About Bleedin' Time

So it looks like the 29 BILLION dollars' worth of research funded by the NIH will finally be open access to the public that paid for it in the first place...

The Washington Post covers this nicely so I won't go into too much detail, but long story short, we pay taxes, government funds research, research gets published in journal, journal costs $500 a year if you want to read the results.‎ Full story...

Medical Myths

Cool little article from BMJ about common myths that persist, even in the doctor's office.

• People should drink at least eight glasses of water a day
  
• We use only 10% of our brains
  
• Hair and fingernails continue to grow after death
  
• Shaving hair causes it to grow back faster, darker, or coarser
  
• Reading in dim light ruins your eyesight
  
• Eating turkey makes people especially drowsy
  
• Mobile phones create considerable electromagnetic interference in hospitals.

‎ Full story...

RHIOs Need Data Not Dollars

GovHealthIT reports on a Harvard study that finds that RHIOs across the USA are failing abysmally. Well duh. Regional Health Information Organisations can only function if and when they have regional health information to organise. Imagine building Google before the Web. Or Facebook before E-mail. That's what we're seeing happen now, and the feds STILL refuse to speak up.

Two systems that work that I think shine a light on how to build a national health network are the Internet and the credit card clearing system. Neither of these systems were written into law, neither came from new taxes, yet somehow they seem to work and sustain themselves.

The calls for funding RHIOs get louder and louder, yet these people HAVE NO DATA to share.

I have a few thoughts:

Incent adoption of electronic health records NOW. We don't need RHIOs, we need records.

Understand that successful implementation of EHRs will REDUCE REVENUE for those people implementing. REIMBURSE THEM.

If we build the data, the network will take care of itself.‎ Full story...

Doctors, Plans, Doctors, Plans...

In an almost humourous move physicians today released a report card of their own: a report card ranking pay-for-performance plans in Minnesota. Coming from the very people who have been staunchly defending themselves against public reporting, this could seem a little tit-for-tat counter-intelligence style of guerrilla physician warfare, but the details are pretty cool.

The Minnesota Medical Association reviewed nine P4P programs and declared the system to be inconsistent, forcing docs to work to nine different tunes. Much of the problem lies in the fact that the health plans themselves don't have a standard way of measuring quality performance, which leads to docs having to chase their tails trying to meet performance objectives.

On a side note, I see again the concern that docs who treat "sicker" patients are unfairly measured as these populations should lead to risk adjustment for the physician.

I don't know about you, but if a medical society is willing to posit that Doctor A treats sicker people than Doctor B, I suggest that instead of grading Doctor A on a curve, we take the medical society at their word that Doctor A is not achieving good outcomes and get his "sicker" patients a better doctor who can actually handle the extra effort required.

If they're sicker, surely they should be getting better-than-standard care, not risk-adjusted average care? Call me crazy...‎ Full story...

I Told You So

"Have them take it out, it's not even necessary". Amidst all the appendixotic shenanigans of this year, people kept reciting this to me. "The appendix is vestigial". "The appendix is useless". "You don't even need it".

Now, I'm not a god-fearing man. I don't subscribe to creationism and only slightly less non-subscribing to evolution. I live in the here and now, and if my body saw fit to grow an appendix then dammit it's there for a reason. I dodged having the thing removed for a long time over this.

Apparently it's where all the good germs live (Science Daily).

So, in some form of anti-Jaz spite contest, the medical community held back on letting the world know what the appendix is for until I had mine removed.

Bah.
‎ Full story...

The-Paris-site: Comments That Rang Clear

The-Paris-site: Comments That Rang Clear....9/27

Interesting story about a blog that is being sued by a hospital. The blog is posted to anonymously, and the hospital is claiming defamation.

I don't know enough about the story to comment, but it brings up something I have to tell a lot of people far too often: there is no anonymity on the Web.

There is a perceived anonymity that has long been inherent thanks to free E-mail accounts, nicknames, forum IDs and the like. If you want to sign up as hotgirl22 or professor55 you're free to do so, but using the Internet requires that you identify your machine. From there, everything you do is tracked.

Every thing you do on the Internet bounces through routers all over the country. You request a Web page and that request goes from your machine to maybe 30 locations, all capable of logging the request. At a minimum both your ISP and the server you requested from will store your information for some time.

