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Transforming Health Care: Values and Cultural Preferences

On his campaign trails, Harry Truman used to call on citizens to go out and vote for themselves, in their own selfish interests. It may sound shallow and divisive, but Harry Truman believed that the individual interests of the people should trump the special interests of the powerful few, and that’s how Democracy should work. Those were simpler times, but the logic still applies today, although it’s becoming increasingly difficult for people to figure out where their selfish interests lie, not because interests have changed, but because the art of spinning messages and the sheer amounts of cash thrown at it have grown beyond what Harry Truman could have imagined. Take for example the controversy around the Patient Protection and Affordable Care Act of 2010, a.k.a. Obamacare, which was spun into one little question: do we want the government to give more poor people health insurance, while forcing everybody else to pay for it? If yes, vote Democrat. If no, vote Republican. But Obamacare...

De Novo EMR Design Part II: The Quest for Information

The Edwin Smith papyrus ca. 1500 BCE In Part I of this series, we engaged in a design exercise for an imaginary software product that has no stated (or hidden) purpose other than to improve patient care. Following our initial definition of patient care, we formulated three general requirements and several constraints, none of which were specific enough to start building software tools from. The next step in our journey will break down each requirement into more specific tasks. What follows below will seem like an unnecessary and laborious statement of the obvious to some. However, I would submit that the careless bypassing of fundamental analysis is precisely what led us to where we are today, and even if we are forced to cut corners eventually, it is imperative that we define all corners prior to cutting them, instead of feigning shock and surprise after the fact. So without further ado, let’s start where we left off. System shall assist with gathering information from various sourc...

In Memoriam FFS

On April 16, 2015, President Obama signed into law H.R. 2, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), effectively sentencing Fee for Service (FFS) to death. The best explanation for how FFS is destroying the nation comes from Charles Munger , vice-chairman of Berkshire Hathaway and ad-hoc health luminary, who is equating what American doctors do, to raising rattlesnakes so they can collect the bounty for dead rattlers offered by the government in an effort to combat a growing snake problem. Based on this, and other equally compelling insights, FFS was found responsible for willful destruction of our great nation. A few months before Congress delivered its coup de grâce to the FFS system, the Secretary of Health and Human Services, explained to the elite group of NEJM paying customers, how “30% of Medicare payments should be tied to quality or value through alternative payment models by 2016 (50% by 2018)”. Other than transforming traditional Medicare into a vi...

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