Hospital Care at Home: Disruptive Innovation

Research over the past 15 years has explored the concept of providing a large amount of what is currently hospital based care in the home setting. This has been validated in numerous studies showing cost savings from 30 to 50%. The history of the concept and validation is below.

1995 Dr. John Burton, of Johns Hopkins School of Medicine, and Dr. Donna Regenstreif of The John A Hartford Foundation conceived a new program to provide safe and effective hospital-level care in the home. A geriatric study team led by Dr. Bruce Leff developed medical eligibility criteria and the basic clinical model and designed the study and measurement methodology.

1996-1998 A 17-patient pilot trial showed the Hospital at Home® was feasible, safe, and cost effective.

2000-2002 A National Demonstration and Evaluation Study tested Hospital at Home® in three Medicare managed care organizations and one Veterans Affairs medical center. Hospital at Home® met disease-specific quality standards at rates similar to the acute hospital. The average patient length of stay was shorter, and overall costs were a third lower than an inpatient stay. Patients also had a lower chance of developing delirium, requiring sedatives, or needing chemical restraints. In addition, both patients and family members were more satisfied with care compared to those treated in the hospital, and family member stress was lower. Patients also regained their ability to do usual tasks more quickly.

2002-Present Hospital at Home® is in practice or is being developed at numerous sites throughout the country, including:

• Presbyterian Health Services, Albuquerque, NM

• Centura Health Systems, Colorado Springs, CO

• Cedars Sinai Medical Center, Los Angeles, CA

• Veterans Affairs Medical Center, Boise, ID

• Veterans Affairs Medical Center, Honolulu, HI

• Veterans Affairs Medical Center, New Orleans, LA

• Veterans Affairs Medical Center, Philadelphia, PA

• Veterans Affairs Medical Center, Portland, OR

• Veterans Affairs Medical Center,Cincinnati, OH

2010 A public/private partnership tested a modified model of Hospital at Home®, in which home-based care is provided by nurses, with physician consult via biometrically enhanced two-way telemedicine-video. The new model is also managed by a physician group, instead of a hospital.

2014  Mount Sinai Medical Center, New York, is awarded an Innovation Challenge Grant from the Center for Medicare and Medicaid Innovation (CMMI) at the Center for Medicare and Medicaid Services (CMS) to develop HaH in a fee-for-service Medicare setting and to develop data to inform the future development of a 30-day bundled payment for HaH care.

Using evolving technologies over the past decade, makes the case for hospital care at home even more compelling. The ability to reduce costs 30 to 50% over performing the same services as an inpatient could radically alter the delivery of healthcare. Telemedicine and the technologies for active monitoring of patients has dramatically changed. The ability to monitor blood pressure, heart rate, oxygen saturation, temperature respiratory rate and weight is quite easy. Video communication also allows direct oversight and monitoring of the patient.

The literature dates back to some original work at Johns Hopkins where they termed the process hospital at home care. Annals of Internal Medicine recently published studying the work at partners healthcare at Faulkner Hospital how effective and reasonable this change in healthcare delivery can be. Abstract of the article is below

Ann Intern Med 2019 Dec 17
Patients receiving hospital-level care at home had lower healthcare costs and fewer readmissions than did similar inpatients.

Providing hospital-level acute care for select patients at their homes — hospital-at-home (HaH) — has not been studied in randomized, controlled trials. Investigators at Boston's Brigham and Women's Hospital and Faulkner Hospital (a smaller community hospital in the same healthcare system) randomized 91 emergency department (ED) patients slated for non–intensive care unit hospital admission to receive either traditional inpatient hospital care or acute care at home, which included daily nurse and physician visits, intravenous medications, point-of-care testing, remote monitoring, and video communication. Patients at high risk for clinical deterioration based on validated algorithms were excluded. Approximately 80% of included patients were admitted for infections, heart failure, or chronic obstructive pulmonary disease or asthma exacerbations.

Patients cared for in HaH spent significantly less of their care time sedentary (12% vs. 23%) or lying down (32% vs. 66%), used significantly fewer healthcare resources (e.g., lab orders, radiologic studies, specialty consultations); and were significantly less likely to require readmissions within 30 days (7% vs. 23%). Adjusted cost of HaH — and HaH plus 30-day post–acute care — was about two thirds the cost of traditional hospital care and remained significantly lower even when physician labor costs were incorporated. Length of stay, patient quality and safety measures, and patient satisfaction were similar between the two groups. No HaH patients were transferred back to an acute care hospital.

