Bingo Medicine

It was a dark and stormy night. My computer didn’t catch fire while typing the previous sentence. No alarms were triggered warning me about the quality of such opening. I wasn’t prompted to select subjects and predicates from dropdown lists. I typed the entire sentence, letter by letter, not at all dissimilar to its first rendering back in 1830. Computer software in general, and Microsoft Word in particular, magically removed the hassles of quills, ink, paper, blotters, sharpeners, ribbons, whiteout, carbon paper, dictionaries, and all the cumbersome ancillary paraphernalia needed to support authoring, but made no attempt to minimize the cognitive effort associated with writing well.  Authoring great literature today requires as much talent and mastery as it did in the days of Edward Bulwer-Lytton.
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For several decades, software builders have tried to help doctors practice medicine more efficiently and more effectively. As is often the case with good intentions, the results turned out to be a mixed bag of goods, with paternalistic overtones from the helpers and mostly resentment and frustration from those supposedly being helped. Whether we want to admit it or not, the facts of the matter are that health IT and EHRs in particular have turned from humble tools of the trade to oppressive straightjackets for the practice of medicine. Somewhere along the way, the roles were reversed, and clinicians of all stripes are increasingly becoming the tools used by technology to practice medicine.

A common misconception is that EHR designers produce lousy software because they don’t understand how medicine is practiced. The real problem is that many actually do, and the practice of medicine is precisely what they aim to change. These high clerics of disruptive innovation would have you believe that “resistance to change” is equivalent to the resurrection of paper charts, thick ledgers, and medical information coded in secretive hieroglyphs. The truth is that physicians want to use modern computers, but they resent being used by computers. And the truth is that if we shed the orthodoxy imposed on us by self-serving “stakeholders”, computer software can indeed help address various problems in health care, some in the here and now, most in a distant future.

One thousand and one elements

This may sound strange to some, but the first step towards putting EHRs back on the right track should be to stop trying to help physicians practice medicine. Clinical decision “support” in the form of alerts, disease specific templates, mandatory checklists, required fields and rigid workflows are some of the things that must be removed from EHRs for two reasons. First, most of these “features” don’t work very well anyway. Second, more often than not, the real purpose of said support is not clinical in nature. For example, alerts about generic substitutes for brand name medications, data fields that must be filled and checkboxes that must be clicked to satisfy billing codes, PQRS or Meaningful Use, and the wealth of screens to be traversed before an order can be placed, have no clinical value.  And in most cases the opposite is true.

Some experts argue that EHRs are failing because they are nothing more than an old paper chart rendered on a computer screen. Many others are outraged by the fabled lack of interoperability (dissemination of information) or the lack of EHR usability, i.e. number of clicks, visual appeal, color schemes and ease of information retrieval. I would suggest that these dilemmas are peripheral to the one foundational problem plaguing current EHR designs – the draconian enforcement of structured data elements as means of human endeavor.

When Google mapped the Earth, it did not begin by mandating how to build and name roads and buildings. When we indexed and digitized books and articles, we did not require that authors change the way they write prose or poetry. When we digitized music, we did not require composers and performers to produce binary numbers at equidistant time intervals, and we did not make changes to musical instruments to allow for better sampling.  We built our computerized tools to ingest, digest, slice, dice and regurgitate whatever humanity threw at us, without inconveniencing anybody. This is why good technology seems magical.

EHRs on the other hand, are obnoxiously demanding that people change how they think, how they work, and how they document their thoughts and actions, just so that the rudimentary software prematurely thrust upon them can function at some minimal level of proficiency.  People don’t think in codified vocabularies. We don’t express ourselves in structured data fields. Instead of building computers that elegantly adapt to the human modus operandi, EHRs, unlike all other software tools before them, demand that humanity adjust itself to the way primitive computers work. The self-appointed thought leaders, who are taking turns at regulating the meaningful clicks of EHRs, are basically demanding that we discard the full spectrum of human communications, in favor of gibberish that supposedly serves a higher purpose.

All the pretty horses

What is the purpose of EHR documentation templates? There is practically no EHR in use today that does not include visit templates. Visit templates are a list of checkboxes, some with multiple nested levels, which allow documentation by clicks instead of by typing, writing, drawing or dictation. Visit templates are created for each disease and contain canned text for findings judged pertinent to that condition by template creators. In all fairness, many physicians like documentation templates because with just a few clicks you are able to generate all the documentation required nowadays to get paid for your work, pages and pages of histories, review of systems, physical examination, assessments and plans of care. Do doctors like templates because they believe this extensive documentation is necessary, or do they like templates because the checkboxes alleviate the pain of typing thousands of meaningless regulatory words? I suspect the latter.

