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Fermi, Filters, and Funky Aftershave

“Where is everyone?”

No, that’s not me looking for people to harass into reading my blog. Those are the words of Enrico Fermi. In case you haven’t heard of him, Fermi was a really famous physicist who was always invited to all the right parties. Oh, he was also pretty much the father of the nuclear age. (I’m not sure what physicist parties are like. Perhaps Kevin can touch on this in his next blog?).

Fermi’s quote has to do with what’s known as the Fermi Paradox. Basically, given that there are tens of billions of planets in our galaxy alone, even if intelligent life is a relatively rare occurrence, we should see evidence of other civilizations all over the place: trashy alien reality television, weird sporting events, unidentifiable fast food wrappers, etc. But to date, nothing, nada, zilch, zippo; thus the paradox.

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A scene from ‘Real Housebots of Andromeda 17’

Ok. I know you’re probably thinking: “But what does this have to do with AI?”

I’m getting there. The road to the truth is sometimes long and bendy.

There are a lot of theories about why we don’t see any other signs of life in the universe. It could be that galactic society took one look at us and then strung up the cosmic equivalent of that yellow caution tape around our solar system. Hopefully that’s not the case.

The explanation I’d prefer to focus on today is called the Filter theory. It says that much like the filter that prevents coffee grounds from ruining the creamy goodness of your triple latte mochaccino, there’s a filter that prevents civilizations from reaching a point where they could accomplish troublesome stuff that far far away astronomers could see through their telescopes and remark, “Hey, that’s weird.”coffee-2616923_1920

So if there is some point in the evolution of civilizations where they all tend to wipe themselves out, the question becomes: Are we Earthlings past that point already or are we approaching it?

 

“That’s all very interesting, but what does it have to do with Artificial…”

I’ll get there. Bendy, remember?

I watch a lot of the History Channel and in the early days of humankind people sought to harness the power of fire so it could be a useful tool versus something that terrorizes them. However, there were many among our ancient ancestors who were concerned that fire was too dangerous and the tribal elders reminded everyone of the consequences of the pointy stick fiasco (I’m paraphrasing).

“Yes, but I still don’t see…”  Bennnn-deeeeee.

And continuing forward through history, every new technological advance has brought with it concerns of filtering ourselves out of becoming the first galactic civilization. So, even though the concern has been there from fire, to gunpowder, to cloning the DNA of dinosaurs as part of a new amusement park venture (that last example may have been from a different channel), I don’t think any of these compare to what is probably the actual filter that all civilizations have to overcome.

Yes, now I’m talking about AI.

“Finally!”

Even though we’re probably many years away from a super-intelligent AI, imagine for a minute an AI with the same intelligence as a person. That would still be a pretty big deal because digital circuits operate about a million times faster than organic ones (in other words, us). So pretend you could put this human-level AI on a problem for a week. That would be the same as a person working on the problem for about 20,000 years, or 20 people for 1,000 years, or 50 people for…

“We get the idea.”

Now imagine that whoever gets this AI first has only a six-month head start on their competition. That’s the equivalent of half a million years in human time. What would another country do if they thought we had this capability or were even close to it? I’m not sure, but I don’t think I’ll be moving to Silicon Valley anytime soon.

This was the idea behind Elon Musk starting his OpenAI initiative. Given that he’s been very vocal about the dangers of AI in the past, at first it seems odd that Elon* would start up a company trying to develop an intelligent AI. (* I like to think Elon is the kind of person who would let me call him by his first name if we ever met; plus, “Mr. Musk” sounds like a really cheap aftershave and I’m not sure I could say it with a straight face.)

Elon’s idea was that by being the first to develop an intelligent AI, OpenAI would have enough of a head start to dictate the direction that AI research and development goes in order to make sure it’s used to benefit humankind. Given the history of filtering mentioned above, that plan kind of makes sense.

Hopefully, whoever gets there first—Elon or others—will have humanity’s best interests in mind and we can maybe be the first ones to make it past the filter point.

Then we’ll be the ones putting up the caution tape.

Well, that’s it for this episode. As always, if you have any questions about AI or Machine Learning, or need some physics party plans (I know a guy), drop me a line.

Thanks!

Not What You Wanted To Hear

Do you like being told no? Of course not. Who does? Maybe crazy people but certainly not your average run of the mill person. We all like to get our way and get what we want. That is human nature. We are needy beings that want want want. However, even Mick Jagger knew that we don’t always get what we want.

 

Hey now, don’t give me that look. I can see you giving me an eye roll and moving that mouse to close the browser window. Just stop for a minute. I have a point here. I promise.

Our modern culture is built on the premise that anything you do can be made faster and/or more efficient with the incredible power of (fanfare please) the internet. I would venture to say that in a lot of ways this is true and if it doesn’t make it faster than at least it’s more convenient. Shopping is easier, taxi rides are easier, education is more accessible, banking is easier, and meeting new people is as simple as a swipe right. So what about healthcare?

A few posts ago I spoke about how the data we leave behind us can be analyzed to make our healthcare easier and cheaper. As a consequence of that efficiency and cost-effectiveness, we may not get the care we are used to or even the care that we feel we want. This isn’t because we are getting subpar care. It is just that we don’t necessarily need everything that might have been done in the past. It is that efficiency and cost savings at work. That fact is that you as a patient may not have much control over your care at all. That may or may not be such a bad thing but I can think of a few situations where someone might get a little ticked that they are told no. angry-2191104_1920Sadly, in our modern world, some adults seem to turn immediately into toddlers when they don’t get their way. Just watch the customer service counter at your local big box store when someone is told they can’t return the doodad they bought 3 years ago… Epic meltdowns for sure. It’s the kind of stuff viral videos are made of.