There is a long list of advantages of hospital care at home and many diagnoses which are amenable to Treatment at home. Bruce Leff, MD one of the founding proponents of this novel approach has stated

“ the admission eligibility criteria and protocols that physicians and other caregivers use to ensure care is standardized and safe include approximately 100 diagnostic-related groups (DRGs). Among them are asthma exacerbation, early sepsis, seizure disorders, and gastrointestinal conditions or diseases. Its founders believe that with the expanded list of DRGs, the model has the potential to vastly increase the number of patients treated at home and deliver care at half of traditional hospital costs. The larger savings ensue from eliminating physician house calls. You really start to leverage economies of scale when you have a doctor who is covering a hospital at home program across wide swathes of geography,"

Some of the easiest diagnosis to care for include Conditions with defined treatment protocols, such as congestive heart failure (CHF),

• chronic obstructive pulmonary disease (COPD),

• community-acquired pneumonia,

• asthma and

• cellulitis

• seizures

• deep venous thrombosis

Real-time interaction and visits including obtaining diagnostic lab test and even imaging studies can be performed relatively easily using mobile technology. Additional advantages include the comfort of the patient who buy most patient centered measures would strongly prefer to be in a home setting. In addition reducing the large number of iatrogenic errors in hospital settings is desirable. Medicare attempts to eliminate hospital acquired conditions such as infection, falls, skin breakdown. Home based care will be dramatically reduce these complications.

For-profit entities have entered the marketplace to provide just this type of service and there have been explorations of this type of healthcare delivery across the world including research done In Australia

The data actually further supports improved both patient satisfaction and outcome and the return on investment is substantial for those willing to transition to this model of delivery. The current expenditures out of the Healthcare budget include 30 to 40% spent on hospital based care and savings of up to half $1 trillion could be achieved. With relative facility certain health systems within the United States of actively explored this model of care including the icon school of medicine at Mount Sinai and under alternative payment models this type of care would be highly advantageous A joint venture between Marshfield Health system in Wisconsin and Contessa health in Nashville has also explored this type of alternate delivery system. The three-year study at Mount Sinai demonstrated many benefits

• Shorter length of stay (3.2 days vs. 5.5 days

• Lower rates of hospital readmissions (8.6% vs. 15.6%)

• Lower rates of emergency department visits (5.8% vs. 11.7%)

• Fewer transfers to skilled nursing facilities (1.7% vs. 10.4%)

• More likely to rate their medical care highly (67.8% vs. 45.6%)

Operationalizing the program is quite straightforward and can be instituted at both an outpatient setting or emergency room. Patients are identified based on diagnosis and strict eligibility criteria. They have their services coordinated with daily clinical visits through nursing, advanced clinical providers or physicians and are provided with monitoring needed for their particular clinical condition Evidence-based clinical care pathways and illness specific care maps and evaluations are used to establish when hospital care at home can be discontinued. Creating the network of mobile or virtual services is easy and can include oxygen, intravenous fluids and medications such as antibiotics, respiratory services and skilled nursing services (PT, OT etc) are all coordinated in the program Even the use of advanced diagnostic imaging such as CT US or MRI can be arranged through transport to an imaging center.

A task list to assess eligibility and care management typically includes the following:

• An emergency department or community physician identifies a patient who is sick enough to be hospitalized but stable enough to be treated at home. Narrowly defined eligibility criteria help distinguish patients who need intensive services and/or multiple visits from specialists—and therefore should be treated in hospital settings—from those whose needs may be met at home by visiting physicians, nurses, and other clinical staff. Conditions with defined treatment protocols, such as congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), community-acquired pneumonia, and cellulitis, are a natural fit.

• The suitability of the home is assessed to confirm it has air conditioning, heat, and running water.

• Responsibility for care is assigned to a physician.

• A greeter meets the patient in the emergency department or elsewhere to discuss the program, arrange transportation, and deliver the biometric and communication devices that will be needed to oversee care.

• A caregiver meets the patient at home and a physician—either in person or via video—explains the treatment protocol. Orders are written and clinical staff, including respiratory therapists, physical therapists, and other caregivers arrive as needed to administer intravenous medications and fluids, provide nebulizer treatments, and conduct tests, including ultrasounds, X-rays, and electrocardiograms. Meals are arranged if necessary. The patient's vital signs are monitored electronically.

• The physician visits the patient daily, or in some models, communicates with the patient via telemedicine equipment. To capture any decline in the patient's condition when clinicians are off site, providers monitor patient using telemedicine equipment.

• Once the patient is stabilized and well enough to return to activities of daily living, he or she is handed off to his or her primary care physician. In one model, providers maintain oversight of the patient for at least 30 days, to ensure he or she is keeping appointments and is not suffering any adverse consequences. During this period, the physician provides updates to the patient's primary care physician. 

Creating direct pathways to the patient’s primary care physician oversight and or other dedicated hospitalist equivalent services is straightforward. This setting creates much less stress for the patient and satisfaction surveys uniformly show that it is well received. While those representing the hospital industry may oppose these changes, the higher quality safer more efficient care with better outcomes and satisfaction will prevail especially when adopted by self insured employers.

The late Clayton Christensen espoused the need for disruptive innovation to alter an industry. We see it here and now. Some have pointed to technology as the ultimate solution but the combination of high tech (telemedicine), evidence based protocols, seamless integration and patient centered care all through hospital care at home is very exciting.

For further information see references below or

Please email me at nargy@nicolasargy.com

References:

https://www.commonwealthfund.org/publications/newsletter-article/hospital-home-programs-improve-outcomes-lower-costs-face-resistance

http://www.hospitalathome.org/

https://www.johnshopkinssolutions.com/employers/

https://www.fhi.no/en/publ/2018/Hospital-at-home-as-an-alternative-to-hospital-treatment-Systematic-reference-list/

Copyright NicolasArgy 2020

The Flu: When NOT going to the doctor is a good idea

Patients are frequently faced with the problem of when or if to go see their physician when they develop simple symptoms of flu cough, fever, muscle ache sore throat. The below list covers the most common symptoms.