Now, for the most part, no-one cares who you are and you can skate through all sorts of Internet life as hotgirl22 or professor55 for years, but the second someone starts to care you should know that someone, somewhere probably knows who you are.

You purchased Internet access with a credit card. You provided a secondary E-mail address. You bought something. You signed in at the library.

There is no anonymity on the Web unless you're prepared to work very hard to obtain it.

Whether or not you have a right to anonymity on the Web is another discussion, but when your mediocre attempt at anonymity falls flat simply because you logged on under an assumed name, don't think for a second you'll be able to preserve your secret.‎ Full story...

New York Regional Health Care Report Card Goes Live

I know, I've been quiet. It's been a while since I posted, and here's why:

First and foremost, I have been buried in data all summer, getting this report card out. More on that in a minute.

Secondly, I determined to take some time to myself this year, so I've taken a slew of short camping trips to spend time with my son, do some fishing, sleep in a tent and generally get some of the city out of me.

Thirdly, I finally had my appendix out after my third and final bout with appendicitis.

So, now it's out. It's online at http://www.nyshaf.org/hcrc and I'd like to take this post to explain how I think it can be used, what purpose it serves, and talk about some of the data involved.

The report card is split into two main sections, HMO and Hospital. In both sections the report is split up by groups of measures that can viewed side by side, some quality, some patient experience, some cost.

One of the main problems with public report cards is that the health data is so complex and so arcane it's practically useless to the lay consumer. Sometimes a lower score is better. Sometimes a higher score is better. Sometimes the score is a percentage, sometimes a range. Sometimes it's a vague statistic definition, such as "not significantly worse that the national mean".

Another big problem is the tendency to predetermine what "good" is, and then try to communicate that top the viewer. Health care providers may say that high quality is paramount, cost is irrelevant. An HMO may say that the best care is given by better high quality, low cost providers. Some people think high volume is a good thing, other's don't. The list, and the permutations are endless.

Finally, the overarching goal is to present as many of these public reports as possible in a single space in a single format. For this year's report we've combined 25 publicly available reports which you'd normally have to obtain from 25 different sources.

So I set about trying to determine how to take all these kinds of different data and represent them in a singular fashion that would be easily and quickly comprehensible, without implying a judgement or a ranking. More than one reporter asked me "which hospital is the best?" My answer is always another question: best at what?

One hospital may be the world's best for cancer treatment; is that where I should go for a scheduled C-section?

There is no best hospital, there is no best doctor, no best surgeon, no best HMO. But there *are* providers that are better for you and your individual needs than others.

So, goals set: translate complex data analysis into visual nuggets of qualitative information, and allow the user to narrow down the qualities and measures that matter to them.


What you see above is one category of HMO data. More detailed information is available with a click or two, but at a glance you can see that for customer service one HMO stands out as being highly rated, three are more or less average, and one has some issues.

At least, I hope you can see that. If not, I just wasted a year.

So how can a consumer use this report card?

Example 1: Heart Attack

I have never heard of anyone having a heart attack and stopping to consult report cards on where they think they should go.

However, once you're in the hospital, your loved ones can consult the report to see how well the facility you ended up at is faring at providing quality treatment. If anything stands out as worrisome, bring it up with your doctor.

Further, several of the measures apply to the care you receive after your emergency treatment. Medications prescribed at discharge for example, including aspirin, as well as smoking cessation counselling.

Mortality rates for heart attack are relatively flat, everyone is going to be pretty much "as expected". If your hospital shows up red for mortality, bring this up with the hospital staff.

You may be looking at a co-pay or even worse, you're uninsured. Use the average charges bill to get an idea of how much the stay will cost you or your employer. You can also see the average length of stay for a heart attack patient, and if it's shorter or longer than you think is right, raise this with your physician.

The overall point is that the level and standard of care can and will vary from hospital to hospital, and nowhere is perfect. It pays to be informed, and remember you are your best advocate.

Example 2: Choosing an HMO

Some employers will offer you a choice of two HMOs. If you or your partner has an ongoing condition such as asthma, have a look at which of the two HMOs available seem to be more on the ball for that condition. Then check out the customer satisfaction ratings for that HMO.

