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November-20-2014

9:43

Let’s “Talk Turkey” About Health

turkey ThanksgivingThe following question recently came up on the Healthcare Leader (#hcldr) Twitter Chat:

“Over the holidays, can we ‘talk turkey‘ about health with family and friends?”

This post happened to be scheduled right before the Thanksgiving holiday, and I had been compiling a list of new consumer health tech that could make a difference – not just for ourselves – but in the lives of our family members and loved ones in the year ahead. The list was not meant to be commercial or comprehensive. But how could we better support each other in health? What technologies could help prevent the most chronic conditions?

At a recent family gathering, we had been discussing our health, and spontaneously decided to check our blood pressure and glucose readings. Although most of us did not have high blood pressure and were not in the range of prediabetes, it led to a lively discussion.

Trends in mHealth, wearable tech, and the Internet of Things attract a lot of diverse opinions. There is a lot to talk about!

Early adopters enjoy the newest technologies and bold predictions, like those from futurists at Exponential Med (#xMed). The skeptics dismiss innovations like wearable tech as just a fad, or just for fitness buffs and “Quantified Selfers.” Others see the implications of new health tech as threats to privacy – like collecting and sharing data with employers and insurance companies.

While some innovations may not take off with consumers right away, like Google Glass, they fare better in B2B applications, according to Dr. Rafael Grossmann. His foresight for Google Glass in medicine is still one of the best use cases for the technology.

So far, Apple has delayed the release of the Apple smart Watch until later in 2015. But a number of smartwatches will soon have the ability to continuously collect biometric data, like the Samsung Simband. While precise readings for heart rate, blood flow, respiration, and glucose can be expected in one device, a system for sharing this data “between” people has not been delivered yet.

Consumer Health Tech 

Ignite a conversation about health with family as smart consumers, and maybe they can avoid becoming patients of chronic disease.

While wearables and health apps are great for fitness and chronic disease, we can now use this technology for everyone to prevent chronic conditions. New tools make information accessible to the consumer that was only previously available by seeing a doctor.

HEART DISEASE: AliveCor

Heart disease is the leading cause of death in the United States. AliveCor lets you manage heart health by recording your own electrocardiogram, and immediately relaying if atrial fibrillation is detected. AliveCor can now also track medications, symptoms (palpitations and shortness of breath), habits (caffeine or alcohol consumption), and activities (exercise and sleep) while using the monitor and app. (AliveCor’s inventor, Dr. David Albert, is also an interesting person to follow on Twitter!)

HYPERTENSION:  Withings Wireless Blood Pressure Monitor

Hypertension affects one in three adults in the U.S. But the “white coat effect” of high blood pressure readings is very real.

Researchers concluded that repeated measurements taken at home may help give a more accurate picture of blood pressure control than a single reading in a doctor’s office.”

Researchers hope to learn more about the disease and correlations as people track their own blood pressure more regularly. Treating signs of high blood pressure early can make all the difference. Why not make it a habit to take family blood pressure readings?

SAD (Seasonal Affective Disorder): SunSprite

Seasonal Affective Disorder, characterized by fall/winter major depression and spring/summer remission, affects up to one in ten people in some northern states. But SAD can even be found in Florida.

Interdisciplinary research is needed to advance scientific knowledge about SAD. Solar-powered SunSprite tracks sunlight impact and measures your UV exposure.

THE ELDERLY AND PEOPLE WITH DISABILITIES: Amazon Echo

All signs point to Home-as-a-Platform. Amazon Echo just launched, and is already attracting a lot of controversy, not unlike the introduction of Google Glass. However, Echo could make life easier for the elderly and disabled with its voice recognition technology that is touted as superior to Apple’s Siri.

BRAIN HEALTH AND MINDFULNESS: Choose Muse

Training your brain can help you reduce stress, improve focus, and enjoy a better quality of life. Why not practice mindfulness with the whole family? The benefits of mindfulness have been proven through medical research, and can even change the brain after only eight weeks of practice.

MUSE cites research that 20 minutes of focused attention training for only 3 days in a row can measurably improve mood, as well as reduce pain, anxiety, and heart rate.

Take a Walk

After the holiday dinner, gather everyone for a walk and talk about how you can improve your family health and fitness. If you are looking for motivation, maybe you will be inspired, as I was, by this series of “films” by Dick’s Sporting Goods – and the stories they chose to tell from people who face real challenges, yet still manage to get out there and run.

