solutions.  Time to upgrade that old black bag, time to go back to the future.

Alan Pitt Health 2.0 - YouTube

There Are Points for Speed

I am radiologist, an MD specializing in CT and MR interpretation. When I was training, I had a Professor who would say "there are no points for speed."    What he meant was, if you missed something, the lawyers didn't care how fast you read the case, just whether you got it right.  Unfortunately, he is wrong.  Speed matters in medicine, a lot.

Doctors are paid for speed.  The current reimbursement system pays us on how much we do, not necessarily how well we do it.  There are metrics related to outcomes and complications, but they tend to be relatively infrequent outliers and disconnected from the care and reimbursement process.  

In the case of radiology, there is an expectation of a certain number of cases/day by each physician.  A radiologist’s productivity posted and often related to bonus pay.  

ED physicians are paid on the number of patients seen per shift.  Doctors have learned to order tests first, and then see the patient second- it is faster.  THis is one of the reasons there has been a 5 fold increase in CT for emergency room patients over the last decade.  Imaging has largely replaced the physical exam  (‎www.emedmag.com/PDF/043070006.pdf).  This results in over utilization of expensive imaging studies and lab work for the patient and for the payer.  

With bundled payments, hospitals are on the hook for this over ordering .  Hospitals are paid a set fee for diagnostic code (stroke, pneumonia, etc..)  irrespective of the number of studies ordered by the doctors caring for the patient.  Ultimately, it may be cheaper for hospitals to incentivize their physicians to slow down and make the right decisions rather than simply order another test.

The medical legal system, thought to protect the patient from mistakes (due to speed) perversely accelerates this process.  Doctors are rarely, if ever, sued for ordering tests.

Doctors are human.  They respond to individual incentives like everyone else.  If the system pays for volume, we will continue to get more volume.  If we want quality, intelligent decision making, incentives need to be aligned for quality.  Unfortunately, as long as there are points for speed, we'll all lose.