Tuesday, April 27, 2010

The Transformation

"Everything changes." "We start dying the moment we're born." "The only constant in life is change." "The more things change, the more they stay the same."

All very trite, but mostly all very true. The changes that become more evident to me daily involve the gentle paradigm shift in medicine. An institution that once held the health of its constituents as its utmost goal, now looking more at profitability than personal responsibility.
It started out insidiously. In the early 70's and into the 80's the quiet voices began to whisper to physicians. "You're here to practice medicine, but you're also a business." "You should be fairly compensated for the work you do." As in any industry, there have always been those who practiced medicine "for the money," but it wasn't until the slow rise of the for-profit hospital and the night in shining armor, the HMO, that things took a system-wide turn away from people and toward dollar signs. While campaigning for the managed care paradigm, a gatekeeper model where a primary care physician would coordinate care and refer to the specialists that were also owned by the HMO, hospitals and large multi-specialty groups began to recruit patients, touting a one-stop shop, a strategy clearly effective at turning a profit, ala Walmart. A good idea in theory, but in practice, the overwhelming number of patients in the system caused long wait times, and accusations of monopolizing and self-referral flew like mad.
I'll be honest. I don't have concrete data to back this up, and there's no specific person, place or time that you can pinpoint as the tipping point. There's simply a slow paradigm shift toward money-centric medicine.

There's nothing wrong with appropriate compensation. I do, however, take issue with abusing new technology as a way to make more money. Don't get me wrong, businesses incur great expense purchasing and innovating new technology. Once it's paid for, though, prices should summarily begin an inexorable decrease. Take the PC industry. Please... (sorry, it just sounded funny in my head, so it stays). Manufacturing processes (equating to, say a CT scanner in this analogy) are discovered to create a hard drive. That process is refined and perfected at great cost, which is transmitted to the initial consumer, the early adopters, but over time the process becomes so well refined and frequently used that income far surpasses production costs and even pays for the R&D.
If we assume that a CT scanner represents that manufacturing process, in this analogy, as the process is perfected, costs decrease exponentially, especially with frequent use. While the cost for your average CT has dropped significantly over the years, it still far surpasses the costs incurred by the hospital for staffing and power, especially after it's paid for.

You'll have to trust me on the math, and this is definitely an oversimplification, but if the average CT Scanner costs 3.5 million dollars, that means only 1000 scans at $3500 each would pay for the machine. There were ~7 million scans performed in the US in 2007 alone. Assuming a hospital large enough to have a scanner does at least a thousand a year, that means the machine could theoretically be paid off in one year. But wait, you object. What about the radiologist and the technician and the energy cost? Won't that put the cost much higher? Calculating average costs for reading fees and tech salaries and power costs (and assuming a random but educated yearly number for insurance on the machine) the numbers may be surprising, just not to me. You need only do an extra 25 CT scans a year to cover those extra costs. So after 1 year of $3500 scans, totaling just 1025 scans, the machine is paid for. Ongoing costs amount to a mere 100 scans per year thereafter to pay the radiologist and the incidentals. The rest keeps the hospital administration and the janitor paid. This is all an average, an educated guess, but it points to a fundamental problem with healthcare and hospital systems... like all other businesses, they're run by people, and people run businesses to make money.

This isn't bad, just problematic. I'm not against a free-market economy, as long as the flow of information is free, as well. Publish the cost. Let people make informed decisions and shop around if they so desire. Don't assume that because you *can* do something, you should. The system isn't broken because we charge $1800-3500 for an average CT scan. It's broken because free market value is no longer determined by the market...

To Be Concluded...

-- Post From My iPad

Thursday, April 22, 2010

Quick Interlude

Sorry it's been so long since the last post.  A lot of moonlighting and reading have occurred since then, all of which has inspired a new series on healthcare as it stands and a glimpse of how I intend to do my part to change it.  Along the way, I'll elucidate how technology is making a lot of what I see as real change possible. All in all, think of the previous post as a quick history lesson, bringing things to their current state.  The next two will focus more on where we are now and more importantly, where we're going.

Here's to your health!