I run because one day I may not be able to. – Steve Bell

It really does help to have other people around.
I run to express the gratitude for the life that I have. – Alica Shay

Happy Thanksgiving!

Let me know if you “talk turkey” about health with your family, and add your recommendations to the comments!

November-18-2014

5:00

When it hits the mark, satire is sometimes mistaken for truth.  For example, when this “article” Nurses Now Required to Chart What and When They are Charting was making the rounds on Facebook I saw more than a few comments from nurses who mistook it as real news. “As if we don’t have enough to do,” and “Like computerized charting isn’t bad enough,” were some of their opinions on it.


The piece jokes that nurses will have to chart that they are charting: “Nurses are required to additionally document, ‘I am currently charting that I documented the prior statement: rang call light for PRN pain medication, dispersed 1000mg acetaminophen.'”

How could something that sounds so silly be mistaken as a legitimate news article? Because good satire contains a bit of truth. In this case, the reality it’s alluding to is nurses’ frustration with EHRs.

According to survey results released in October by Black Book Market Research, 92% of nurses were dissatisfied with inpatient EHR systems. They reported the technology has disrupted workflow and productivity and negatively affected their jobs. Lest you think this is just another case of front line staff being resistant to change, hospital administrators validated these statements. Some 84% of administrators at not-for-profit hospitals and 97% of administrators at for-profit hospitals confirmed that EHRs’ impact on nurses’ workloads were not considered highly enough when selecting an EHR system.

Here’s more specifics on the nurses’ responses regarding EHRs:

  • 98% of nurses at for-profit, chain facilities are dissatisfied with the time allowed to be spent with patients versus the time allowed to document on the EHR.
  • 94% of nurses do not believe the use of their current EHR system has improved the communication between nurses and the care team.
  • 90% of nurses said their facilities’ current EHR systems negatively impacted communication between nurses and patients.
  • 30% of nurses believe their hospitals’ IT departments and administrations respond quickly to make changes in the EHR when nurses recognize vulnerabilities in documentation.
  • 26% of nurses agree with the statement, “As a nurse, I believe the current EHR at my organization improves the quality of patient information.”

Achieving Meaningful Use has been a motivating factor spurring facilities to adopt EHRs, and according to the ONC it improves quality, safety, patient engagement, and care coordination. But are these goals really being met? The nurses’ responses aren’t exactly a resounding endorsement from the professionals giving the bulk of hands-on patient care.

So what can be done to improve nurses’ experiences with EHRs?

First off, bedside nurses need to be included in the decision making process when selecting an EHR system. It’s not enough for nursing administrators or managers to be the only nursing representatives evaluating the options. They may understand financial and business reasons surrounding EHRs, but they don’t have a handle on nurses’ day-to-day workflow and how EHRs may affect patient care. Those using the technology to provide patient care 24/7 need to have a say.

Speaking of finances, 88% of nurses blame financial administrators and CIOs for selecting low-performing systems based on pricing and incentives and for cutting corners at the expense of care quality. Yes, being fiscally responsible is important but sometimes you get what you pay for. I’ve seen the results of this firsthand and it’s not pretty.

One employer had an unbearable EHR system. Part of the problem was nurses’ workflow had not been considered when implementing the system. But another issue was the organization had not paid extra to have the system customized for its specific needs. Because of this, nurses faced excess amounts of charting just to get through screens and fields that were irrelevant.

There must also be continued evaluation of the system. You can’t just launch an EHR and be done with it. There needs to be follow-up to see how it is performing and how it is or is not interrupting nurses’ workflows. There needs to be hard data collected regarding time spent charting versus time spent providing patient care so an honest evaluation can be made. Patient outcomes and experiences also need to be assessed to see how the technology is affecting those situations.

Finally, issues brought to light by nurses need to be fixed in a timely manner. Sadly, respondents to the survey did not have kind words for their IT colleagues. In addition to being slow to resolve problems, 69% of nurses in for-profit inpatient settings reported their IT department as “incompetent” when describing the level of expertise their organization’s in-house staff has working with the selected EHR software.

The results of the survey may sound harsh and critical of EHR and IT, but it’s essential that the nurses’ message be heard. All the patient satisfaction measures, quality improvements, safety initiatives that are now being championed will be worthless if workflow and patient care are impeded to the point that patient outcomes are being negatively affected.  It’s time to start listening to what nurses using EHR systems are saying before there is a crisis involving patient outcomes.