• Fever above 100 F (38 C), though not everyone with the flu has a fever

• A cough or sore throat

• A runny or stuffy nose

• Headache

• Muscle aches

• Chills

• Fatigue

• Nausea, vomiting or diarrhea (most common in children)

The overlap of flu symptoms and simple viral upper respiratory infection are broad and can be difficult to differentiate.

SYMPTOMS

While there are a host of symptoms that point to the need for further evaluation including persistent fevers which are high, symptoms which last for a long period of time, shortness of breath as well as many others, A phone call to your doctor who can access your risk is best, prior to driving to an ED, outpatient urgicenter or scheduling to see your physician..
Much of the assessment of the need to see a physician includes determining your underlying health, chronic health conditions, age and past medical history

RISKS FACTORS

• Are younger than 12 months of age

• Are 65 years old or older

• Are pregnant or have given birth in the past two weeks

• Have certain chronic medical conditions, including lung diseases such as asthma, an airway abnormality, heart disease, diabetes, neurological or neurodevelopmental disease, and kidney, liver or blood disease

• Have a weakened immune system due to factors such as long-term use of steroids or other immunosuppressants, HIV, organ transplant, blood cancer, or cancer being treated with chemotherapy

• Have a body mass index (BMI) of 40 or greater

• Live in a long-term care facility such as a nursing home

Going to a crowded waiting room filled with other patients who may have the flu actually may increase your chances of either spreading your condition or contracting the flu from one of those near you. If your waiting room doesn’t distribute masks to those who are actively coughing or sick please ask them to do so and if you are ill you should wear one as well.

My physician frequently screens patients over the phone and treats empirically but another alternative is telemedicine which can allow physicians using technology to listen to heart and lungs and look in your throat

Depending on technology available some telemedicine can include checking of blood pressure and oxygen saturation
Since many of the antiviral drugs used to treat the flu are not effective after two days of the start of symptoms significant intervention to limit symptoms or shorten the disease is not available for most.

The flu typically kills 20,000 to 60,000 people a year in the United States.
The vast majority of these are the elderly or very young and many have comorbid conditions which leave them with little reserve
Consulting with your physician and using telemedicine may be a much better alternative than the knee-jerk reaction to rush to see a caregiver at the earliest symptoms

Being cognizant of the risks of going to your doctor for a self-limited illness is important

Early phone consultation with your doctors office can make you a better and safer consumer

Please remember vaccination especially for those at high risk is the best strategy… prevention rocks!

Copyright NicolasArgy 2020

Distracted Driving: Public Health Crisis

Almost 1000 Americans are injured every day due to distracted driving, yet only 20 states have prohibited handheld cell phone use in the car. Numerous organizations are working diligently to decrease the occurrence of injuries associated with distracted driving but very little progress has been made in decreasing injuries or the use of cell phones while driving.

Over 80% of individuals agreed that no one should engage in distracted driving yet almost 40% of them admit to doing it themselves.  There is a cognitive disconnect between the danger versus the convenience of texting or using a cellphone while driving and most people incorrectly believe they can multitask safely.

Distracted driving has become a public health crisis and almost 4000 people a year die due to distracted driving.  This number has increased steadily in the past 10 years.  As usual changing human behavior is exceptionally difficult and simple education is one of the poorest means to effectuate long-term sustained changes in human behavior. Simple written warnings are most often equally ineffective in achieving the goal of decreasing distracted driving. Some estimates range as high as 20 people daily being killed by distracted driving and tragically the injuries and deaths disproportionately involve youth with teens being the largest age group suffering harm.

While legislating behavior is one means to change behavior, rigorous enforcement is needed to maximize the effectiveness.  While these facts are not disputed by the mass majority of stakeholders, effective intervention is wanting. What is left for our society to do?

Action Items

1.      Passing and enforce legislation nationwide on both a federal and state level which prohibits and penalizes distracted driving. In addition strict enforcement of these prohibition including by remote camera surveillance and ticketing, as is done for speeding which has proved effective, can be initiated.

2.      Educating both youth in school and adults using public service announcement and other media campaigns should be encouraged. Education must not only provide narrative information but also use neurocognitively proven educational techniques to imprint the importance of the message.

3.      Lastly and probably most effectively using technology.  Everyone is aware that many GPS devices cannot be utilized when the car is moving.  Simple software installed on phones would eliminate dramatically the harms associated with distracted driving.  Once a car is in motion the phone could be disabled from interaction.  GPS function of the phone could be maintained but with disabled keyboard and phone/text function would be useful. 

The unfortunate growth of cell phone use during driving creates a dangerous situation, putting both driver and the public at large at risk. Simple interventions and most importantly using technologic solutions are likely to reduce the harms that have been growing out of control.

Copyright NicolasArgy 2020

TOP TEN OF THE DECADE Medical articles

Below please find the top ten articles of the decade as published by JAMA

These articles have been selected by our editors as the most important published by JAMA between 2010 and 2019. Click below to read them for free.

