Failure to Translate: Why Have Evidence-Based EHR Interventions Not Generalized?

Failure to Translate: Why Have Evidence-Based EHR Interventions Not Generalized?

The adoption of electronic health records (EHRs) has increased substantially in hospitals and clinician offices in large part due to the “meaningful use” program of the Health Information Technology for Clinical and Economic Health (HITECH) Act. The motivation for increasing EHR use in the HITECH Act was supported by evidence-based interventions for known significant problems in healthcare.

In spite of widespread adoption, EHRs have become a significant burden to physicians in terms of time and dissatisfaction with practice. This raises a question as to why EHR interventions have been difficult to generalize across the health care system, despite evidence that they contribute to addressing major challenges in health care.

Problems Motivating Use

EHR interventions address known problems in health care of patient safety, quality of care, cost, and accessibility of information. These problems were identified a decade or two ago but still persist. Patient safety problems due to medical errors were brought to light with the publication of the Institute of Medicine report, To Err is Human, with recent analyses indicating medical errors are still a problem and may be underestimated. Deficiencies in the quality of medical care delivered was identified about a decade and a half ago and continues to be a problem. The excess cost of care in the US has been a persistent challenge and continues to the present. A final problem motivating the use of EHRs has been access to patient information that is known to exist but is inaccessible, with access stymied more recently by “information blocking”.

Evidence Base

These problems motivated initial research on the value of EHRs. One early study found that display of charges during order entry resulted in a 12.7% decrease in total charges and 0.9 days shorter length of stay. Another study found that computerized provider order entry (CPOE) led to nonintercepted serious medication errors decreasing by 55%, from 10.7 events per 1000 patient-days to 4.86 events, with preventable ADEs reduced by 17%. Additional studies of CPOE showed a reduction in redundant laboratory tests and improved prescribing behavior of equally efficacious but less costly medications. Another analysis found that CPOE increased the use of important “corollary orders” by 25%. Additional studies followed from many institutions that were collated in systematic reviews published first in 2006 and then updated in 2009, 2011, and 2014 that built the evidence-based case for EHRs. There were some caveats about the evidence base, such as publication bias and the benefits mostly emanating from “health IT leader” institutions that made investments both in EHRs and the personnel and leadership to use them successfully.

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Bob Wachter’s 2017 Penn Med Commencement Address “Go to Radiology”

Bob Wachter’s 2017 Penn Med Commencement Address “Go to Radiology”


Dean Jameson, Trustees, Faculty, Family and Friends, and most of all, Graduates of the Class of 2017:

Standing before you on this wonderful day, seeing all the proud parents and significant others, I can’t help but think about my father. My dad didn’t go to college; he joined the Air Force right after high school, then entered the family business, which manufactured women’s clothing. He did reasonably well, and my folks ended up moving to a New York City suburb, where I grew up.

There were a lot of professionals in the neighborhood, but my dad admired the doctors the most. He was even a little envious of them. This became obvious on weekend evenings when he’d get dressed to go out to a neighborhood party. He’d look perfectly fine – slacks, collared shirt, maybe a sweater. But there was one thing out of place: he’d be wearing our garage door opener on his belt. “Dad, what exactly are you doing?” I would ask, somewhat mortified.

“There’ll be lots of doctors at the party tonight,” he’d reply. “They all have beepers, I have nothing.” The strangest part was when the party was next door, the garage door would sometimes go up and down, as dad showed off his “beeper.”

You can just imagine how proud my dad was when I was accepted to Penn Med and chose to come to this special place.

When I was a second year med student, evidence was emerging in the literature that an aspirin a day might prevent heart attacks. I told my dad he should start taking one. A few months after starting the aspirin, my mother called to tell me my father was in the E.R., having passed out on his way to work. He was bleeding into his stomach.

I was overcome with guilt, certain that my baby aspirin had caused the GI bleed. I rushed home to be there for his endoscopy. The gastroenterologist attached a teaching scope, so I got to watch my dad’s procedure. “I’m sure we’ll see an ulcer or gastritis,” he told me reassuringly. He was wrong.