Clinical templates, along with the automated clinical decision support they enable, are advertised as time savers for physicians. The time saved is the time previously spent with patients, and most importantly the time spent thinking, analyzing, and formulating solutions. For most, it’s also the time spent rendering thoughts in a manner that can be understood by another person. Furthermore, when your note taking is template driven, most of your cognitive effort goes towards fishing for content that fits the template (like playing Bingo), instead of just listening to whatever the patient has to say. Even in “efficient” practices where staff does the clicking and physicians have the luxury of asking “open ended” questions, the patient story, the quirky details that are irrelevant to the template, are not documented (highlighted, circled, noted on the margins, etc.) anymore. Is this a good thing?

If we proceed on the assumption that IBM Watson and the likes are eventually going to be artificially intelligent enough, and big data are eventually going to be big enough, to respectively analyze and represent a complete human being, then yes, we can safely dispense with old fashioned human expertise. However, we are most certainly not there yet, and regardless of industry rhetoric, we are not certain that we will ever be there, and we are not even sure that we want to ever be there. While this utopia (or dystopia) is portrayed by interested parties as “inevitable”, chances are that for at least several generations we will be forced to contend with imperfect digital renditions of medicine, instead of allowing EHRs to follow the growth of underlying technologies. This is akin to summarily confiscating and shooting all the horses, on the day Henry Ford rolled the first Model T off his assembly line. Where would America be today, if we did that on October 1, 1908?

Furthermore, what type of doctors are we producing when we teach medicine by template, supported by clinical decision aids based on the same template, and assessed by quality measures calculated from template data? Medicine does not become precise just because we choose to discard all imprecise factors that we are not capable of fitting into a template. Standardization of processes and quality does not occur just because we choose to avert our eyes from the thick edges were mayhem is the norm. Dumbing physicians down is not the optimal strategy for bringing computer intelligence closer to human capabilities. EHRs should not be allowed to become the means to stifling growth of human expertise, the barriers to natural interactions between people, or the levers pushed and pulled at will by greed and corruption.

Bildungsroman style

Instead, EHRs could be the scaffolding for IMB Watson and other emerging contraptions to grow and become truly useful tools for both doctors and patients, and yes, also for legitimate and beneficiary secondary uses of clinical information. Instead of mandating that doctors think and work in ways that serve Watson’s budding abilities, we should require that Watson learns how to use the normal work products of humans. Instead of enforcing templated thought and workflows, whether through direct penalties for doctors or indirect certification requirements for software, we should work on teaching Watson how to parse and use human languages in all their complexity. Watson should grow up to be the multi-media scribe behind the computer screen, the means by which the analog music composed by physician-patient interactions is digitized into zeros and ones without loss of fidelity and without interference with actual performance.

Billions of years of evolution endowed the lowliest human specimen with cognitive abilities that machines will most likely never attain. The glory is in the journey though. We need to accept delayed gratification, and we need to accept that the challenge will span centuries, not just one boom-bust cycle of a fleeting global economy. We need to accept the fact that we will all die long before the ultimate goals are achieved, instead of declaring victory whenever each negligible incremental step is taken. If we are going to create a new form of intelligent life on earth, we need to assume the same humility Nature, or God, has been exercising since the dawn of time and counting. Otherwise, we are all just a bunch of hacks looking to make a quick buck on the backs of our fellow men and women.

2015 Vegan Gift Guide

Things have been silent around here for a while (same old, same old) and although I don't plan on updating much more in the future, I thought it would be nice to do a little vegan gift guide now that it's the holiday season. You see I have been struggling quite a lot trying to fully transition to a vegan lifestyle. Don't get me wrong, I've completely sworn off meat, dairy, eggs, honey and whatnot but I'm still surprised to find out how many different things in our everyday life contain animal products. That is why I've compiled this miniature guide to help you find your loved ones 100% cruelty free but nonetheless awesome Christmas presents.

Hopefully you'll find this guide helpful and perhaps even get some ideas for your own wish list. If you'd like to leave your own recommendations below, I would be more than happy to read them! So let's get to it!

1. Daniel Wellington Nato Strap Watches

I. Love. These. Watches. Classy, timeless and gorgeous timepieces that will make the perfect gift for anyone in your family! Literally everyone, as they have both small ones and big ones, ladies' and men's, classic styles and bolder colours. They also offer free shipping worldwide and my very own promo code "TILDASDW" will get you 15% off until January 15th! Yay! (Also, go for the Nato Wristbands to stay vegan!)

2. CLEAN Perfumes

Let's be honest, we can't always be bothered trying to find specialty vegan store and brands to buy all our stuff. As much as I love visiting these shops, it can really be a pain in the ass to have to go halfway across Stockholm just to find a vegan perfume. Enter CLEAN perfumes,  100% cruelty free, mainstream and absolutely wonderful! My favourite is the White Woods pictured above but all of their scents are beautifully fresh and well, clean. A vegan must-have.

3. Handmade Heroes Beauty and Skin Care

I was lucky enough to receive an adorable little care package from Handmade Heroes a while ago, filled with some of their vegan beauty products. Pictured above are their green clay face mask, coconut lip scrub and two different lip tints. The gorgeous packaging aside, I've genuinely enjoyed using these products and the lip scrub is so natural that you can eat it. It actually tastes really nice hehe. Though I would suggest you don't have it all for an afternoon snack. That would be a total waste of lip scrub.