The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)Mervyn Singer, MD, FRCP; Clifford S. Deutschman, MD, MS; Christopher Warren Seymour, MD, MSc; et alManu

2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8)Paul A. James, MD; Suzanne Oparil, MD; Barry L. Carter, PharmD; et al

Antibiotic Therapy vs Appendectomy for Treatment of Uncomplicated Acute Appendicitis: The APPAC Randomized Clinical TrialPaulina Salminen, MD, PhD; Hannu Paajanen, MD, PhD; Tero Rautio, MD, PhD; et al

Intensive vs Standard Blood Pressure Control and Cardiovascular Disease Outcomes in Adults Aged ≥75 Years: A Randomized Clinical TrialJeff D. Williamson, MD, MHS; Mark A. Supiano, MD; William B. Applegate, MD, MPH; et al for the SPRINT Research Group

Development and Validation of a Deep Learning Algorithm for Detection of Diabetic Retinopathy in Retinal Fundus PhotographsVarun Gulshan, PhD; Lily Peng, MD, PhD; Marc Coram, PhD; et alMachine Learning Website

United States Health Care Reform: Progress to Date and Next StepsBarack Obama, JD

Health Care Spending in the United States and Other High-Income CountriesIrene Papanicolas, PhD; Liana R. Woskie, MSc; Ashish K. Jha, MD, MPH

The Association Between Income and Life Expectancy in the United States, 2001-2014Raj Chetty, PhD; Michael Stepner, BA; Sarah Abraham, BA; et al

JAMA Health Disparities Website

Eliminating Waste in US Health CareDonald M. Berwick, MD, MPP; Andrew D. Hackbarth, MPhil

Silencing the Science on Gun ResearchArthur L. Kellermann, MD, MPH; Frederick P. Rivara, MD, MPH

IS HEALTHCARE BURNOUT UNIQUE... NO

Burn out appears to be a major focus of the healthcare industry especially with regard to physicians.

Is this a real new problem in healthcare delivery or merely a manifestation of an ongoing broader issue within our society? While traditionally physicians have had very high job satisfaction, they have now become like the remainder of the population with approximately 50% of workers being discontent and burned out in their positions

Certainly there are a myriad of factors contributing to burn out in healthcare delivery.

1 The electronic medical record
2 Much higher rate of employed physicians
3 High pressure to place revenue generation over good patient care
4 Corporatization of the delivery of healthcare
5 Technology mandates and reporting requirements that mire the caregivers in bureaucracy

Two major themes have emerged in the discussions of burn out
A Resiliency
B Systems remedies

Invoking resiliency as a solution, is a means to place blame on the victim and should be rejected de novo. The concept that individuals need to take personal responsibility for system-wide failures in the day-to-day operations of healthcare delivery is absurd
While many individuals in all forms of employment may have inordinate stress in their personal lives as well as their professional lives it is incumbent upon the employer in workplace environment to provide a healthy nurturing understanding culture of safety as well as just culture. The ongoing pattern of allowing hostile work environment’s, bullying, discrimination, sexism have dramatically exacerbated the underlying problem of burn out in many industries.

Systems solutions are long overdue and employers should be held accountable for the work environment which are a primary source of frustration tension depression and potentially compromising good quality care. Myriad avenues exist for all of us to address system based deficiencies including reaching out to colleagues, human resources and leadership/management to address poor work environment

Beyond that individuals have the ability to work with colleagues to bring joy and fulfillment to their professional and personal lives by focusing on those things that they find meaningful
Mindfulness, meditation and living in the moment are also great techniques for stress reduction.

Burn out is neither new nor novel but has now become equally difficult within the healthcare environment
Greater social problems with stress related to finances, technology mandates, the isolation of interpersonal interaction and even bigger issues such as income disparity and the polarization of our society with high levels of acrimony both in a political and social sense being manifest constantly.

Here is an opportunity to reach out to workplaces, colleagues and neighbors to change this toxic environment

The time is here to make a difference.

Copyright nicolas argy 2019

The ice bucket challenge, Throwing axes And patient safety

We live in a world where the latest rage or viral sensation dominate our perception of the world. With the recent passing of Peter Frates, the legacy he has created and the tens of millions of dollars he has raised for ALS cannot be forgotten. Concomitantly the latest rage for bars and recreation including ax throwing befuddles and entertains

So how do we use these two examples of capturing the fascination of our cyber public with the importance of patient safety and medical errors. We need a vehicle which will go viral which will create a unity of purpose for both the public and the healthcare industry to reprioritize patient safety and medical errors. The third leading cause of death in the United States is medical errors. Every 90 seconds another patient dies due to a medical error. Why is this not on the front page? Why has this topic not generated outrage and comprehensive action to correct ?