My 51-year-old father had gastric cancer. It had already spread to a lymph node, which dropped his chances of cure to 5-10 percent. In fact, it probably was my aspirin that caused the cancer to bleed. After a massive operation, my father quit his job, got his affairs in order, and hoped.

One of his hopes was that he’d live to attend my Penn Med graduation three years later. He did, and I recall his pride, a pride that all of you are feeling today as you reflect on your loved one’s accomplishment.
By the way, my dad turned 87 last month.

The experience taught me many things. How terrifying illness is for patients and family members. How doctors aren’t necessarily too great at prognosticating. And how important human-to-human contact is in medicine – not just between doctors and patients, but also among members of the care team. That’s what I want to talk to you about today.

When I started my ward rotations at HUP, it became clear that the central hub of the hospital was not the mahogany-paneled C-suite, or the glittering O.R. of the most famous transplant surgeon. Rather, it was in the dimly lit chest reading room in the radiology department on the ground floor of the Dulles Building.

You see, there lived Dr. Wallace T. Miller, chief of chest radiology and the kind of teacher that you remember vividly 35 years later. Every day, each clinical team – medical, surgical, ICU – cycled through Wally Miller’s chest room like cars going through a car wash. Sure, they were coming to look at their films – perhaps later, some of the elders can explain to the young folks what films were. But mostly, they were coming to See the Oracle.

I was a third-year student, and my team had admitted an elderly man with a fever and cough. Wally pulled up the film, and I began my little speech. “This is a 78-year-old man with a week of fever and productive cough,” I said. “What do you think?” asked Dr. Miller, pointing to an upper lobe infiltrate. “Pneumonia,” I answered feebly. “Mwaaaaa,” he said, an unforgettable sound that was both endearing and terrifying. “Look at this,” he said, pointing to a subtle area of cavitation. “It’s tuberculosis.”

Two decades ago, the field of radiology went digital. This was no less of a magic trick than podcasts, Amazon, or GPS. You could now see images anywhere – on the wards, in the clinic, even at home. The films, the contraptions called alternators on which they were hung, the cluttered film library… they all left the building, literally overnight.

Sadly, just as abruptly, radiology rounds ended. Nobody said that they should, nobody predicted that they would. They just did. Now that you didn’t need to schlepp down to radiology to see your films, people simply stopped going.

And with that, an important medical ritual died. Not only did we lose the collegial exchange and the learning – learning that enriched both the front-line clinicians and the radiologists – but we all lost the opportunity to slow down for a few minutes and to think deeply about each case. Instead, we briefly glanced at the image on a computer screen (or sometimes didn’t even do that), read the radiologist’s report, and continued on our sprint to get through rounds and polish off our checklists.

Your careers are launching at the start of a period of massive transformation in healthcare. When you entered college, medicine was an industry whose information backbones were the piece of paper, the three-ring binder, the post-it note, and the fax machine. Now it is the electronic medical record.

History has shown that, while information technology ultimately reshapes every industry it touches, it doesn’t immediately deliver on its promised improvements in quality and productivity. This lag is known as the Productivity Paradox of I.T. You see, humans aren’t quite imaginative enough to appreciate the opportunities or to understand the changes inherent in going digital… until they’ve actually gone digital. So they get it wrong. As it happens, this is an age-old problem in technology: Henry Ford was reputed to have said, “If I’d asked people what they wanted, they would have said, ‘faster horses.’” They had no ability to imagine their world with cars until there were cars.

During the past few years, we’ve witnessed our own maddening version of the Productivity Paradox. Doctors and patients no longer looking at each other, both feeling alienated and more than a little pissed. Residents hunched, dead-eyed, over their computers. The numbers tell the story: from the E.R. doctor’s 4,000 clicks a day; to the 2.5 million alarms – virtually all of them false – that go off in my hospital’s ICUs each month; to skyrocketing rates of physician burnout. There are a number of culprits, but high on the list are digital tools that are poorly designed, often unhelpful, and sometimes even dangerous.