4. Vegan Chocolate

Nowadays there are numerous vegan chocolate brands to choose from and getting your loved ones their chocolate fix doesn't have to involve any cow's milk whatsoever. I have included a few of my favourite kinds above, namely Pana Chocolate, The Raw Chocolate Company, Lovechock and Squarebar.  The Pana Chocolate is amazingly silky and has a softer texture than the other tree while The Raw Chocolate Company and Lovechock are both more like traditional dark chocolate but -obviously- better. My absolute favourite would have to be Lovechock's Mulberry Vanilla. Lastly we have the Squarers which are actually more of a chocolate coated vegan protein bar but I had to include them on this list as well as they're just so darn delicious. One of the best,most indulgent vegan protein bars out there!

Hope you've enjoyed reading this post and that you'll all have the best holiday season surrounded by family and friends! Much love to you all!

The Middle-Aged Consumer in the Coal Mine

Whenever you read a health care article, paper, book, blog post or even tweet, that substitutes the term consumers for patients, and the term providers for doctors, or physicians, you should inherently assume that the authors are advocating for something that will not benefit you or the people you care for, something that will most likely harm you financially and if you happen to be less than independently wealthy it will harm you physically in real and immediate ways. These advocacy pieces usually come dressed in the sheep clothing of empowerment, liberation, convenience, savings and democratization, but underneath it all, and often unbeknownst to the authors themselves, there is always an ominous incarnation of the wolf of Wall Street.

Whenever you read something emanating from selfless, do-gooder (usually public or supposedly not-for-profit, but certainly for-revenue) institutions, alliances, consortia, coalitions, and such, note how you are always addressed in the third-person plural. There is no “we” in what passes as enlightened health care conversation. As Dr. Victor Montori astutely observed, there is no “sense of a shared fate. Of a shared journey with our kin.” The wolves of Wall Street, and the hyenas of Silicon Valley dancing at their feet, have no kin and no intention of sharing in our fate.

Consumers and providers are a uniform mass of transactional entities, neatly described by a finite number of discrete financial events. Consumers and providers are hence computable entities. You don’t often see articles about consumers being sad or happy, consumers laughing or crying, consumers falling in love or dying. Providers are never sued for malpractice, never accused of fraud, never disillusioned and they never commit suicide. The vocabulary used for consumers and providers requires that we strip everything human from the subject matter, and leave all that is mercenary and precisely quantifiable in dollars and cents. As the consumer/provider vocabulary is ported to health care, the entire endeavor by necessity is divesting itself of human considerations, including kinship and any remaining sense of a shared fate.

Consumers, although sometimes patronizingly described as savvy, are not assumed to possess any particular wisdom. The only discriminatory behavior ascribed to consumers is the ability to discern cheap from expensive. Consumers are expected to incessantly shop for consumable stuff, like so many rats frantically searching for bits of cheese in a carefully constructed maze. We are expected to shop when things are hunky dory and when things are down in the dumps. We are ordered to shop in the face of national tragedies, and now we are ordered to shop when personal tragedy strikes as well.  We are ordered to shop for life saving medicine. We are ordered to shop for surgeries, and we are ordered to shop for “relationships” with our “providers”. We are effectively ordered to shop for dear life, and to “share” and “rate” our shopping “experience” to better inform the maze designers.

The government of the United States wants us to shop for health insurance every twelve months. Health insurance companies want us to shop for cheap services all through the year. ProPublica and the unparalleled paragon of social beneficence called Yelp, are volunteering to help us do a better job at shopping for “providers”. Glitzy startups like Amino, will “harnesses health Industry data for consumers”, to show us some information about some doctors, for no particular reason and free of charge, because “the initial goal is to create an appealing product, and then figure out a business model later”. Yes, it makes perfect sense that Mr. Vinod Khosla and company would sink almost $20 million in something not projected to have any returns. After all, the entire Silicon Valley Empire was built this way, and now the time has finally come to fully align health care with Silicon Valley and Wall Street ways of doing business.

A fundamental shift in how we are being programmed to think about health care is therefore underway. The rather recent term “consumer-centric healthcare” is now brazenly accompanied by musings on who will be “herding” consumers’ medical records. Following the subtle transformation of health care to “healthcare”, we are beginning to shift the conversation to just “health”, because the “care” part seems redundant. Health care is not too expensive because insurance companies operate like Columbian drug cartels and pharmaceutical companies are essentially drug cartels. Health care is not too expensive because hospitals are coalescing into regional and national monopolies, unchecked and undeterred by the perpetually fund-raising legislative and administrative corps of career politicians. Health care is not too expensive because people who work for a living haven’t gotten a raise in decades. No siree, Bob!