We live in a world where the deferential attitude to medical care and western technology acts as a serious impediment to recognizing the extent and nature of medical errors and iatrogenic harm. We shatter our mortality and confidence in healthcare and destroy “therapeutic illusion” when we acknowledge our vulnerablity to errors. The time has come to find the vehicle by which we raise the profile of safety quality and medical errors

We need the next ice bucket challenge. We need to capture the public frenzy of ax throwing so that we hit the bull’s-eye of minimizing medical errors and patient harm. Patient education research and facts don’t have the impact. Nothing has changed in the 20 years since the report “To Err is Human” was promulgated

Working for a new target, a new vehicle, a new focus, a viral message can save lives and enhance healthcare delivery. It’s time to make a difference

Copyright Nicolas Argy 2019

"Zero Tolerance for Surgical Bullies"

In June of 2019 JAMA Surgery published results of a study linking reports of unprofessional conduct by surgeons with higher complication rates for patients. This article parallels the literature of less efficient, less happy and poorer care with poor communication and poor culture of safety.

http://bit.ly/2EOx2Ox

It likely comes as no surprise that unprofessional conduct including creating a hostile work environment, poor interpersonal skills and inappropriate behavior and communication likely affects those same interactions with patients. The exact etiology for increased complications is not defined but the plethora of likely causes for this association is easy to envision.

With the increasing importance of team based care, culture of safety and just culture, it is predictable that alienating professional colleagues would compromise communication and cooperative care which is crucial to safe care. Once again it is critical for unprofessional conduct to be reported and corrected. Without accountability and consequences, inappropriate conduct will not be eliminated. Remediation and education should be a primary avenue to address unprofessional conduct but when ineffective, punitive measures must be instituted.

Speak up, do not tolerate unprofessional conduct and make a difference in patient care and the work environment.

“Zero tolerance for bullies” needs to move into the healthcare setting

Make a difference.

Copyright Nicolas Argy 2019

HIGH VOLUME IN SURGERY MEANS BETTER CARE

Minimum volume standards

What you don't know can kill you

In 2015 three major academic medical centers made a pledge to impose minimum volume standards that would eliminate hospitals with low volumes from performing certain high risk procedures. This was done in order to enhance quality and reduce both morbidity and mortality associated with these high risk procedures

This pledge was not uniformally endorsed and was criticized by many as self-serving

The fact that minimum required numbers of procedures as a mandate for credentialing has been well-established for years and those who perform procedures especially more complex ones more frequently have better outcomes has been well-established for years. Minimum numbers of procedures for cardiology, stroke centers, and myriad other procedures are routinely required for both certification and reimbursement but not for other major procedures like cancer surgery. Frankly even simple procedures when done in greater volume often have the best outcomes. Take for instance hernai repair center in Canada, Shouldice Hospital. It comes as no surprise that Congressman Rand Paul traveled out of the country for his surgery.

GREED TRUMPS SAFETY

It seems intuitive that institutions would only perform procedures which they can do at the highest level of competence but tragically this is not the case. Many of these procedures generate large amounts of revenue for hospitals which they are reluctant to forgo. They rarely reveal these facts to the patients and the lack of informed consent about their higher complication rate is likely both a violation of informed consent and immoral. The horrific story of St Marys Medical center in Florida made national headlines with triple the death rate for pediatric cardiac surgery which continued (all the time getting paid) until the press excoriated the institution.

More lawsuits should be brought against institutions that continue to perform surgeries which they cannot justify based on low volume. My experience on committees for safety and quality identified institutions performing procedures with disproportionately high complication rates. The most telling was one where open bariatric surgery was performed and patients were not even aware that the procedure can be performed much more safely laparoscopically. The untold suffering and unnecessary deaths that resulted remain uncounted and unrecognized.

The arguments against maintaining volume pledges and minimum required procedures to maintain competency are exceptionally weak. Staying local for the convenience of friends and relatives is trumped by the reduced complication rates and deaths at high volume centers.

It is important that patients specifically query their physicians with regard to the volume of procedures they perform and their complication rates. In this way an informed and engaged patient can be their best advocate Further, soliciting a second opinion from another clinician can only enhance your knowledge and care.

A recent article in JAMA surgery once again highlights the disproportionate outcomes for discretionary high-risk cancer surgery when performed at low volume centers. This is unconscionable. This practice should not be allowed to be continued.

In the accompanying invited commentary points out the fact that low volume centers are allowed in other countries where there is centralization of complex surgery by law and enforced by healthcare financing. This approach should be adopted in the United States. The term "Lyft therapy" is used in the invited commentary, meaning that a simple car ride to a more experienced center will have a much more salutary effect than any other intervention including chemotherapy or radiation.

The marketplace has failed us when institutions put profit over patient safety. We should follow the lead of other countries which prohibit low volume institutions from billing for procedures. The time for intervention through legislation and regulation is now.

copyright nicolasargy 2019

PRIVACY NO MORE

Has privacy become a thing of the past?

With video cameras monitoring our every move and face recognition software becoming ubiquitous, we have now become completely transparent in our identity and presence in the public setting

The traditional measure of whether our privacy should be protected under the constitution

“Having a reasonable expectation of privacy”

Has become a thing of the past. We need a new standard… mandating privacy within a certain context and create statutory requirements to achieve this goal.

In the past the government has tried to protect privacy especially with regard to healthcare information (HIPAA) by having specific requirements for de identifying data which is published

Unfortunately these techniques have become ineffective. Large data bases of information can re-identify even anonymized data. JAMA recently reported an AI algorithm able to reidentify anonymized data.