You’ll be glad to know that the history of the Productivity Paradox offers room for hope. We’ve learned from other industries that it takes about a decade after widespread digitization for the massive potential of IT to be realized. In healthcare, of course, it’ll take longer – we’re complicated, there are boatloads of regulations, and the Silicon Valley mantra of “failing fast” isn’t terribly appealing when failing can mean a dead patient.

But IT will eventually deliver on its promise in healthcare.

There are two messages I want to leave you with regarding this transformation.

The first is that you will be the ones to figure out how to make this work. Believe me, we’re counting on it! It turns out that the key to overcoming the Productivity Paradox is that people need to reimagine the work. It’s smart young people like you who are best positioned to do that.

They ask – you’ve probably already asked this yourself – Why is the doctor’s note a flat digital document, accessed by clicking on a tab? Because that’s what the note looked like when it sat in a three-ring binder. And so, when we ditched the paper, we just digitized the same old note. And young people say, “That’s absurd. Haven’t you ever seen a Facebook wall? Or a Twitter feed? How about a collaboratively created note, a la Wikipedia? Why isn’t there audio or video?”

Reimagining the work doesn’t mean that you need to learn Java Script, move to Menlo Park, and begin hitting up VCs to fund your start-up. It does mean that you are constantly on the lookout for ways to improve the systems you work in. This involves some skills, yes, but much more importantly a mindset – one that says that the great doctor is no longer just a smart diagnostician or a talented proceduralist. He or she is also a great leader, an improver of systems, a relentless re-imaginer. Having graduated from this extraordinary school, everyone will be looking to you for leadership and inspiration. I know you’ll deliver.

My second message to you is just as important. As the work becomes digitized and the software gets better, we will spend more of our time interacting with our digital tools, and less interacting with each other, and with our patients. This is natural, and – assuming the tools are any good – it might even be OK. After all, computers will hold much of the information, and they will be where we develop and implement many of our diagnostic and treatment plans.

But, there is a huge danger from hunkering down in our digital caves.

You can never fully understand a consultant’s thinking by reading her note. You can never place a complex radiology finding in context without speaking to the radiologist. You can never allay the anxiety of a sick patient’s spouse by sending a text message. And you can never comfort a dying patient without sitting at the bedside and holding his hand.

In his magnificent commencement address at Kenyon College in 2005, the late author David Foster Wallace began with the classic parable about the two young fish swimming along. An older fish briefly joins them and asks, “How’s the water?” A bit later, one of the younger fish turns to the other and asks, “What the hell is water?”

Wallace ends his speech – the only commencement address he ever delivered – by talking about the real value of an education: “[It] has nothing to do with grades or degrees,” he said, “and everything to do with simple awareness – awareness of what is so real and essential, so hidden in plain sight all around us, that we have to keep reminding ourselves over and over: ‘This is water…. This is water.’”

Our digital tools offer us breathtaking capabilities, and we have to use them to our fullest. But it is the people who are real – our patients, our colleagues, our teachers, our students. They are what matters. They are our water.

So take full advantage of the magic of technology, and figure out how to make it work. And then go to radiology. Talk to your colleagues. Be with your patients. You’ll be a far better doctor. And you’ll be happier.

Several years ago, our UCSF department chair at the time was leading a faculty meeting. He was ticking off the massive changes in the world of medicine: new payment models, new technologies, new regulations, new pressures to improve value. I could see many of the faculty, particularly the older ones, squirming in their chairs. A few were mentally tallying the value of their Roth IRAs to see when they’d be ready for retirement.

One of our senior cardiologists, an amazing clinician-teacher but most decidedly of the old school phenotype, got up to speak. He was usually quiet in these meetings, so all of us perked up.

“You know,” he began, “this could be worse.”

This was surprising, coming from him. But then he continued.

“I could be younger,” he said.

You, my young colleagues, should listen to such lamentations with sympathy – after all, change is hard – and humor. And then you should emphatically reject them.