Health care is too expensive because consumers lack the wisdom to be healthy, and providers, i.e. the nondescript entities tasked with pushing “appropriate” processes and products to consumers, are failing to keep consumers healthy (a.k.a. profitable). Consumers must be reformed to be healthier, and providers to be more productive producers of health. To prime the pump, health care itself needs to be transformed from a quirky personal service to a standardized population management industry ripe for plunder (a.k.a. disruption). And then, who better to reform consumers than the high tech propaganda machine? Over the years we were reformed to happily ingest every edible poison known to mankind. We were reformed to bash the brains out of fellow consumers every Friday after Thanksgiving. We were reformed into a trembling mass of righteous fear and indignation that can only function (when properly medicated) in “safe spaces” devoid of intellectual ambiguity.

We were reformed to not just accept, but clamor and pay a premium for the right to carry consumer profiling devices in our pockets, which are used to chart our future in minute detail. Healthcare “futurists” are painting for us abstract visions of healthcare where “health is primary”. Futures where medicine is devoid of hospitals, human doctors and human patients. Futures where you buy genetic analysis from 23andMe on your TV, and fixing your baby in utero is a weekend DIY project. Futures where we need not care for each other because the iPhone Gods are caring for us all. Will we be happy? Will we be free? Que sera, sera….

But our health has always been affected mostly by social order, and less so by health care. As Silicon Valley and Wall Street are taking command of our health, what will be, will be affected by factors far removed from the myopic analysis of our healthcare experts. Fortunately, we are bringing our canary on the journey down this shaft. Unfortunately, the canary is dying.

Mortality rates have began to rise for white, middle-aged Americans without a college education, arguably the people most vulnerable to the mercantile siliconization of life. They use mostly alcohol and opioids to numb the pain and eventually they numb it for good. Unless we find our way out of these toxic dungeons where life is money and money is life, right here, right now, most of us, consumers and providers alike, will suffer the same fate. This is the real clear and present future of consumerized health.

Dead Woman Living...Tips on Life After Being Dead for 35/40 Minutes

Hi All,

I have not written in a long time.   As many of you know I died on April 24th for about 35/40 minutes...My kids were told by doctors to say good bye to me...that even if I woke up...that my brain would be limited at best.  This is all in the middle of surviving stage 12 cancer...:).....if you have not read the other 500 posts ..you should.  Everyone was in tears as that surgery was by choice to remove one tumor and not life threatening.

Well I woke up....I had a long recovery for me in my body...my brain is fine ( although some might say different :)))....I have no memory of the entire event until I woke up in the ICU after a few days in a coma...I have no memory even checking into the hospital on that surgery day.

I am called a true miracle by all the doctors and nurses involved.  I was in the hospital for a week or so and everywhere I went people said, OMG...you are that lady that everyone is talking about" .  Very strange indeed.

So now it is October......After a long recovery for me ....(about 2 and a half months)...I flew to New York to my 50th High School Reunion and saw many old friends.  It was a gift for sure...

I came home and started to digest the whole events of the last months.    In between a few best friends in the fight of Leiomyosarcoma passed away..people I had known for many years...

I had my own scans and they were fine....still tumors not growing...another miracle...scans again end of November ...beginning December......

So now I find myself completely amazed after over 14 years.....  of really what should I do with my time that will make me happy?    Whether months or years?

There is definitely a bit of PTSD in my head...people are waiting for my book that I am never sure if I want to finish....

And the feeling that I am never doing enough for my fellow cancer folks...when all I want to do is lay on beach somewhere for the rest of my life and do nothing ...I can not do that either.

I will post here a few times a week...come back....Tips coming.....biggest one being life will never be as you plan...nope...not at all.

The Quantified Doctor-Patient Relationship

In a previous post we explored the doctor-patient relationship, which according to many is an important factor influencing the health care trifecta of quality, outcomes and cost. So far the doctor-patient relationship escaped rigorous quantification, because “relationship” is largely a nostalgic quantity, and because “communications” was deemed to be a reasonable substitute. There are various tools and instruments for subjective measurement of communications with one’s doctor, with the most common being the ubiquitous patient experience survey. However, if we accept a broader definition of the doctor-patient relationship, such as the 6C’s proposed by Dr. Emanuel, a more objective measurement of the relationship seems not only possible, but desirable even for those who may be questioning the value and purpose of quantification in general, and obsessive measurement in particular, present company included.

Let’s take the 6C’s from the top, leaving out communications and compassion, which are subjective quantities. The intent is to create an accurate picture of relationships patients can expect to have with a physician within the boundaries imposed by their financial circumstances. Most suggestions presented here are not attempting to score the physician directly, since relationships are always affected by more than just intrinsic qualities of the two parties relating to each other. For example, a relationship with the most compassionate and articulate physician may turn into a disastrous affair if conflicts of interest dictate how communications are conducted and how and when compassion is expressed. Ideally, a patient specific “scorecard” composed of the criteria below, would be compiled by a non-biased third party, or by physicians themselves, and made available to patients.