If you don't have a choice and your HMO plan scores poorly, then use that as a reminder to make sure you get the care you need by advocating for yourself. Have a look at the care provided by other HMOs and demand that same care from your primary physician.

If you have children, compare the two youth sections. In my county, only one HMO has all green for appropriate youth care.

Example 3: Appendicitis

I have a bit of personal experience here. I had the symptoms of acute appendicitis for a few days, and finally went to the ER after the symptoms didn't go away. i was a little atypical, and was in little danger of perforation, but nonetheless you may be able to do what I did.

I looked at the five hospitals nearest me, and compared the length of stay for an appendectomy, the surgical infection prevention score,a dn the price.

I'm price-sensitive even though I have good health insurance. The company where I work pays for the health care I receive, and the last two years have seen a steady increase in both the company cost as well as my family rate contribution to the plan. Further, all my co-pays went up significantly this last year.

Because health care is so often paid for with invisible dollars it can feel a bit like Monopoly money, you never see it, you never worry about it, you get a long, arcane bill that you never have to worry about. However, I know that if I can get an appendectomy at hospital A for $10,000 less than hospital B, I just saved the company money. Saving the company money puts more dollars in the kitty for my next pay raise. And being relatively young and by all accounts rather stoic, I'd rather have the cash up front than ploughed into a pool for a rapidly greying employee population.

In my county, appendectomy hospital bills range from $7,000 to $30,000.

Let me repeat that.

In my county, appendectomy hospital bills range from $7,000 to $30,000.

That's before the surgeon's and anaesthetist's bills.

I actually placed more importance on finding a hospital that had a low average length of stay with good surgical infection scores. I wanted somewhere under $15,000 with three or so days stay on average.

The hospital I chose actually had a poor score for timely antibiotics, so instead of choosing a different hospital, I questioned the staff when my first antibiotics were given and ensured I was less than an hour from surgery.

Example 4: Mother to be

Some women search for hospitals that are less inclined to perform a C-section. In my county, the C-section rate varies from 17% to 34%. That's double the rate. For primary caesareans, the rate goes as low as 11% at a hospital that also shows a high rate of vaginal births after C-sections, clearly a hospital that can help you have a natural birth.

Others may choose the scheduled C-section route, and look for a hospital that performs a good number of the procedure. You can compare the number of times the procedure was performed in a year at all your local hospitals, as well as the surgical infection prevention scores.

Looking to get home quickly after the surgery? Some hospitals have you stay for three days, others for five.

--

In my next post I'll go into more detail about the different data sets including the different kinds of measures available, where we get the data from, and how accurate that data is.

In the meantime, I am very interested in hearing from anyone who has used a public report card similar to this one in a real life situation. Was it useful? Did it complicate things? Did you bring anything up with your doctor?

Finally, if you wish you had similar resources in your community, consult www.abouthealthtransparency.org/ and click your state. You can also check out www.consumerhealthratings.com/
‎ Full story...

Appendix Ultimatum

So, the old appendix flared up again, as of course it should. Same symptoms as before, it was evident what was coming. I left work, drove home, and prepared for my first hospital stay.


(Quick reminder for the uninitiated: I visited Hospital A in February with symptoms of appendicitis, waited six and a half hours in the E.R. until giving up and going home. I then visited Hospital B the next day and had the most awful day I've had in quite some time, culminating in me being seated on a gurney two corridors away from the E.R. outside the isolation room where a guy with full-blown tuberculosis and his wife were wandering in and out of isolation back and forth in front of me complaining of the heat. I've had a dodgy appendix for quite some time. Read the full story in all it's glory here.)

I gathered a book, a change of clothes, and the average length of stay for the five hospitals closest to me - not including hospitals A and B from my prior sojourns. I then had a good night's sleep in my own bed, and mentally prepared to lose myself to the system for a few days.

I saw that my hospital of choice had lower than desirable scores for infection prevention, so I made a note to bring it up when antibiotics first appeared.

My plan was to hit the 8 a.m. shift change, but my subconscious desire to not go to the hospital had me pacing the living room until nine, so I didn't get to the hospital of choice until ten. Nonetheless I was triaged within 12 minutes and was seen by a doctor within another 15.