From Managed Care to Miscommunication (Part I)

The current healthcare system, while the subject of much debate, evolved out of several smaller pieces of legislation.  Like the glacier, this movement toward an insurance-based economy moved slowly but inexorably toward prominence, thanks in large part to a number of legislative efforts aimed at giving the consumer of healthcare protection from perceived exorbitant costs.
The real problem arose when we stopped regulating the companies that swooped in to protect the "little guy."
According to Wikipedia (that great bastion of knowledge):
The McCarran–Ferguson Act, 15 U.S.C. §§ 1011-1015, is a United States federal law that exempts the business of insurance from most federal regulation, including federal anti-trust laws to a limited extent. The McCarran–Ferguson Act was passed by Congress in 1945 after the Supreme Court ruled in United States v. South-Eastern Underwriters Association that the federal government could regulate insurance companies under the authority of the Commerce Clause in the U.S. Constitution.
In essence, this Act gave insurance companies a free pass, avoiding common regulatory practices enforced on large corporations. No anti-trust laws.  No federal oversight. States have ultimate control, though even this is debatable. Whether you agree with the practice of federal involvement or not, there exists little doubt that, unwatched, most corporations minimize expenditures and maximize profits by whatever means necessary.  This is evidenced by the practices of the insurance industry that most proponents of the curent reform bill reference: closed purchasing within a state, denials for pre-existing conditions, dropping patients who are "really sick." 
These problems are simply symptoms of a broken system and a broken economy, both the result of misguided consumerism and economic profiteering.  Breaking it down simply, in the current system people buy insurance because they fear getting sick and having high medical bills.  Insurance premiums are paid to the company supported by their employer (a sketchy proposition at best, which I'll discuss in a minute) and the patient offsets some of the cost personally (current figures approximate 85% employer/15% employee).  IF the consumer gets sick, THEN the insurance agrees to cover a portion of the medical bills, often only after a certain amount ("the deductible") has been paid by the consumer. In other words, you pay money to avoid paying money, then have to pay more money before the money you already paid is given back to you with a modicum of interest. 
In some cases, specifically conditions requiring long hospital stays or significantly expensive treatments or for patients who require frequent treatment, this process pays off.  For most, however, the entire process is simply a demonstration of how poorly people as a whole calculate risk.  Without going into too many details about pooled risk and actuarial calculations, the average consumer with private insurance rarely meets their deductible, but still pays, on average family plans with no deductible a premium of $12686 each year, while plans with an annual deductible of $10,000 had an average premium of $5380 each year (per the report Individual Health Insurance 2009: A Comprehensive Survey of Premiums,Availability, and Benefits). So in essence, you, as a private insurance consumer, pay at least $5000 a year, then another $10000 if you get sick, to prevent paying for long stay or frequent hospitalization. Unfortunately, few people actually stay longer than 2-3 days in a hospital setting.
Current consumer healthcare system based on large companies providing pooled risk insurance charge large sums to both you and your employer, and prior to the health care reform bill, could simply drop you for any significant illness.  They could also refuse to cover any medical condition you had prior to receiving their insurance.  Legally.

Tuesday, April 6, 2010

Pleasantly Surprised

I type this sitting on the couch in the call room at the hospital. On my new iPad...
For the last few weeks I've been saying that I wouldn't buy the first iteration of the iPad. I'd wait until they worked out all the kinks. There's not even a front-facing camera!
Then I held this amazing piece of technology in my hands, and the quiet realization that this was a new quantum state in computing. There's something familiar about the platform, even with its amazing innovations in small areas. Yes, the iPad looks like nothing more than a giant iPod touch. It's not. Scale matters.
Don't misunderstand. This isn't perfect. There are things I wish were different or better, but all in all, this is a new way to compute.

The design, while a little heavy, puts controls and inputs in easily accessed places. As I sit here, I'm typing with my right thumb, index and ring fingers while holding the iPad in my left (watch an old episode of Star Trek:TNG to get a visual...). It doesn't fatigue my hands, and I can type relatively fast. Taking advantage of the auto-complete feature increases the speed and accuracy.

When it come to apps, I'm not as app happy as I am with the iPhone. There aren't nearly the number of $.99 or $1.00 apps. This serves the dual purpose of limiting the app store to relatively useful apps for which people would be likely to pay more and making me more conscious of my app spending. A nice combination, free of Fart apps.

Several of the apps, like the iWorks trio, are well worth the added cost and I already completed a presentation (which I gave today) entirely on the iPad. Lying in bed typing, dragging photos, shifting slides, editing text styles. I can see where this will become my primary business device, even it's current iteration. While there are obvious changes (which will hopefully be announced on Thursday) that could make things easier and better, I can easily type papers, e-mails, create presentations, browse web references and hopefully textbooks. The device disappears, becoming merely a vector or a platform and allowing the software to really shine.