Choice

For patients, this means choice of practice type and settings, primary care physician, specialists, hospitals, and choice among treatment alternatives. Surely the degree to which these choices are available to patients can be objectively calculated, rated and ranked as is now fashionable. For example, where patients are assigned to physicians by third parties, the relationship would score a big fat zero. A point or two would be awarded to a vertically integrated system where patients can choose from the physicians employed by the group. Scores would be proportional to network size and variability for more traditional plans, with Medicare fee-for-service and cash-only practices getting the highest scores. Obviously, patients will need to account for individual scenarios for incrementing or decrementing scores.

Choice of specialists and hospitals can be inferred from the same variables as measured above, but adjustments will need to be made to account for hospital privileges and referral patterns of the primary care physician. This too can be measured and scored pretty accurately from easily obtainable hard data. Choice among treatment alternatives is a bit trickier, particularly in primary care. Using process measures, sample documentation and insurance plan policies, one could derive an individualized measure of choices available to patients. It is important to note that here we are not measuring “appropriateness”, “stewardship of scarce resources” or how “wisely” people choose, nor do we measure “education” about options. We measure the actual availability of treatment options.

Competence

How does one measure physician competence? Arguably, all current “quality” measures, public reporting and board certifications are aiming to quantify and ensure precisely the competence of doctors, in a roundabout way that is failing to measure anything of consequence. If we describe a competent physician as one who stays up to date, has good technical and diagnostic skills, exhibits good clinical judgement and is cognizant of his or her own limitations (as Dr. Emanuel did), we could devise better ways to assess competence. Staying up to date is trivial to measure. Technical and diagnostic skills, as well as clinical judgement, are very difficult to assess objectively, and perhaps this is why all our faux measuring schemes seem woefully inadequate.

We can certainly envision physicians assessed by their peers (perhaps anonymously or through virtual grand rounds collaboratives), but competence cannot be discussed until we quantify the prerequisite time variable. It makes little difference whether a physician is competent or not, if the patient rarely sees the doctor, or if visits are limited to a few minutes of furious typing, clicking and scrolling. So here is one variable that can be objectively and rather easily quantified: time spent with patients by severity of chief complaint, patient health status and vulnerability. We can get fancy and measure frequency of visits and total time spent per patient per year, adjusted for a host of variables.

Another factor closely related to competence in primary care, and not explicitly addressed by the 6C’s framework, is comprehensiveness. This too can be measured objectively. The range of conditions treated by the physician, and the list of those routinely referred out can be compiled, ranked and assigned relative scores accounting for frequency of occurrence, along with patient characteristics. For example, a physician treating large numbers of elderly diabetics with multiple comorbidities, would garner more competence points than a physician who spends most of his time taking telemedicine calls for minor and limited ailments.  A physician who admits and manages her own patients when hospitalized would rank higher than physicians who never set foot in a hospital.

Continuity

Continuity of care is another word for long lasting, comprehensive relationships, and it can be accurately quantified with very little effort. Both PCMH and standard patient experience surveys include vague attempts to quantify continuity, but those could be misleading. Continuity of care is now applied loosely to teams of clinicians, such as residency groups, and it does not account for how appointments are conducted. When the patient is seen by a team member, and the billing doctor sticks his head in for a few seconds to say hello, does this count as continuity? When any and all patient interactions that do not involve a face-to-face visit are “handled” by other team members, and never the physician, does that count as continuity? How about outsourcing complex care management in between visits altogether, which is the “unintended” consequence of the new Medicare chronic care management fee?

It is important not to confuse continuity of care with continuity of medical records, or care coordination, when quantifying this aspect of the doctor-patient relationship, but other than that this may be the easiest factor to quantify objectively. A physician who always sees his or her patients, is always available in between visits to provide clinical advice, and has maintained this relationship with individual patients over long periods of time, would score high on this factor. Almost by definition, solo practitioners and many direct primary care physicians should top the charts on continuity. Similar to the quantification of patient choice, here too we must account for the vagaries of health insurance marketplaces which are increasingly empowered to break any relationship at any time on a whim.

(non) Conflict of interest

This is arguably the most important factor in the doctor-patient relationship, and other than random incendiary headlines, there are no serious attempts to measure or even shed light on the mushrooming conflicts of interest systematically inserted into the traditional doctor-patient relationship. Ideally, physicians would always act solely in the best interest of the one patient in front of them. Most people still believe that this is the case and most physicians will insists that regardless of circumstances, this is what they strive to do, but there are objective data points that could more precisely quantify the alignment of interests between doctors and patients.

We all know now that accepting the smallest gifts from pharmaceutical companies represents a conflict of interest. But how about directly tying salaries, and other compensation for labor, to corporate revenues? How about enforcement of corporate protocols and suppression of “disruptive” behavior? How do these things jive with the clinical judgement required by our “competence” factor? How about coercive “reimbursement” rates that force physicians to limit time spent with patients, and exclude certain patients from their practice? How about participation in incentive programs that pay doctors to substitute the interests of “society” for the individual interests of patients (as “misguided” and “wasteful” as those may be)? These are precisely quantifiable data.  