Emergency Preparedness

The E.R. proper was impressive; clean, lots of open space, certain areas were labelled - such as the asthma section. The doctor who saw me was amazingly friendly, very informative, listened and heard the story of my history with appendicitis and it's atypicality. I drank the stuff you need before going for an MRI and was confirmed to be suffering from appendicitis by around 3 p.m.

I was told that I'd be admitted to the E.R. and therefore settled in for the wait.

It should be noted that this whole time I was in my regular clothes. No gown. Clothes. I cannot begin to describe the difference compared to sitting in Hospital B in February all day in a gown.

I was in the E.R. up until around 7 p.m. During the entire day, I felt like I was in a place that was very aware of its patients. My E.R. doc was fantastic. Checked on me every once in a while, I received regular updates about my status. Around tea-time the learner doctors began arriving one after the other to poke and prod.

I was given a form to sign that acknowledged I had received various forms and information. I asked for the said forms and information, but was told I would receive it the next day. After a brief exchange of dry sarcasm, I elected to shut up and sign the release, making a mental note to see when the information actually arrived.

It was given to me two days later.

As the reality of surgery became more and more present, I asked the learner doctor surgery chap who was taking all my details down about how I could remove my appendix home with me. While it may seem odd to some, I am part of a large group of people who actually want to keep their hands on the bits that come out of us. I asked earnestly about my ownership of my slated-for-removal organ, and even offered to go halvsies on it so that pathology could have something to look at. I asked two different surgery doctors to check on this for me, I never got an answer nor did I see those doctors again.

Slowly, as my status was swinging from profitable E.R. visitor to run-of-the-mill appendectomy last thing on a Friday night, I became less of a customer and more a vocal cadaver.

Special Ops

Looking back, the thing that really peeves me is that no-one ever told me what was going to happen *after* the surgery. I did not know I was going to be shaved "down there".

I did not know I was going to wake up with tubes up my nose and another down my throat into my stomach. I did not know there would be metal staples in me. I did not know I would spend the night in a recovery room full of other people.

None of this was impossible to deal with, but knowing it beforehand would've made waking up after surgery a whole lot easier.

Seems to me that pre-op I should be given a one-page handout along the lines of "Appendectomy for Dummies" that covers what they're about to do and what things will be like after.

One page. A couple of paragraphs. That's all I'm asking. I don't want half an hour with a very busy surgeon stroking my hand and reassuring me. Just give me the handout.

So I woke sans appendix. The operation took longer than expected as my appendix was reluctant to leave, for which I feel proud in a silly way. The surgeon chap, when trying to impress upon me how aberrant my appendix was, exclaimed "that was one ugly appendix", at which I was offended in a silly way. It was twisted around and clinging on, he described it as having to "peel it off out of there".

The first 24 hours were simply uncomfortable as I had this pipe down my neck. I finally made it to a room, where I experienced my first real time in a hospital bed.

Overall, the stay was great, everyone was polite and friendly. The only real grumble I have is that the surgeon was very obviously agreeing to anything I asked like "please take this pipe out of my stomach" or "let me eat some ice chips" but he had no intention of doing so, which he could have just said so instead of trying to placate me.

For example, he told me the pipe could come out within the hour, left the room and gave no such order. This happened three times, all the while he actually wanted the thing in there about 36 hours. He told me this after it was removed, along with why it had to be in there for so long in the first place.

Information I could have really used, say, 36 hours ago.

Feed Me

Due to my atypical presentation, the guy wanted me in hospital for four or five more days. I worked really hard on walking around, looking healthy, and passing gas "back there". Given that I chose the hospital based on their apparent ability to kick people out relatively quickly, I felt I should give it the old college try. The surgeon really wanted me to stay in, but after talking to the resident who was visiting me, the surgeon came by eventually and checked me out. Again, I really felt listened to, like what I was saying was relevant, that I knew my limits and capabilities, I knew my body, and I felt like I would recover better at home. I was passing gas "back there", I was walking around unaided, I was peeing like a racehorse. The guy let me go home, albeit reluctantly and with many cautions about when to come back if such and such happened, but the point is they listened to me and let me go home.