The new paradigm shift that we must all acknowledge is that essentially nothing we do short of isolating ourselves completely from the Internet, credit cards and all other forms of social media will protect our data. Your cell phone with myriad apps tracks your location, surfing purchases banking and email. Natural language processing algorithms can unravel the meaning of your emails

Recent comments that giving out your phone number reveals a plethora of data regarding who you are and what you do belies the fact that your name and address provide virtually the same amount of information

YOU CANNOT HIDE

No longer are fossil fuels our greatest resource in terms of financial value. It is our data. Especially when used to market us products which we are known to need or find useful. The most immoral use of personal privacy data is identifying certain predilections and weaknesses such as vulnerability to gambling addiction. Using this information social gaming companies take advantage and target advertising for games which can lead to financial ruin for individuals

The future may hold the use of similar type of data to target those susceptible to addiction to nicotine, alcohol or other substances which are legal

Europe has taken a more proactive approach to protecting privacy but the technology seems to thwart most efforts

We need a new redoubling of efforts to ensure privacy or at least recognize that everything we do is essentially discoverable and therefore act appropriately within that context

Copyright nicolas argy 2019

BATS, RABIES and PRACTICAL ADVICE

Today I received a phone call from a close friend who said that a bat had flown into her home and asked what her risks were? She wasn't sure if the bat had rabies and or what the risk to her was. After googling the event she told me that that bat saliva exposed to mucous membranes ( eyes mouth nose) could transmit rabies

She went on to say that sometimes bites are occult and are not recognized by the victim and so there is a theoretical chance of transmitting rabies.

Lets drill down on real risks and prudent course of action. Bats are well known to carry rabies

Most sources advise opening doors and windows and leaving the bat a clear path outside the house without any direct contact. Clearly that is prudent

A local epidemiologist in the state communicated that an exposure while awake without direct contact is not considered significant and did not warrant any further intervention or vaccination. The reality is that in the past 10 years only 23 cases of rabies have been reported in the nation and of those eight were contracted outside the United States

That means the likelihood of transmission of disease is essentially zero

For those of you with excessive concern, you should give up driving your car or going out in the rain since you are far more likely to die in a car crash or being struck by lightning then contracting rabies

It certainly makes sense to contact your local animal control officer and state department of public health for current advice but for the most part a bat in the belfry is not an issue for serious concern

Public health advice needs to be based on realistic risks and informed decisions

copyright nicolas argy 2019

Primary Care Model- Is it time to Tweak?? YES!

The primary care model needs to be tailored to provide efficient, high quality care . Under the most common applications in the market it does neither.  

Medical information doubles every 12 to 18 months.  Primary care doctors have the herculean task of keeping up in every field which is impossible.  Specialists have only their discipline within which to stay current. The more fundamental question is whether every patient needs to be seen by a board certified generalist or specialist on first presentation.

Well known facts

The vast majority of diagnosis which present to physicians are self limited and require no immediate intervention or aggressive workup

Over 80% of visits to physicians are followups or routine monitoring of known diagnostic conditions which almost certainly can be performed with high quality and efficiency by advanced care providers eg HTN , cardiac, diabetes, pulmonary/asthma etc.

Over 60% of ER visits are for nonemergency conditions. Clearly the the triage does not always require a board certified ER physician. A perfect example is my son being seen by an ER trained PA for a wrist sprain after trauma. She did a complete and thorough history, exam and ordered an xray without the involvement of the doc who checked her work and signed off on the case in 90 seconds.

Independent practice units have been proffered as a multidisciplinary solution to disease specific management which bypasses the primary care model for all existing conditions and the work up of specific symptoms…back pain, headaches, knee pain etc

Team based care with primary care physicians supervising/overseeing care are being increasingly used and popular with patients

Using advanced care providers with subspecialty training in all specialties is the model for future care.  Ortho, endocrine, cardiovascular, neuro, dermatologic, ob, etc trained NPs, PAs can provide excellent care and when needed refer  to primary care or specialty MDs

Time to tweak and revamp a primary care delivery model which is anachronistic. Burnout is epidemic in primary care because it is a model domed to failure due to unrealistic expectations that generalists can remain state of the art for all symptoms, diagnoses and disease management .

Generalists are invaluable in the work up of diagnostic dilemmas and their skills can be critical in the management of patients with elusive diagnosis and who fail conventional work up. Typical examples would include , abdominal pain, weight loss and a host of other conditions which do not neatly fall into a subspecialty designation 

If you are seeking to change your delivery model, the time is now!!

Copyright NicolasArgy 2019

TELEMEDICINE the REAL McCoy

So many health encounters don't require in person communication and some specialties could easily be supplanted by remote servicing of clients

Counseling services and behavioral health are areas where telemedicine can solve huge access problems for patients.  Nutritional counseling also is very amenable to telemedicine.   AI has already shown amazing high quality results comparable to experts on the use of telemedicine in dermatology. Numerous other examples exist and even CVS is expanding their minute clinics in certain regions to use telemedicine

The not well publicized fact that almost 80% of health care visits represent followup appointments or maintenance for chronic conditions is another example of opportunity in the telemedicine sector.  Almost all these patient encounters can be easily converted to telemedicine.