We have the opportunity today to do more for our patients than ever before. And you have the knowledge, skills, values, and habits of mind to thrive in this changing world. You are the ones who will reinvent the work to deliver for our patients. And you will figure out how to balance our new digital capabilities with the enduring truth that medicine is, and must remain, the most human of professions.

Thank you for the honor of speaking to you today. Congratulations to each and every one of you.


Universal Coverage Means Less Care and More Money

Universal Coverage Means Less Care and More Money

The reported success of the Affordable Care Act (ACA or ObamaCare) is based on enrollment numbers. Millions more have “coverage.” Similarly, the predicted disasters from repeal have to do with loss of coverage. Tens of thousands of deaths will allegedly follow. Activists urge shipping repeal victims’ ashes to Congress—possibly illegal and certainly disrespectful of the loved one’s remains, which will end up in a trash dump.

Where are the statistics about the number of heart operations done on babies born with birth defects, the latest poster children? How about the number of babies saved by this surgery, and the number allowed to die without an attempt at surgery—before and after ACA? I haven’t seen them. Note that an insurance plan doesn’t do the operation. A doctor does. The insurer can, however, try to block it.

Also missing are figures on the number of courses of cancer chemotherapy given, or not given, or the time from diagnosis to death in cancer patients before and after ACA. Five-year survival of cancer patients in the U.S. is generally better than in countries that have universal coverage, or the type of plan progressives want to import. Again, the insurance plan isn’t medicine. You can get medicine without insurance, and if you have insurance it might refuse to pay.

There are selected comparisons of change in mortality rates in states that did or did not expand Medicaid (such as New York vs. Pennsylvania). On the other hand, mortality did not decrease in one state (Oregon). These estimates—guesstimates really, are based on the weakest type of data, and the differences may have nothing to do with Medicaid. Maybe it was better AIDS treatments. We hope that the FDA does not use evidence this poor to evaluate drugs.

But what effect did ObamaCare have on overall U.S. mortality?

Between 2014 and 2015, U.S. mortality rates increased for the first time in decades. This primarily affected less-educated whites. Is ObamaCare the cause? There are many factors involved, drug abuse probably being the most important. But I suspect that if repeal had happened in 2012 or 2013, it would have been blamed.

We hear many complaints about medical bankruptcies. These happen because patients got their treatment, and then got a bill. Often the bills are outrageous, and hospitals may be ruthless in collection efforts. That is a serious problem, but it is not caused by lack of universal coverage. And remember, bankruptcy is a way out of debt. Creditors take a haircut. In contrast to medical debts, student loans cannot be discharged by bankruptcy but follow a person for life.

Medicaid expansion may have alleviated fears of medical bankruptcy, but we don’t know that more patients got treatment. In single-payer Canada, there is no fear of a medical bill. But there might not be any treatment either.

We do know that after Medicaid expansion “nonprofit” hospitals are banking windfall profits, while charity is essentially gone. In Oregon, Medicaid enrollment increased from 626,000 in 2013 to 1,056,000 in 2016. Providence Health & Services now has the biggest pile of cash reserves of local companies—$5.8 billion vs. $3 billion for Nike. Hospitals are using the cash to buy new assets, not to lower prices or improve quality. They pay their executives like a Fortune 500 company.

The experts advocating for universal care know very well that resources are limited, and that spending (“costs”) must be contained. They also understand that the burgeoning bureaucracy and its minions and retainers must be well paid. So the answer is to cut services. Some plans “incentivize” doctors to make more money by skimping on care. Others call for a “global budget”—the deliberate creation of scarcity. When the money is gone, treatment is canceled. There will be fewer beds, fewer CT scanners, fewer drugs, and fewer doctors. But all will be fair. No rationing by price, just by waiting lines, political pull—and death. There will be no medical bills to pay after a service, if you get any service. Only taxes in advance, service or no service.

That’s why the universal care advocates count enrollees, not the number of services, and constantly harp on “excessive” treatment, even while planning to make patients wait months for an appointment.