November-14-2014

11:58

The IHE IT Infrastructure Committee has selected its work items for the next annual cycle. This year, a significant increase in total work made it through the process. To accommodate the extra work, some load balancing will be done and a staggered approach will be applied. Here’s a quick summary of the approved work items:

  1. RESTful ATNA – Provide a way to query into an ATNA repository through REST. Likely to use the FHIR SecurityEvent resource.
  2. Alerts targeted at Humans – Send alert messages to one or more recipient.
  3. RESTful PIX –This is the query transaction from the PIX profile, but using FHIR.
  4. MHD – Version 2 of MHD. The goal is to get this out to Public Comment in January so that the USA IHE Connectathon can do some limited and targeted testing, under “New Directions”.
  5. DE-Identification for Family Planning – Takes a QRPH profile on Family Planning, and creates a whitepaper to show how data could be de-identified for Family Planning specific purposes. This will be the first formal use of the De-Identification handbook, and the whitepaper will hopefully benefit others who need to de-identify patient data.
  6. DSG – Update the Document Digital Signature profile to the current IHE documentation template, and possibly improve it.
  7. XD* Re-Documentation – This is an effort similar to the Volume 3 cleanup we have done, but this time focused on fixing up Volume 2.
  8. XDW-XCA – Extend XDW capability so that a workflow can exist across multiple XDS affinity domains. The proposal creates two new supplements: XCDR, a cross-community push, and a cross-community extension to XDW.
  9. German/French National Extensions – Both Germany and France have provided national extensions to the PAM (Patient Administration) profile.
  10. Change Proposals – This is ongoing work in every year, but must be managed with the other work items.

See more detail here at John Moehrke’s Healthcare Security/Privacy blog, including links to the detailed proposals. Participation in the development of these work items is encouraged.  Learn more about that here.

November-11-2014

11:24

Here’s Part II (Part I) of my interview with Michael Dermer, the Chief Incentive Officer at Welltok, where we talk about engaging different patient populations, Apple Watch, and IBM Watson.

LK: Let’s talk about the Engagement Spectrum, which I’ve written about before. It’s easy to get someone who is maybe looking at a very scary situation, even death. It’s easy to get people engaged at the bottom of Maslow’s hierarchy, someone who’s just had a heart attack, for example, to change. Then there are the quantified selfers, there are those at the top of the hierarchy that are after optimizing their personal performance. But what do we do about the ‘C’ students in the middle? The 35 year-old that’s in pretty good shape, not great shape, but doesn’t think to much about health? Are rewards the answer there? Do they matter for her?

MD: Just like there’s a continuum of behaviors, there’s a continuum of personalities. From an extrinsic reward perspective, the thing we need to do is line up the dollar value with two major things. Number one is the level of effort, what you are asking them to do. Number 2, frankly, is their income. A $50 reward will not work as well for someone who’s making several hundred thousand dollars a year.

That’s the foundational part of it. There’s no question that some will do things without an incentive, some will never do anything no matter what the incentive is, but 80%, if you look at the studies, probably can be influenced to a degree. They will engage, but you have to optimize the dollar value you give them relative to their behaviors.  Some of the early forays into the pay-for-performance incentives on the provider side, for example, didn’t work very well because they were just too small.

LK: You’re talking about, say, a highly-paid physician wasn’t going to pay attention to some of these smaller rewards given everything else they’re dealing with?

MD: Yes. So, take the example of e-prescribing and the Medicare e-prescribing incentives. If you give $100 to a physician that’s making over a couple hundred thousand dollars a year, you won’t get much movement. But if you give the same to an office administrator that makes $40K/yr, chances are you will get movement.

It’s not “if incentives” it’s more “how” (incentives). The interesting thing about the Medicare e-prescribing program, they credit the program to getting e-prescribing to over 70% across the country, and the incentives were not that big.

But typically, you’d expect, for someone who’s pretty well and not engaging with the healthcare system for prevention, or others at different levels, you have to get it right around what you are asking them and how much you are offering them.

LK: So it’s similar to the Fogg Behavior Model, there’s a trigger and there’s motivation and there’s how difficult the behavior is, and you need to find out where you are on that graph between difficulty and the reward needed to create the motivation (if it doesn’t exist already).

MD: When you think of people on Medicaid, for example, they are hard to communicate with because they are transient and they are dealing with fundamental life issues, but money is really important. If you can reach them, $50 is a lot of money. So you need to make those things available, food and communication. That’s why I use the term art and science, some of it is the science and the analytics, but a lot of it is the art of how those things are communicated based on who you’re trying to reach.