Either that or someone googled me and figured they should let me go before I caused a scene

By the by, why is the no Internet in hospitals? I worked every day checking E-mails, I would have loved to do some research on recovery from appendix surgery, check the rugby. I was reduced to working on my phone which is mind-numbing after any decent amount of time. Get some wi-fi people! We'll pay for it, don't worry, you can bill it to the room just like the TV.

Three days later, when I was becoming ready to kill the next passing orderly for a tub of strawberry jelly, the senior resident for the day, after having asked me about 15 times if I was passing gas "back there" agreed to let me get some "clears", code talk for jelly, stock and tea - which in American means Jello, broth and... tea.

UK jam, US jelly
UK jelly, US jello
UK stock, US broth
UK broth, US chunky soup


I was so concerned that these orders wouldn't be passed on I ninja'ed the "Nil P O" (no food by mouth) sign above my head and removed it to the wastepaper basket.

That lunch time I received a tray with two jellies, a bowl of beef stock, a cup of tea and a bread roll which certainly doesn't seem clear to me but I wasn't about to give it back.

Never has a bowl of beef-flavoured water tasted so good. Three days without food is cruel and unusual in my book.

Nailed To The Door

All in all I'm glad the appendix is out, I wish I had it at home, and the hospital experience was middling. The E.R. was truly great. Everything else was vanilla. Maybe it all comes down to who's on duty that day. I don't know. I know I'm writing a letter to the E.R. doc and her boss to say thank you, they really exemplified everything I want to see when I'm in the E.R., I couldn't have been happier or more pleased with the care.

The only truly awful moment came on my third night when a roaming minstrel was allowed onto the floor and he minced from room to room with his guitar taking requests and singing to the patients. It was bad in a comedic, wincing kind of way.

I half hoped he'd break a string so I could make a luthier reference, a joke I'd been crafting for just the right moment, but the chance never came.

Ah well, it was a stretch anyway.








‎ Full story...

EBM vs CSBE

As the launch day of this year's health care report card draws near, I've been fighting the good fight on publishing volume data. Specifically, volume of procedures for low-volume surgeries such as esophageal and pancreatic resections. Working from billing data, I can find out how many times each procedure was performed in a given hospital for a given time period.

In some instances, I'm seeing a volume in certain areas that is under 10 for most facilities and then one hospital cleans up with 100 or 150. Is this qualitative data? Can anyone be reasonably expected to form a judgment from this information?

Sure, I can provide mortality rates, but at one death per year for most hospitals, what value is that? Surely if a hospital performs ten times as many procedures than the one next door, I can expect better outcomes?

In the normal world, of course the answer is yes. Midas will do a better job on my brakes, AAMCO will do a better job on my gearbox/transmission. In medicine however, it's not true until the literature says it's true. So until the community performs enough studies to validate the obvious, it's not defensible.

Even where literature exists showing better outcomes for certain procedures that are performed a certain minimum number of times, it's apparently not overwhelming enough to convince everyone.

This is the basis of evidence-based medicine, not to mention... science. Science is, after all, nothing but a bunch of measurements.

However, given that any practitioner will loudly declare medicine to be half science and half art, I hereby coin a term I've been using for quite some time:

Common sense-based evidence

Simply put, if Doctor A has done it once, and Doctor B has done it 200 times, Doctor B is more experienced. End of story. I don't need a $30,000 study performed to risk-adjust the patient mix.

Bolster the common sense with evidence, of course. I am the first person to say that no one measure stands alone. But failing to provide a complete picture is hurting the public and denying us the transparency we seek.

The report cards I work on I try to introduce enough data to allow the user to decide on the important factors and make an informed judgment. The medical community works exactly the opposite way: they want specialists to make the judgment and publish it in very expensive journals we can't afford to read.

I don't presume to know whether you care more about mortality rates, volume, or proximity to a Starbucks, but I'll continue to work as hard as possible to provide as much comparative data as I can get my hands on.

It is, after all, good common sense.‎ Full story...

Doctor No

Scanning the health blog universe I wandered across a post on Kevin MD about a council on aging member urging the elderly to demand more than five minutes of a doctor's time if it was needed. What follows is an anonymous comment that appears to heve been made by one such doctor.