Jane Orient, MD is Executive Director of the Association of American Physicians and Surgeons (AAPS) since 1989. She is currently president of Doctors for Disaster Preparedness. Since 1988, she has been chairman of the Public Health Committee of the Pima County (Arizona) Medical Society.

Lessons From the 100 Nation Ransomware Attack

Lessons From the 100 Nation Ransomware Attack

The world is reeling from the massive ransomware attack on at least a hundred nations’ computer systems. The unprecedented malware spasm infected hundreds of thousands of computers, and would have infected millions more but for a 22-year old computer science student who found a vulnerability in the malware that he used to curtail the infection. He found it looked for a non-existent URL, so he a set up that URL and found he could stop it spreading. Of course, now the hackers know that, it is an easy matter to update the malware to use other URLs and other techniques. Clearly, this iconic malware attack is not going to be the last.


What do we know about the malware? The NSA (the US National Security Agency) found that there was a vulnerability in some of Microsoft’s operating systems. The NSA was itself hacked, and ransomware was developed that exploited the vulnerability. This ransomware was then distributed on the black market. The original flaw is called “EternalBlue” and it was converted into the now notorious ransomware program called “WannaCry.” It is important to note that no special skills are required to actually use ransomware: WannaCry is just a tool a criminal buys in the hope of causing chaos or making money or gaining fame.

The NSA has an interesting problem. It discovers a backdoor that may help it fight terrorism, so it makes sense to keep it secret. In hindsight, once the flaw is known to hackers it is quickly exploited, and the rest of the world is unprepared for the consequences. In any case, Microsoft, on March 17, 2017, issued patches for the vulnerabilities for its currently supported software, which most people use on a day to day basis.
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The Mysterious Case of the HHS Secretary, the Reporter and the Pre-Existing Condition

The Mysterious Case of the HHS Secretary, the Reporter and the Pre-Existing Condition

Did you realize that the American Health Care Act (AHCA) recently passed by the Congressional Republican majority will allow insurers to deny coverage for mental illness? Did you realize that the AHCA permits insurers to charge women more than men because they get pregnant? That the AHCA will allow insurers to terminate a family’s coverage if they incur claims that exceed their annual premium for three straight years? That at the urging of Attorney General Jeff Sessions, a group of Republican lawmakers in the Senate has proposed language that would make medical marijuana a pre-existing condition? And that the same group of lawmakers is mulling a requirement that would grant immigration officials sweeping new powers to review records of patients suspected of committing crimes or posing as a loosely-defined “threat to community health.”


Hey, I just made that up. But we have a lot of that going on right now.

Case in point. Journalist Daniel Heyman was arrested after shouting questions repeatedly at HHS Secretary Tom Price. He was charged with disruption of government processes, a misdemeanor, and was released on $5,000 bail. Based on just those facts, that sounds outrageous. Predictably, the story has gone viral with shrieks of gestapo tactics and outraged indignation by the Fourth Estate.

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New Checks and Balances For Big Pharma

New Checks and Balances For Big Pharma

“Pigs get fat, but hogs get slaughtered,” the saying goes. And so may it prove to be true for the pharmaceutical industry.

Three articles, all published recently, illustrate the greed and egregious pricing by certain drug companies that are gaining public recognition and scrutiny.

Marathon Pharmaceuticals LLC serves as a case in point. Over the last 15 years, its chairman and CEO Jeffrey Aronin generated a billion-dollar valuation for the company. As reported in a Wall Street Journal article, “Drug Price Revolt Prods a Pioneer to Cash Out,” he achieved this milestone not by inventing new drugs but, rather, by buying the rights to old ones, then raising the prices excessively with disregard for patients’ ability to pay.

As an example, Marathon invested $370,000 to obtain the license for the data on “deflazacort,” a steroid available for about $1,200 a year in the United Kingdom. This medication is prescribed to treat muscular dystrophy, a condition that predominantly affects young boys. The company then secured FDA approval, renamed the drug “Emflaza,” and sold it to patients in the U.S. for $89,000 a year. Through the approach it used, Marathon invested only minimal dollars, avoided having to complete late-stage clinical trials, and was never required to compare its efficacy against other, relatively inexpensive generic alternatives.