Ideally, I would love to see a comprehensive, and frequently updated, list of all potential conflicts of interests for each physician, by health insurance plan, publicly displayed in every practice and on every practice website. Why? Because conflict of interest, whether by choice or externally imposed, affects the most basic ingredient of any relationship: trust. If you were charged with a crime, would you trust a lawyer who is payed to keep society safe from criminals? Would you trust an accountant who is paid to increase IRS revenues?  Would you trust a hair dresser paid a fixed fee per client per year? Would you trust a mechanic who gets a little kickback from your insurance company to use the cheapest replacement parts for your car? Same goes for doctors.

In summary, there is absolutely no reason why we should not collect objective data, which is readily available in quantifiable formats, and combine it to create an informative picture of each physician and the environment in which he or she is practicing medicine. We may not be able to come up with a simplistic single score on some artificial scale, and we may not be able to punish or reward doctors for the “relationship measure", but people have a right to know what lies behind studied communications and standardized compassion, and most of all, people have a right to know how health care reforms are affecting a physician’s ability to maintain relationships with patients. If I’m not mistaken, this is what transparency is all about.

The Crisis Masters of Health and Death

There are three visions of peace in the seemingly never ending, but really rather brief, Israeli-Palestinian perpetual crisis. One peace features two independent countries living in collaborative harmony on a piece of land approximately the size of New Jersey. Another peace yearns for a messianic Jewish state stretching from the blue Mediterranean shores to the Jordan River, and possibly beyond. The third and final peace is expected to materialize after the Zionist entity has been permanently erased from the face of this earth, or at least from the face of that New Jersey size holy piece of land.  Each definition is amenable to slight compromises in form, but not at all in substance.

There are three visions for the future of medicine in the seemingly insurmountable, but really rather minor, perpetual health care crisis in America. One future of medicine sees physicians unencumbered by useless administrative tasks, wielding sleek and useful technology tools, offering the best medical care to all patients who need and want attention. Another future is yearning for the revival of chickens and charity as bona fide methods of payment for whatever medical care the free market wishes to bestow on the less fortunate. The third and final future is one devoid of most middling and often faulty doctors, where the health of the nation is enforced by constant computerized surveillance with fully automated preemptive interventions.  Each definition is amenable to slight compromises in form, but not at all in substance.

Years ago I used to walk the streets of East Jerusalem, buy dates in the open air markets of Jericho, and search for the perfect plate of hummus in Ramallah. Everywhere I went people wanted the same things I did. They wanted the rain to stop, or the hamsin to break. They wanted their coffee hot and strong and their bread soft and warm. I said shalom and they said salaam and we all meant the same thing, because ironically people in the Middle East always wish peace upon each other, and people like us, who buy and sell cheap jewelry or dates or hummus, actually mean it.   

Years ago I used to hang out with software programmers, writing code for hospitals, doctors, nurses, billers and schedulers. Everywhere I went these strange looking techie nerds wanted the same things I did. They wanted the overhead lights in the office to be off, and the whiteboards to be bigger. They wanted their Java to compile without error and their curly braces to be perfectly aligned. They worked days, nights, weekends and holidays to keep the lab printers running on every floor. They managed to convince themselves that somewhere in a hospital far away, a patient may get better sooner, or a doctor will see something he may have missed, and an exhausted nurse will breathe a sigh of relief, if they managed to get the face sheets to look just right.   

There is always some effort underway to fix the Israeli-Palestinian problem. Many such efforts have gotten as close to an equitable solution as Moses got to the Promised Land, only to discover that the last barrier is insurmountable. What’s to become of Jerusalem? Who owns the holy ruins of past civilizations, and the tombs of dead prophets? Whose religion bestows the ultimate rights of ownership over rocks and boulders that are coveted by all religions? Should it be the religion that started it all? Should it be the religion with the biggest cathedral, or the religion with the biggest guns? Is possession nine-tenths of the law? Perhaps ownership is the wrong way to think about this. Perhaps access is a more pertinent concept and the historical manifestations of God on this earth should become the commons of all religions. Perhaps, but not today.

There is always some effort underway to fix health care in America. Decades of legislative, regulatory and business driven efforts have gotten us almost universal access to the most unaffordable health care system in the world, only to discover that “information blocking” is a barrier to health. Information is power, but aggregate information is also a tool for amassing wealth, and massive information, of the big data type, is practically legal tender. What’s to become of this seemingly self-generating big data? Who owns the streams of life once they are transformed into data? Whose role in the digital extraction process bestows the ultimate rights of ownership over the monetary value of people? Should individuals own their digital emissions (defeating the entire purpose of this exercise)? Should the collectors own the data? Should the purveyors of data containers own what’s being accumulated inside? Is possession nine-tenths of the law?  Perhaps ownership is the wrong way to think about this. Perhaps access is a more pertinent concept and our aggregate digital lives should become the commons of all people everywhere. Perhaps, but not today.