1. You are not paying them. You have shrugged that responsibility and the right to represent you onto the government and whatever secondary insurers you have hired. You are entitled to have what they pay for on your behalf, not whatever you want.

2. If you are the sort of person who wants that extra time you feel entitled to, then don't complain when you get seen later than your appointment time. It may be hard to think of someone besides yourself, but imagine for a moment an entire patient schedule of patients like yourself, all feeling entitled to a little more than what they really have paid for. Bring a book.

3. Enjoy bothering the staff? In my office, you will enjoy that just once. They are hard to replace. I want them to stay and if possible , stay happy. You, the botherer, can be replaced easily. It isn't rocket science to run that algorithm. Learn to be nice, even if it kills you.

4. Medicare is not the same as you paying for something, like a dinner. Electing to bestow your custom on a practice, your Medicare custom that is, is not an example of free give-and-take. Ever wonder why many practices limit the numbers of new Medicare patients? It isn't because they're getting rich seeing them, that is for sure. No Medicare heavy practices are worrying about back injuries while carting all the cash out the back door, that is for sure. No one says you need to grovel, but you should get real about what you are and are not bringing to the table. Oh, and your good word and its value in drawing other seniors to a practice? Everyone likes to be spoken well of, but it isn't the bonanza you might think it is. Every Medicare-aged patient has the potential to displace a better-insured patient, if you want to think of things that way.
# posted by Anonymous : 10:46 PM

There's so much that's wrong with that comment, but I'll address the one thing that stings:

Medicare is not the same as you paying for something, like a dinner. Electing to bestow your custom on a practice, your Medicare custom that is, is not an example of free give-and-take.

Utter nonsense. Keeping consumers tied to this belief is propping up a fetid market. Airlines, restaurants, car rental agencies, IRAs, supermarkets, all compete for dollars that you don't have in your hand. They seem to understand that the decision maker, not the payer, is the customer. That's what we're missing in health care. Consumer empowerment begins with us understanding our purchasing power.

To the doc who wrote the above, I challenge you to send your feelings above to each and every one of your bread-and-butter Medicare patients with a list of other doctors, and willingly lose a large percentage of them. Posting anonymously on the Internet may have made your feelings a little better, but I feel sorry for your patients who are unable to evade the system and remain on Medicare and feel they are being adequately cared for by you.

What happened to the word "care" anyway? This doc obviously doesn't "care", yet we call it health "care", "care" givers, it's baloney. Avis cares. Hilton cares. Jetblue cares. My mechanic cares.

Bring back care to health care, and we'll cut back on the apparently-untenable bothering of you and your staff.
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Note to Pharmacists

Stop pressing my buttons! It's my question, I'll answer it!

The last three prescriptions I filled I encountered the same complete lack of customer service that is really beginning to peeve me off.

During checkout, here in NYC at least, after the money has changed hands the little screen pops up a screen that allows you to respond "No I do not need advice" or "Yes I received advice on my medication" or something to that effect.

Each of the last three times, the person handling the transaction leaned over and clicked the "no I don't need advice" button for me.

Un-flippin'-believable.

The first time was an independent pharmacy where I was getting my son's first ever dose of penicillin and yes, actually, I had some questions. I was worried about an allergic reaction as this would be the first time to find out, and I wanted to know the signs to look for if things were going wrong. "Instructions are in the bag" I was told. This was after the lady had clicked the "no I don't need advice" on the little touchscreen I put my PIN into.

The second time was at a Rite-Aid. I picked up some antibiotics for the boy but in fact had no questions so I was only mildly annoyed when the chap reached over the counter and hit the "no advice needed" button.

An hour later I was back to pick up my Chantix prescription for which I did indeed have questions and was subjected to (a) the checkout process completing before I was told they couldn't fill the whole three month prescription and (b) hitting the "no advice" button for again!

Drives me mad. Is this limited to New York or does anyone else experience this? Maybe it's just my face, maybe I look like someone who doesn't want to be helped.‎ Full story...

Ineffective Efficiency

NYT has a section today on "who pays for efficiency", several articles and a handy flash map from Dartmouth Atlas look at cost of care around the country, disparities in coverage and reimbursement, and the price of efficieny and who ends up paying versus who ends up benefitting.


‎ Full story...