Outrage from parents of children with muscular dystrophy, combined with harsh criticism from several U.S. senators, forced Marathon to recognize that it had painted itself into a corner. The only exit at hand was to sell the rights to the drug to another company—for $140 million plus 20% of future sales and the potential for a $50 million payment. As a result of negative publicity, Marathon’s valuation has dropped significantly, and the company’s future is uncertain.

How Big Pharma Became So Big

Of all sectors in healthcare, the most profitable is pharmaceuticals. They now account for nearly as much cost as hospitals, and prices continue to rise at a rate two to three times faster than overall medical inflation. As a result, according to the U.S. Bureau of Labor Statistics, prices for U.S.-made pharmaceuticals have climbed over the past decade six times as fast as the cost of goods and services overall.

The pharmaceutical industry is generating large profits for both its shareholders and its CEOs. Increasingly, drug companies have figured out ways to bring to market a variety of drugs with minimal to no investment in clinical research, and almost no risk. To protect its high margins, the industry spends freely on direct-to-patient advertising, as well as on promotion to doctors and campaign contributions to elected officials. And despite growing recognition of the problem and the consequences to the cost of healthcare in the U.S. from excess drug costs, little has happened legislatively to curb these abuses.

The public is learning how these practices translate into extremely high salaries and perks for drug company CEOs. As an example, last year Mylan was lambasted for increasing the cost of its EpiPen product by 550%. The drug is epinephrine, a naturally occurring protein, and is therefore not able to be patented. But the injection device that the parent or child uses to administer the drug, even though it was developed by a NASA engineer decades ago, could be and was patent protected. As reported in a Wall Street Journal article, “Big Pay Day for Mylan Chairman,” the company’s chairman received $97 million for his efforts. His golden parachute also included stock and a $1.8 million annual retainer.

Can Business As Usual Be Nearing An End?

The Marathon and Mylan stories represent the types of abuses of the patent system that have become standard. The approaches employed by these two companies are similar to what dozens of other pharmaceutical firms have done—namely, use the current patent laws to drive up prices for their medications, all without having to invest major dollars in R&D.

What is new, however, is the realization that states with federal approval might be able to upend these egregious practices and bring about a solution. And if that can happen for government-sponsored programs like Medicaid, maybe legislation could be passed to allow this approach to be used more broadly on behalf of all patients, thus slowing this dangerous, runaway train.

The State Of Louisiana As Potential Bellwether

According to a Washington Post article, “Louisiana Seeks to Tap Century-Old Patent Law to Cut Hepatitis C Drug Prices,” the state currently faces $764 million in costs for new, direct-acting antiviral medications that treat hepatitis C. This infectious disease is a major public health hazard, and Louisiana has an obligation to provide the required treatment for its Medicaid recipients. The companies that manufacture the drugs to treat this medical problem, have figured out they can raise prices exorbitantly with relative impunity—in this case close to $100,000 for a three-month course of treatment per patient.

Louisiana has a big problem. The state’s entire healthcare budget, funded through its legislature, is only $3.6 billion. If it has to pay more than three-quarters of a billion dollars for this one drug, it would need to appropriate 20% more than today to provide the medication to a relatively small number of its citizens. And to do so, the dollars would have to come out of those currently being spent on schools, public services and infrastructure programs.

As a result, Louisiana is considering invoking a law, passed in 1910, that allows federal regulators to appropriate the right to inventions and use products in the interest of the public good. This statute would apply to the treatment of hepatitis C, whose eradication would be a major health advance for the people of Louisiana and the economic health of the state. The federal government used this provision in the 1960s to good effect in order to procure 50 medications it needed during a time of war at a reasonable price. And the U.S. Army Corps of Engineers, among other government agencies, has applied this same provision as a means to serve the nation’s best interests.