The technology sector has myriad devices for the remote evaluation of blood pressure, temperature respiratory rate, pO2  heart rate even EKG. More technology for viewing the ear drum, checking sugars transcutaneously are being investigated.

Telemedicine is burgeoning and should be embraced and fostered both for enhancing access and reducing costs.

Contact me to discuss the application, business development and operationalization of your ideas in telemedicine.

Copyright Nicolas Argy 2019

Black Swans or Disruptive Innovation CHANGE IS HERE

December 16th 2018

We are desperately seeking innovation and solutions to ever growing cost, quality and inequity concerns in healthcare delivery. The ultimate answer, as I have previously written, will be found in addressing the social determinants of health with social prescribing through linked workers and community health workers. Fortunately, we still have many opportunities to improve on the delivery side of services.

Three forces will dominate the market

1 Artificial intelligence and big  data analytics

2 Patient engagement through transparency of pricing,  transparency of objective data measures of quality and practice of evidence based medicine.

3 Technology using telemedicine services which can lower costs and minimizes disparities of care

I have been approached recently by three companies each working in these domains to transform healthcare  The first uses  AI to identify real time evidence based medicine practices.  The second queries real time pricing to bring market forces and competition back into the healthcare market.  The third uses objective outcome measures, analyzing large data sets to assess quality. These companies combined with telemedicine can provide cost effective, high quality services.

In a time when "value" is the watchword of the industry, we need to understand the formula  cost divided by quality calculates the solution.

Using these three tools and many more yet to arrive in the market, we are poised to change health care. The adoption of innovation will likely led by self insured employers but clearly the writing is on the wall and providers and institutions will eventually adopt change to stay competitive in the market. If you know of services or products working to disrupt the market please comment and reach out to me to discuss so all can benefit. 

Creating a network of solutions allows all to share progressive trends in this ever changing landscape.

Copyright Nicolas Argy 2018

Opioids, Substance Use Disorder and Compassion: Losing the War

Rethinking our war on drugs is imperative to promote treatment, minimize the incarceration of victims, minimize the disparate incarceration of minorities in our criminal justice system and create a more uniform policy on how we deal with substances with addictive potential. Howard Koh MD, public health policy expert, has just published "A Smarter War on Drugs" JAMA. 2018;320(22):2301-2302.

We have explored various approaches to dealing with substances with the potential for addiction and lethal consequences including the two most deadly, cigarettes which kill 400,000 per year and alcohol which kills 80,000 per year.  These two legal substances kill five times more people than the opioid epidemic kills.   Nicotine is more addictive than heroin yet it still remains legal.  Alcohol destroys lives and causes untold suffering.   Is there a ground swell of opinion to make alcohol and tobacco products illegal or jail those with addiction to nicotine or ethanol?

We are all aware of the lack of success of prohibition on dealing with alcohol addiction and while deaths from cirrhosis decreased during prohibition, a huge criminal enterprise to supply alcohol was created.  It is no surprise with our current penal code that  the US has the highest incarceration rate in the world.  Tragically the for profit nature of the prison system creates huge incentives for that industry to promote  penal policies.  There is strong support for local police departments that did not punish drug users for voluntarily surrendering their drugs and being sent for treatment rather than to jail. Compassion and treatment should guide our policies, not punishment.

Whether we label addiction a disease or condition, few experts endorse a philosophy that substance use disorder (SUD) is a moral failing.  The topic is complex and multiple etiologies and risk factors exist.  Many environmental, social and genetic factors are associated with SUD.  The world health organization and others have resources for school based programs.  Prudent educational and treatment based policies are available to mitigate the epidemic of SUD

Worldwide other countries have taken a non punitive approach such as the Nederlands and Portugal and there has been no spike in SUD.  Portugal has the second lowest rate of drug related deaths, 3 per million as compared to the EU average of 17.3 per million

Next steps

1. Use compassion and treatment as our approach to addressing SUD 

2. Promote school based education and use societal resources to help minimize the devastating impact of SUD. Tax substances with abuse potential like cigarettes and alcohol and direct those funds for minimizing SUD.

3. Explore and test different non penal approaches to dealing with SUD following the experience of other successful systems

How many times have we heard that we have lost the war on drugs? We need to rethink our a penal approach to drugs and adopt a prevention based and treatment based approach to address SUD. We need a strategy which treats those addicted to illicit drugs no differently than alcohol and tobacco, recognizing we can dramatically improve our overall impact on SUD.

Copyright Nicolas Argy 2018

Thin Ice: Is Personalized Medicine Savior or False Prophet

Recent National Academy of Medicine report suggests Expanding the Role of N-of-1 Trials in the Precision Medicine Era: Action Priorities and Practical Considerations

While their is some intuitive appeal to the most highly tailored personalized care being best... the notion that this constitutes research or can be extrapolated to others is highly suspect.  This is more akin to trial and error with no means to establish a causal link between treatment and outcome 

below are the conditions thought to be requisite to engage in N of 1 research

Conditions necessary for N of 1 trials

DISEASE:

Chronic stable slowly progressive condition frequently relapsing and not emergent or imminently life threatening

TREATMENT:

No established standard effective treatment, rapid therapeutic effect, ability to try multiple different interventions safely and sequentially

OUTCOME MEASURE:

Objective established measure of effectiveness

PATIENT SUBJECT:

Willingness to participate after obtaining full informed consent

Warning bells should be sounding!!