LK: Were there any big surprises on what came out of payments made to physicians (by pharma and device companies) that was released by CMS? (Speaking of incentives.)

MD: I think what’s going to happen with the evolution of providers is that it’s going to come down to something similar to what we’ve learned with consumers: that is, it’s not the concept of rewards and incentives, (that’s ultimately what’s happening when you’re reworking a whole payment model) it’s that you have to make it meaningful for providers for what you are asking them to do. In some cases, when it will be tied to what patients need to do when they leave the office. You have to make the incentives (for providers) meaningful enough so that the providers will invest in communications and new resources for follow-up and population health. We’ve always said that that people should do these things on their own, that providers should do these things anyway, but now that patients and providers are both being held more accountable, I think we’ll see that we’re in the very, very early stage of pay for performance and ACOs. We’ll really need to put our money where our mouths are in terms of how much we need to spend for different decisions and behaviors.

LK: So do you see the economics working out? Do we have enough to spend on rewards to change behaviors and reduce costs and then still come out on top and make overall savings and quality? Is it that easy?

MD: Yes, if we can help providers get over the initial investments in population health tools, then aligning the dollars will make sense.  Once providers have those things in place, once they go through the, “I’m an ACO. What are the real foundational assets I need to invest in and have in place?” so they maybe need to get their EMR wired to population health management tools and medication protocols. They’ll need to get those kinds of assets in place and then wrap the incentives around them, then we can make the economics work. Health plans and employers in many ways have already gone through that, they’re deploying more and mores assets every day around different conditions and risk factors. If providers can do that, then the math will work fine.

LK: Is that something Welltok is doing? Who’s going to provide these services and help them see that the math works, that it’s worth the investment, as it really is a whole new business model?

MD: When you look at what we’re doing at Welltok with a health optimization platform, we’re organizing all those assets into one place. We do that for health plans today and more and more for providers. Right now health plans have a lot of assets in place and we’re helping them to organize them and optimize the assets. Providers, a lot of times, are even less versed in that and so I think a lot of providers will get their assets from their health plan partners. Aetna’s accountable care services businesses say, here’s what we’ve learned, we’ll provide those assets to the provider groups to help optimize. Then once those assets are aligned for the provider, they can get aligned for the consumer and you have that complete alignment. There’s still things that need to flesh out on the ACO side, but hopefully we can help them do that so they can focus on the behaviors that need to happen before, during and after they are in the doctor’s office.

LK: I can’t have this conversation without asking about the Apple Watch and what it might mean to the behavior and health incentive business. I wrote a few weeks ago about how it seems they are really going to be able to tie location, behavior, messaging, purchasing and payment and activity into a pretty unique, comprehensive package. Do you see them as a threat, an opportunity, how might this play out?

MD: I think any time you give the consumer a way to organize all the ways they are interacting with the health care system, that’s terrific, and hard to do. I think I mentioned last time we talked that we were the first investment of the IBM Watson Portfolio. And now IBM Watson and Apple have struck a deal to work on some of their health care initiatives together. What Apple brings to the table is a lot of things, a trusted brand and certainly a great consumer experience. And what everyone is fighting for in health care is a great consumer experience. So I think there’s great alignment for Apple to start to bring together a lot of assets that could make up a great consumer experience in health care.

The caveat to that of course is that, if you look at Health Vault and some other attempts to do this in health care, there’s a lot of complexity compared to other arenas, with privacy and HIPAA and protected health information. All that has to be wrapped together.

But at the end of the day, if you look at what Apple has done, what Wal-Mart has done (Wal-mart has $110 million people in it’s health rewards program), they’re not just rewarding for shopping at Wal-Mart, they’re rewarding for using Fitbit and all sorts of other health behaviors

For orbs like that that have a brand that’s somewhat trusted (unlike health plans), there’s a massive opportunity.

LK: And it seemed like Microsoft and Google were maybe a little early, because the technology transparency wasn’t there and it wasn’t automated—consumers still had to manage and even enter that data. Then there’s the whole trust issue, as you say, is it a trusted entity (unlike health plans)?

MD: Yes, and it’s heavier lifting to bring together claims data and all these other kinds of data, even more so than the financial services industry’s transactional data (even though that’s complex).

So if you look at IBM’s and Apple’s relationship with us, it’s the realization that it’s difficult stuff to pull all these complexities together. Our leadership now at Welltok, as you know, is the former leadership from Trizetto, which was heavy-duty claims and administration. IBM brings that gravitas. To your point, Microsoft may have been early. The idea was good, getting all this info in one place, but maybe there was a lack of understanding this complexity as well.