For Louisiana to move forward on behalf of its Medicaid patients, it would require approval from the Secretary of the U.S. Department of Health and Human Services. Such approval would be highly significant as a warning to Big Pharma. It would counterbalance the monopolistic pricing afforded drug companies, and begin to put the needs of patients and public health first. As Peter Bach, director of health policy at Memorial Sloan Kettering Cancer Center, told the Washington Post, “This is exactly the moment and exactly the kind of scenario for doing so.” Extending this practice through new legislation could ultimately benefit the majority of people with private insurance in the country.

Protecting The Underdog

The role of government is to protect the health of all the people of the nation, and to act for the common good. It’s expected that the government will use its legislative power in pursuit of this end. Patent protection, on the other hand, is a privilege. It’s accorded companies like drug manufacturers to promote investment in R&D and to encourage the development of medications to treat life-threatening conditions. It was never meant to enable companies to raise prices with impunity for life-threatening conditions. If drug companies take the risks and allocate large R&D dollars, then it makes sense to let them earn a profit commensurate with their investments. But to permit them simply to buy the rights to well-established drugs and then use patent laws to protect themselves as they crank up prices 500 to 5,000%, that’s simply wrong.

If the pending Louisiana “purchase” prevails, it could restore the balance needed between the people of the state and the drug companies that manufacture these essential medications. Companies would still be entitled to earn reasonable and fair profits, and be rewarded for taking risks on expensive investments in R&D. But they would no longer be able to game the system, and as a result, make healthcare unaffordable for patients.

The American people should be rooting for the underdog—in this case, Louisiana and its citizens. Maybe if this approach works, it can be extended more broadly, and the excesses of the past 15 years can be brought to an end. Patients would be able to afford the medications they require, and the families of children with life-threatening allergies, muscular dystrophy and other major diseases would know they would be able to receive the essential medicines they need, now and in the future. It’s a small step toward addressing the current abuses, but at least it would represent progress.

Dr. Robert Pearl is the CEO of The Permanente Medical Group, a certified plastic and reconstructive surgeon, and Stanford University professor. Follow him on Twitter: @RobertPearlMD.

Design for Health Award Submission EXTENDED! Submit by Friday, May 19th at 11:59PM EST.

Design for Health Award Submission EXTENDED! Submit by Friday, May 19th at 11:59PM EST.
We know improving health through design doesn’t happen overnight, so we decided to extend the submission date for the HxRefactored Design For Health Awards to Friday, May 19th at 11:59PM EST. Now you have one extra week to show us your best service design, digital product, website, process improvement, health communication, data visualization, physical environment, or mind-blowing new thing. Whichever way you’re improving the experience of health, we want to see it.


The Design for Health awards launched three years ago, and since then, some really amazing projects have contributed to the health experience. We can hardly wait to see what you’ve been working on this year!
All award winners will be announced at the HxR Awards Ceremony at HxRefactored June 21st. we’ll see you there!

Apply Today!

Jill Merrigan is the Marketing Manager of Health 2.0.

Would the World End if We Eliminated the Deductible?

Would the World End if We Eliminated the Deductible?

While Congress ponders a true fix for the Affordable Care Act (ACA), consider this about health coverage.

Problem #1, Can’t Use It: Healthy people, or people who don’t make a lot of money, sign up for the cheapest health insurance policy available. It gives them catastrophic coverage, protecting their family and home in the event of a big-time medical condition. But it also makes them mad. They pay a monthly fee for health insurance they can’t use until a large deductible is satisfied. For example, a person might pay $300 a month but have a $7,000 deductible. Do the math. That’s well over $10,000 before that person gets to use what they are paying for every month.

Problem #2, January Comes Too soon: Health is not an annual event. Maybe you go all year and suddenly need a bunch of medical help in December. The deductible hasn’t been reached so you pay the bill “out of pocket.” Nasty, because in January you still need medical care for the same thing, yet the deductible goes back to square one. Not nice. This makes more people mad. Solution for Problem #1 and Problem #2: eliminate all annual deductibles and replace with co-pays.