The above criteria are so restrictive in nature that virtually no condition or patient would qualify. The suggestion that N of 1, is research, creates the illusion of science while in essence we are creating individual guinea pigs exposed to significant risk with virtually no benefit to be realized other than by pure luck.

Personalized medicine has been dramatically oversold as a solution to “your” health needs and while very useful to establish effectiveness of certain tumors to individualized chemotherapeutic agents, is still in its infancy.

Cost has also never been factored into the impact of personalized medicine which could be prodigious

We need to proceed cautiously with deliberate, informed, slow and prudent course of action or risk breaking through the ice and being much worse off.

NEW ENGLAND JOURNAL of MEDICINE MISSES the MARK

WHOOPS

Extremely misguided and unscientific recommendations by a recent New England Journal of Medicine, Nov 22, 2018, article  suggests we  move beyond evidence based medicine (EBM) to a new paradigm described by Thomas Lee, MD as "interpersonal medicine"(IP).  The article describes the need for caregivers to respond to the individual circumstance and capabilities moving beyond EBM.   While every caregiver already understands that tailored individual care is the hallmark of fulfilling the fiduciary obligation to every patient, we must redouble efforts to base those tailored decisions on a very strong foundation of objective science and EBM.  We must decry the use of anecdotal and experiential care which risks offering therapies and interventions which offer no improvement over placebo but subject the patient to risk of harm without any proof that there is a benefit.

I applaud every effort to engage in shared decision making and encouraging patient engagement but only through EBM.  We return to the days of snake oil and witch doctors when we move away from science and EBM.  We currently do not practice EBM in the vast majority of patient encounters ( a fact admitted in the article) Please see previous articles I have written on the topic.  The decades of work of Iaoniddis highlight that 85% of the published research is either biased,  invalid  or non-reproducible proves this.  Understanding the importance of care coordination, psychological implications of the caregiver patient relationship, communication and understanding the impact of social determinants is critical but only if founded on EBM.

The author touts the benefits of "intuition" and "instincts" in care-giving which is frankly heresy and anathema.  We have over thirty years of data proving that  our medical instincts and intuition are more often wrong than right and that is why we need clinical decision support, artificial intelligence and other technology solutions so that science based decisions trump anecdotal medicine.  The work of Kahneman highlights the cognitive biases which pollute objective decision making.  When obtaining informed consent research shows that physicians routinely underestimate risks and overstate benefits when communicating with patients.

One major point of agreement is that science will not solve our biggest problems in health care but rather addressing prevention and the social determinants of health.  I have written most recently on the benefits of social prescribing and link workers/community health workers as a evolving solution to preventative care.  Still the practice of medicine should be EB, scientific, not intuitive, instinctive or anecdotal.

Creating good health policy should be based on science not anecdote.  Patient surveys identify preferences but do not create cures for disease

Lets embrace

• Shared decision making

• Informed Consent

• Enhanced communication

• Prevention through the social determinants of health

• Clinical decision support, artificial intelligence, technology 

• EBM

Lets de novo reject

• intuition

• instinct

• anecdote based care

• interpersonal medicine which moves beyond EBM

nicolas argy copyright 2018

GUN VIOLENCE: The REAL Issue and SOLUTION

The debate is vociferous, scathing and vitriolic. Many blame unfettered access to guns as the cause of our epidemic of violence. The media/public focuses its attention on mass shootings and rapid fire weapons. The NRA touts the need to preserve our second amendment right to bear arms and the need to defend our homes. The issue is neither easy access to large capacity rapid firing guns or the mentally ill committing crimes with guns...

Both groups have overlooked a simple fact. almost 70% of gun deaths are suicides. 

People with schizophrenia and psychosis do not have an increased incidence of criminal gun violence except in those with substance use disorder (SUD) but no higher than those with SUD alone. Further a recent review of the literature stated

“… little population-level evidence supports the notion that individuals diagnosed with mental illness are more likely than anyone else to commit gun crimes.” 1

The Supreme Court has ruled that reasonable regulations on gun ownership are constitutional. The majority of Americans favor background checks and gun registration. Rather than promoting a political agenda of the fight against mass killings, or blaming psychosis, a balanced debate is needed.

The vast majority of gun owners are rational, sane, law abiding citizens… hunters, sportsman gun aficionados without extreme political agendas. They love this country, oppose violence and have no interest in seeing the epidemic of suicides persist or grow.

While guns make suicide attempts much more lethal, the underlying problem still remains depression and suicide, not firearms.

Please lets redirect our energies away from attacking guns and mental illness(schizophrenia/psychosis). Let’s join forces to address the underfunding and lack of resources to deal with depression and suicide. The United States Preventative Services task Force has highlighted the need and value of screening for depression.

What do we need

1. A balanced rational debate with both sides listening

2. Finding common ground

3. Fair and reasonable gun regulations

4. Recognition that we need to minimize suicides

We need to make more resources available to address depression.

Suicide and depression are the major underlying problem we face. Lets attack the real enemy and help those who are suffering and desperate.