It’s a very exciting time to see all this power in the hands of consumer, which is what everyone is seeing as the right way to go.

LK: Is your work with Watson about learning what works for consumers?

MD: What’s really interesting about our partnership with Watson is being able to take all this unstructured data from a consumer’s life and bring it back to them in a way, with tasks and reward and opportunities, to help them make healthier choices. That could be location services, marrying that with health information to make recommendations. So when you get off of a plane, Watson can recommend a gym and where to eat lunch. To bring together all that unstructured data, and present it in a way that’s meaningful, that really has the opportunity to be groundbreaking.

November-6-2014

10:45

One day, we are going to work. Mid-day, we start to feel sick. We go to the doctor’s office. We are evaluated and given a pill to get better.

Sounds like a normal story, right?

Typically, we take medication and we get better. However, what happens when we don’t comply with the doctor’s instructions or if the symptoms get worse?

We know the drug’s side effects are listed on literature included with most medications. For those medications that are taking in conjunction, a doctor and/or pharmacist will let us know what we can expect; however, what do we do about the side effects that may not be known to us and purposely hidden?

I recently watched a documentary called “The Dark Side of a Pill,” and it certainly shines light on a perspective that is not normally seen. (The entire video is embedded at the end of this post) The video showed that a certain percentage of people who took anti-depressants showed suicidal or homicidal behavior within the first set of days. While we know that there are medications that have extreme side effects, what might not have been expected was the drug manufacturer hid that information in order to keep afloat or to make a profit.

There are certain regulations in which a pharmaceutical drug must pass before being released into the market. Sometimes, one or two drugs can cause a company to make its big financial break, and this was no exception. During the approval process for Prozac in Germany, Germany rejected the anti-depressant drug because it was more harmful than beneficial. When FDA approval was sought, a different version of the documents was submitted. Upon their own investigation, the FDA found questionable results and inquired about the reasoning behind Germany’s rejection, but the company, Eli Lilly, had stated that they answered all questions posed to them and had not heard from Germany in over 10 months with doubts or questions.

Prozac was later approved by the FDA for release in the U.S. Since then, Prozac and other anti-depressant drugs have been released and have been in use by the global market for over 15 years. A statement released by Eli Lilly showed that by their research, this drug has helped many users, and they strive to meet the evolving FDA criteria. During the same time period, many patients, doctors, and healthcare providers questioned the efficacy of the drug. As a result, at a later date, warnings were placed with the anti-depressants to provide awareness of suicidal thoughts and behavior.

Not surprisingly, there is more to this story than meets the eye.

This story is not about assigning blame to a company or to prove if a drug is effective. The Dark Side of a Pill shows a domino cause-and-effect scenario from the producer to the patient, where miscommunication resulted – and may continue to result – in patients engaging in non-typical behavior, such as murder or suicide.

Ranbaxy, an Indian drug company, has dealt with multiple scandals in which the company falsified data to win FDA approvals for another set of generic drugs. The company failed to meet the FDA standards and continued to make inaccurate statements. In this particular case, the company distributed bad drugs that resulted in patients not getting better or even killing themselves.

Over the years, we read and hear about select pharmaceutical companies failing to meet regulations or committing some type of wrongdoing, but these particular scenarios are particularly alarming. They are alarming because it indicates that there is a percentage of people who may get substantially worse, and in ways that were unexpected, rather than better. They are alarming because it interferes with the oath that healthcare providers abide by, the Hippocratic Oath. If a patient asks for information about a specific drug, doctors and pharmacists should be able to provide any recommendations and instructions based on what is expected in the drugs, and they should be able to rely on the pharmaceutical companies, who manufacture the drugs, to help them perform their duty with the highest level of care. The trust gets broken in these relationships within all groups – patients, providers, pharmaceutical companies, and government entities, and this is all in the name of profit. Any type of business should show integrity, authenticity, and responsibility in their practice, whether it is dispensing drugs or providing a service, and trust is an indispensable part of the foundation. Once it is broken, it is almost too difficult to restore. These two cases put a fear into a person on whether the drugs we are purchasing will actually be beneficial or detrimental. It can make us doubt the experts, those who we have entrusted to help us get better, and as an end note, that is depressing indeed.

If the video fails to load, you can view it here: https://www.linktv.org/programs/the-dark-side-of-a-pill

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