This is where my greatest expectations lie. Software could make this device awesome, instead of just amazing. The app store is a mere fraction of that for the iPhone, but already some amazing apps have surfaced. With the hardware now available for testing and tweaking, they should only continue to get better. Things like the Netflix app and the app Jump, which allows for remote desktop control, do a great job already. I'm already salivating while waiting for the ePocrates drug app and their recently announced EMR app.

All in all, this is an amazing device with a few bugs and a whole lot of potential.

//sidebar ramble
I ended up visiting the local Best Buy on Saturday to play with a demo iPad. I figured that there wouldn't be any stock left, and I could handle a demo model and leave. They had four demos, and after handling one for 10 minutes, I was not only impressed but sold that the potential for this device was huge. Then the guy next to me asked if there were any left. Apparently, this store got 15 or so of each model, and while the 15 GB was sold out, most of the 32 and 64 were left.
The rest, as they say, is history.
///end ramble

-- Post From My iPad

Location:Spring St,Greenwood,United States

Thursday, April 1, 2010

Geeking Out Over the iPad Revolution!

So, I didn't pre-order an iPad. I won't be standing in line in Augusta to get one. I do, however, agree with the camp that see this new offering from Apple as a whole new way of looking at HIS in medicine and more specifically, Primary Care.

As a family doc, there's nothing more precious than time (see my post on First-Order Retrievability below). With the advent of the Cellular Age and the movement of our business society first to Palm's original Pilot device, then to the "Crackberry" and now the Android and iPhone platforms, the speed at which we conduct business, and everyday life as an extension, became astronomically high. Gone are the days of the answering service/machine and the "While you were out..." pink memo pads. If we desire, we can be connected to anyone and everyone, nearly 24/7.

There's also something to be said for "always on" social media, like text messages, blogs, Facebook and Twitter. These services, though not secure, can be used to transmit small packets of information to and from multiple sources very efficiently.

That trend hasn't caught on widely in medicine, though there are a growing number of physicians that are recognizing the power of continuous access and "multimedia medicine" and applying it to the "Cellular Generation." Por ejemplo, there exist a burgeoning number of physicians who are now offering e-mail as an alternative in addition to phone triage. A simple, rapid way to present the signs and symptoms of illness obvious to the patient and allow the physician to assess the need for an E.R. visit versus a clinic visit at your leisure. Beyond being two-way asynchronous communication, it's also readily available thanks to our smartphones and PDAs.

Some physicians even go so far as to "see" patients, and more commonly consults from other physicians, by video chat! A novel idea, but with the increase in broadband service, an idea whose time has finally come. Video allows physicians to visualize the patient (potentially in 3-D) and speak in real-time. Still images can also be used for rapid triage, if the clarity and pixel densities are high enough. Audio of a child's cough could even be used to triage "croup" vs a run-of-the-mill viral upper respiratory infection. Microsoft even markets a still camera that records everything you do, all day long...

Add to that the decreasing price for storage, and what emerges is something that some may dream of and others fear. A medical record that contains all of the above (video, audio, stills), as well as audiovisual representations of the entire office visit. Why not? We spend hours a day (especially in primary care) "charting" as we call it. Writing out descriptions that often inadequately represent the symptoms and physical signs they represent. Don't get me started on eponyms. Instead, this new record could be a more complete, more accurate representation of a patient's medical history. Something that would be infinitely more useful for future generations of physicians than a handful of old paper that may or may not have accurate descriptors, often colored by perception.

All that to say, the iPad makes this more convenient. While this generation of the device has no camera, you can bet your Aunt Fanny the next one will. It does have a mic and the ability to view video. You can pull up streaming video from any webcam using multiple services and you can utilize any of the above social networking tools as well. I've even toyed with the idea of a text message server that could take messages from linked cell phones and deposit them directly into an EMR record for that patient. Near real-time monitoring of a patient's data like blood pressure or glucose. This would be easily accessed on the iPad.

Moreover, as a 6-year owner/user of tablet computers, this form factor isn't as bad as many of the technorati make it out to be. We are tactile creatures by nature and the user interface of the iPhone is popular for a reason. To be able to use nothing more than a finger to make selections is very familiar to even a one year old.

Without having an iPad on hand, I can't vouch for the completeness of these claims, but if the reviews hitting last night and today are any indication, we may just be entering that "brave new world."