Jerusalem is not the real problem. There will be no resolution for the Israeli-Palestinian crisis until hate is defeated, or at the very least silenced. Standing with your back against the deep sea and listening to incessant drumrolls of death, dismemberment and extermination is enough to ruin the best gin and tonic at the best club on the most beautiful night on the Tel-Aviv promenade. Deep down you know that the people you met in Jericho, Ramallah and East Jerusalem would much rather get drunk with you in the club, than blow themselves up at the door, but that doesn’t seem very comforting tonight. Jerusalem and all its holy ghosts will be solemnly shared only when everybody benefits from this arrangement, including the millions of people whose lives are at stake here, and excluding the fiery tongued hate mongers who pass as leaders in some parts of this world. Until that day comes, Jerusalem will keep taking our lives, our children, and worst of all, our humanity, in the biggest hoax ever staged by mankind.

Information blocking is not a real problem. There will be no solution to our health care crisis until greed is defeated, or at the very least tightly controlled. Siphoning hard cash in the form of “information” from medical facilities into the coffers of third party data processors, seeking to supplant traditional medicine with computerized cost-benefit analysis, cannot possibly be met with enthusiasm by the doomed. Serenading the public with psychopathic prophecies of eternal health, while stealing their personal information to more accurately find and extract money from their wallets, and to curtail all freedom of choice, is not helping either. Information will flow freely only when everybody benefits from the torrent, including the millions of people whose lives and liberty are at stake here, and excluding the smooth tongued wealth extracting machines which we call leaders. Until that day comes, information will flow haltingly, under duress, in the biggest jail ever created by mankind.

There is an old saying in Hebrew stating that a dead fish stinks from the head, but there is also an old saying in Arabic promising that each dog shall have his day, so there may still be some hope. We the people who are happy and satisfied with hot coffee, a loaf of bread, a nice whiteboard and a little less light shining on us, have no use for crises of any kind. It is the power drunk, greedy and shamelessly opportunistic (mostly) men calling themselves leaders, who manufacture crisis after crisis, to justify their own miserably exalted existence, because crisis and leadership are like a nightmarish version of the chicken and the egg dilemma.  There is no material difference between the rough lunatics, preaching fear of thy neighbor, and promising boundless paradise in return for mindless violence in this world, and the sleek captains of industry, preaching fear of natural life, and promising boundless health on this earth in return for mindless submission to infallible algorithms for the duration.

The crisis masters of Middle East death and American health are both driven by the same “selfish and boundless thirst for power and material prosperity” (to put it delicately). The former manifests itself in the lucrative fire and brimstone raining over that hapless portion of the world since the day Abram chose to change his name to Abraham. The latter is how we the people of the new world go gentle into that good night.

How much is that PCMH in the Window?

Much has been written about the Patient Centered Medical Home (PCMH) model of primary care, both complimentary and critical. Most evaluations and opinion pieces refer to the particular PCMH flavor defined by the National Committee for Quality Assurance (NCQA), since this is by far the most widely adopted model, and all other models are just minor variations of the same. Practically all reviews, studies, opinions and assessments pertain to the ability of PCMH practices to improve “quality” measures and generate savings for the system, and in all fairness both evidence and opinions are mixed. One aspect of the PCMH that is rarely discussed, is the cost incurred by the practice for sustaining PCMH operations over time.

A new article published in the Annals of Family Medicine estimates ongoing PCMH costs to be approximately $105,000 per physician FTE per year, in personnel costs only. Data was collected through interviews and staff surveys at 20 primary care practices, 8 owned by an academic institution in Utah, 7 private practices and 5 sites of a Federally Qualified Health Center (FQHC) in Colorado. Only the Colorado practices were recognized by NCQA, while the Utah practices had their own proprietary definition of PCMH. The authors reached their shock and awe inducing figure by adding self-reported increases in time spent by staff on each task listed in the NCQA PCMH 2011 Standards, and then priced this incremental effort based on staff compensation.

Unfortunately, the cost of individual PCMH Elements and Factors is not available, but even in aggregate form, the analysis is perplexing. The average $105,000 per physician per year is not an absolute number. It is the incremental difference, according to the authors, between running a “traditional high-performing” practice and running a PCMH practice. As such, the dollar amounts depend on how one defines the baseline. The article does not provide an exact definition for the “traditional high-performing” primary care practice baseline and this is obviously problematic. The authors mention that not all PCMH Elements were fully implemented in the surveyed practices, but an exact list of implemented functions is not available either.

Basically, we don’t know what the starting point was, and we don’t know what the end point is, but we are told that it takes an outlandish $105,000 worth of work to get from the former to the latter. Outlandish, because any independent solo practice faced with half of those costs would go bankrupt in six months or less, and in spite of that, there are many solo practices recognized by NCQA at the highest possible PCMH level, which is more than the practices in this study have accomplished. Here is a riddle for you: how does a micro practice, with one physician and no staff, sustain the highest levels of PCMH operations when according to this study, one would need to add approximately 2 FTEs to the traditional model?

