HEALTHY ONLINE

According to a Kaiser Family Foundation poll earlier this month, it seems that three years after its passage, opinions about the Patient Protection and Affordable Care Act of 2010 (ACA) remain divided. Interestingly, since the fall elections, Republicans seem to be slowly warming up to the ACA, while Democrats and Independents are experiencing significant disenchantment. I wonder why… So what do people dislike most about Obamacare? Obviously the individual mandate to buy insurance takes first place, and in a typical Stockholm syndrome manifestation, the second most disliked Obamacare feature is penalties for large employers that do not provide health insurance. But there are lots of other things in the law that most people seem to like. They like tax breaks for small business, closing the “doughnut hole” for Medicare prescriptions, keeping adult children on parents insurance and they like subsidies to buy insurance on the new exchanges. People even like the Medicaid expansion, and of...

Continuing our fantasy journey towards a patient care oriented EMR for primary care physicians, let’s quickly recap our progress. After much ado about nothing, we came up with the following set of requirements in Parts I and II : System shall assist with gathering information from various sources (TBD) at the point of care System shall assist with information recording at the point of care (needs more specificity) System shall retrieve and accept information from external sources System shall respond to all external legitimate requests for information System shall have the ability to access published clinical information (consider buying) System shall assist with synthesis of said information System shall assist with patient-doctor relationship building System shall not make the task harder to perform for the user In the real world of software design, this would be a good place to seek validation for our thought process. We can do that here too although we have no real users. A recent...

We spend a lot of money on health care in the U.S., but we spend a lot of money on other amenities as well, so how do we know if we are spending too much money on health care? The phrase too much implies a frame of reference and some sort of valuation; too much for too little value, or too much compared to others, or both. Leaving aside the ideology of who should pay for what, the only thing that is increasingly obvious is that other developed nations, a natural frame of reference, are spending at most two thirds of what we do and their health results are as good, if not better than ours. You would think that the next logical step would be to observe how these other nations finance and deliver care, and apply lessons learned to our system, and there is no shortage of observational studies, surveys and reports . Since health care is a huge and complex beast, perhaps the best place to start is primary care, which, as its name implies, should be the point of entry into any health care sys...

A dark wind is beginning to blow through the tortured landscape of health care in America. At the confluence of the corporate cold front with the warm front of technology innovation, a storm is brewing. A storm that may grow into gentle and much needed rain showers, or the grandest tornado ever experienced by mankind, and unlike the wondrous works of nature, the path taken here is completely within our control. The US government and all its federal, state and local branches spent over 1 trillion dollars of our tax money on health care for the poor, elderly and disabled last year and we spent well over 1.5 trillion dollars of our own on health care for everybody else. Most of these monies are going to medical service delivery systems, some is going to financial management intermediaries and a fraction is going to companies providing services to these corporate entities. Obviously, this level of expenditure is unsustainable, and when we look at other developed countries, we realize that ...

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...

IBM ’s Dr. Watson of Jeopardy! fame has finally completed its residency and fellowships and, presumably to its creators’ utter delight, is now a practicing Oncologist. The prodigy “cognitive system” completed its training in less than a year at the illustrious Memorial Sloan-Kettering Cancer Center, and although only proficient in lung cancer right now, Dr. Watson’s career as an advisor to oncologists everywhere is off to a great start. A recently released video demonstration shows Dr. Watson in action, researching, evaluating and treating a 37 year old woman with newly diagnosed stage IV lung cancer in his advisory capacity to a hurried and pretty uninspiring human oncologist. Regardless of the slightly weird scenario, it is worth noting that in a fraction of a second Dr. Watson, scours 3,469 text books, 69 guidelines, 247,460 journal articles 106,054 other clinical documents and 61,540 clinical trials, and evaluates their contents against the patient’s EMR to identify need for furt...

Our ancestors began using tools millions of years ago and humanity assumed control of the planet it lives on through a succession of tools ranging from sticks and stones all the way to iPhones and drones. The basic process for discovering or inventing tools hasn’t changed much over the millennia, and it follows two basic patterns. Either an existing artifact is examined for fitness to various purposes until one such purpose is discovered accidentally or through organized efforts, or a problem is identified and a tool is then invented, or located, to solve the problem. The problem itself could be something that was thought impossible before, such as flying, or a more mundane desire to reduce the effort and expand the capabilities associated with an existing activity, such as moving goods from one place to another. Tools can have limited effects, revolutionize an entire economic sector or can change history, and some tools can have harmful effects that must be balanced with the benefits ...