Problem #3, We Need To Build a Wall: Even by eliminating deductibles there are people who are required to pay more than they can afford. Fixing or replacing the ACA needs to build a wall of protection that limits the total amount—a percentage of income—paid by individuals or families in a calendar year—a guarantee that includes the cost of prescription drugs.

Imagining a Doctor Shortage

Imagining a Doctor Shortage

Now, I’m just a country doctor, but I have to say I find it very hard to understand why folks in this country on one hand keep talking about a doctor shortage in primary care and on the other hand keep piling sillywork on those of us who are still here. The net effect is that the doctor shortage is going to be a whole lot worse than it has to be.

But it may just be a relative or imaginary shortage because of how this country defines the duties of doctors.

Public Health agendas have infiltrated health care to a degree that threatens to paralyze it. Physicians are increasingly told their primary concern should be their “population” and not their individual patients. We are charged with preventing disease rather than treat it.


Public Health clinics regularly provide travelers with necessary immunizations. Pharmacists are now giving pneumonia and shingles shots on prescription and flu shots without. States are mandating immunizations for children, and penalizing physician practices with low immunization rates. There are whole departments within every level of Government trying to get people tho behave in healthier ways.

Why should we take the heat for something you don’t need a medical license to do?


A physician’s duty is first and foremost to serve each patient’s needs in treating actual disease. Isn’t that what people worry about when they imagine how a physician shortage would affect them?

Let’s think:

Who would worry that with a physician shortage, they wouldn’t get their flu shot?

Who would worry that there would be nobody to tell them to lose weight, stop smoking and eat less junk food?

Who would worry that there would be nobody to screen them for alcohol misuse or domestic abuse?

Who would worry that they’d be at risk for tripping on their scatter rug because there is no doctor to talk with them about their fall risk?

On the other hand:

You’ve had a cough for a month, and you’re short of breath. Who will diagnose your symptoms?

You have a nosebleed that won’t stop by itself. Who will cauterize it for you?

You have diabetes and can’t control your blood sugar with diet alone. Who will prescribe the right medicine for you?

You’ve become increasingly depressed and are at risk of losing your job because of your symptoms. Your therapist suggests you consider medication. Who will prescribe it for you?

America, the choice is yours: What is the best use of your primary care physicians’ time if there aren’t enough of us to be everything for everyone?

How Is This Medical Bill Possible?

How Is This Medical Bill Possible?

Two recent hospital admissions and the medical record dictation records events, visits, and documentation of physical examinations that did not occur.

Hospital stay 1 was for asthmatic bronchitis.  Thru the ED I was admitted to a FP, who consulted a Pulmonary doc.  The Pulmonary did H & P and all of the treatment and exams during stay, and did a great job.

The FP spent about 2 minutes total during the stay.  He did no exam ever, yet billed Medicare for multiple visits, exams and did discharge note, including physical that was never done.

Is this the new way if generating income by false documentation and upcoding?


Hospital stay #2 was admission for removal of benign meningioma.  Early morning admission, visit with surgeon about 2 hours after surgery and no further doc visits that day.  Medical record documents extensive note from critical care team, including physical exam of me that never occurred.

Day 2 was noteworthy for increasing headache from 6 level to 7, then 8, then 9.  Complaints of severe headache and severe nasal congestion finally discovered by my own research of side effects of Kepra, started without any discussion with me.  Multiple complaints to nurses 3 times finally resulted in doc visit after he went to lunch.  Significant change in Med’s and Ct scan resulted in decrease in pain after 4 to 5 hours.  I had demanded d/c of Kepra prior to this.  At about 1 PM there is documentation in medical record of another critical care team visit with NP and MD supervisor noting another non-existent physical exam stating patient in no distress.

On contact with hospital they continue to assert that the exams did occur as documented.

Contacted IG of Medicare with no response.

Multiple letters and phone calls to hospital.

Is this new and accepted practice to compensate for low reimbursement levels?  Anything further to do or am I beating my head against the wall?