The answer is that the lump sums presented in this article are meaningless. For example, the highest incremental expenditure for the studied practices, to the tune of $3,000 per physician per month, was attributed to NCQA Standard 3, which deals with providing medical care to patients. There are several items selectively listed by the authors in the description of Standard 3, so let’s assume that those are the tasks that generated incremental effort and costs. The first task on the list is the notorious daily huddle. This is most certainly a new PCMH construct that wasn’t there before. However, would the daily 5 or 10 minutes spent on huddles in a PCMH, not be spent on the same exact tasks peppered throughout the day in a traditional practice? Did the study account for such considerations? We don’t know.

Another item listed for this Standard is implementation of evidence-based guidelines. What does this even mean? Should we presume that traditional high-performing practices are not practicing evidence-based medicine? Were they using magic 8-balls to diagnose and treat patients prior to PCMH implementation? The same can be said for multiple other items, such as medications reconciliation or monitoring patients on high-risk medications or making sure that lab orders are resulted at some point, and a host of other tasks routinely performed in any practice, although in different form and perhaps in a more ad-hoc fashion. Of course, we can only speculate here, since the details behind the $105,000 figure are not available, but these seem to be typical examples of the rampant misconceptions regarding the meaning of PCMH operations.

What sets the NCQA PCMH initiative apart from your run of the mill data collection and reporting programs, such as Meaningful Use, PQRS and even ACO, is that it provides a holistic framework for improving practice operations without being narrowly prescriptive on how to accomplish that. It is a comprehensive tool for the practice to examine its inner workings once every three years and brainstorm on ways to improve its processes. There is nothing in the NCQA PCMH framework that does not occur or should not occur in a modern “high-performing” practice. With the exception of some Meaningful Use measures, I would challenge anyone to point out to even one PCMH factor that cannot, or should not, be implemented in a way that benefits patients and the practice itself. And it all starts with the initial recognition process.

Much has been written about the trials and tribulations of obtaining NCQA PCMH recognition, from the extensive documentation requirements to the onerous costs of labor and expertise. There are two approaches to PCMH recognition that generate these types of complaints, and later on may generate the theoretical $105,000 costs. One approach common in large institutions is to view PCMH as a top down initiative managed and executed by a central office, with little or no input from practice staff, including physicians.  The other extreme is the small practice chugging through each PCMH factor, trying its best to generate mountains of screenshots and reports with no particular strategy in mind other than getting enough points to pass the “test”. Both models may get you PCMH recognition, but with much frustration and zero benefits to the practice.

And then there is the right way, which harnesses the PCMH recognition process to benefit the practice and its patients. Forget about “readiness assessments” and “culture change” indoctrination. You were ready and fairly well cultured the day you finished residency. The question you should ask yourself is not whether we do this or that thing, but whether we are doing it well. You may have some pink colored slot on your schedule called same day appointment, but is it where it should be? Is it solving a problem, or is it creating one, or is it there for decoration purposes only? How are you planning to stop the upcoming hemorrhage of patients to non-descript retail clinics and iPhone “doctors”? Should you maybe use this opportunity to revisit your 10 years old scheduling process?  This is not about NCQA. This is about dollars and cents for your practice.

How about “implementing evidence-based guidelines”? Should you be deeply offended because someone dares to ask you to implement clinical practice guidelines for a sore throat? Or should you look at this as an opportunity to write some standing orders for your staff, so that you don’t have to go in an out that exam room more than once, and maybe, just maybe, you can squeeze in a couple more minutes with your little patient, and notice that mom seems to be unusually worried and distracted? And maybe you'd want to ask her about it. And maybe that’s what “patient-centered” is all about. And maybe all the administrative PCMH stuff you do, should be purpose built by you to make this possible. And maybe this is not about recognition, but about creating a safe little space where you can be the doctor you always wanted to be.

We don’t know how the PCMH was implemented in the study. We just know that it was implemented to a certain degree. We don’t know if the missing pieces are minute or crucial for practice financial health and patient care. We don’t know if the physicians in these practices were given the opportunity to build their own medical home, or if someone else decided how to shuffle the deck chairs. We don’t know if the subjective incremental effort reported by staff on each factor was offset by reduced effort elsewhere, or if it represents better use of previously underutilized positions. We have no objective numbers for “before and after” payroll expenditures, although those should be rather easy to obtain for large facilities. There is more than enough missing and undisclosed data in this study to render the $105,000 suspect.

Are there ongoing costs for a PCMH practice? No doubt, there are plenty, but these costs are no different than the costs of running a traditional (or non-traditional) high-performing practice, because PCMH is just another name for high-performing practice. Perhaps the most useful conclusion from this paper is that high quality primary care costs more than mediocre or outright irresponsible primary care, and those who decide how much primary care doctors get paid, should bring this largely self-evident fact into account, when defining physician fee schedules and future payment schemes.

[Disclosure: I am the founder of BizMed, a company whose mission is to support the viability of independent medical practice, and to that end it offers free software and tools to reduce administrative complexity in private practice in general, and for PCMH recognition in particular]