Now back to the story. Coordinated care groups, cooperatives of providers, and even the participants within a payer network may not allow a patient access to certain procedures they deem unnecessary or superfluous or allow a patient to see anyone outside of the confines of their group. Why you ask? Because they feel that if they control what procedures are done and who a patient gets to see for a specific procedure then they can guarantee the quality and the cost of an entire episode of care. And if they cannot guarantee it then at least they would have a pathway to open communication to make sure they can adjust or understand better the care a patient receives. So that means that patients can’t really choose who they get to go to or whether or not to get the “extra” tests that somehow make them feel more trusting of the care they are receiving. Despite the fact that healthcare should be all about choices, those choices may start to dwindle and if you start an episode of care, say for a surgery, with one group then you likely won’t be able to move to another.

Now I imagine a lot of you thinking “What is this guy talking about? Of course I can choose what doctors I see and what providers I want to use.” But if you think about it, I don’t mean that you can’t choose what you want, only that you won’t be able to do so without consequences. A doctor who is being paid based on the health outcome of your care will be hesitant to let you out of their “area of influence” so to speak. Also, your insurance company will not be pleased and may force you to pay more if your choice moves you into a situation where quality can no longer be measured effectively. (This brings up the issue of how to measure quality which is not an easy question to answer.) There is a silver lining here though. Remember that things would not be as they are now. If you are in the midst of an episode of care it is likely that the group doing the treating is already pretty good since they will get paid based on the quality of care that they administer and not just by the procedures they complete.

So remember that even though value-based care may mean that you don’t get the same things that you used to, it also means that you are probably getting a better deal anyway. Everyone wins but only if we let the system work for us and try not to work against it. It is hard to lose control (if we even had it to begin with) but giving up some things means we can reap the benefits elsewhere. In this case, your bank account or in a more grandiose fashion the coffers of the whole country. Nothing is ever perfect but if we let the change take hold we can all be better off. In closing, I challenge you not to start humming the Rolling Stones after you read this. I said no. Don’t you do it!

See the theme here?

What’s In Your Electronic Health Record (EHR)?

Remember the days when people used to write on paper with a pen or pencil. Will the pen and pencil someday be in the Smithsonian Museum of History?

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Future Smithsonian Exhibit

I guess my typing class in ninth grade is paying off after all. What’s the point of studying for spelling tests when we have spell check on our computers and at our fingertips? Spellcheck even tries to help guess what we are spelling by presenting suggestions for us to choose from or just changing the word automatically for us. Take the abbreviation “EHR” for example, the computer helps me out every time by reorganizing the letters for me into what it thinks I meant to spell.

Writing activates parts of our brain involved in thinking and memory. It helps one think more thoroughly about the information one’s documenting. Since writing is slower and more tedious, it makes it harder to take notes verbatim. Therefore, one has to actually process the information and summarize it in a way that makes sense to us and forces our brain to engage with the information. A draw back, everyone’s handwriting is different and not everyone’s handwriting is legible to read (the unofficial term for bad handwriting—chicken scratch).

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Unamused chicken. 

This makes the reader have to decipher at times the written word. Hmm…. almost like the computer spell checker does for words it does not recognize.

On the other hand, typing encourages verbatim notes without giving much thought to the information. This mindless transcription can lead to a lack of meaningful understanding of the information. Although typing allows words to be documented more quickly and more legibly, that doesn’t mean what is written is any more understandable. This can be especially noticeable when there is redundancy in text data, incorrect concepts are used, or references are made to data that was accidently or intentionally copied from other sources, i.e. another office visit’s notes.

Now that we can access our medical records electronically through our doctor’s patient portal and they are legible to read, have you ever sat down and read the medical note your provider wrote about you? Putting aside the medical terminology, how did it flow? Computer technology makes it very easy to cut and paste or copy and paste data from one location to another. While this technology is great to help save time, especially if you are a slow typist or very busy, it can have it consequences if not done correctly or quality checked for accuracy. Providers are not only expected to see and care for many patients throughout their day, but they are also required to make sure whatever is done is also documented clearly in the patient’s medical record. As technology makes things easier and faster for us to do our jobs, it also makes it easier and faster, when in a hurry or busy, to make factual errors, or use boilerplate or copious amounts of text of little relevance to the individual patient.

Back to question about reading your medical record. Have you? Being a nurse, I have seen records where a person’s age and sex changes within the same office visit note (date of service) and social histories or physical exam documentations appear to stay the same from one office visit to the next. I have seen words misspelled or spelled correctly, but the wrong word was used in the sentence which can lead to confusion. You know, like when you send a text to someone and the word you typed is changed by your smartphone and now the message you sent to your friend sounds encrypted and you don’t even recognize what you said even though you sent it.

I have also seen records that have diagnoses listed when the note within the visit states they have been ruled out. And by the way, according to CPT® there are specific rules about billing ruled out diagnoses, depending if the service was performed inpatient or outpatient. Yes, many of the mistakes are human errors that are easy to make when using technology such as, copy & paste, spell check, etc. Technology is great, but the human is still necessary (as referenced in our Machine Minded blog).

The bigger concern about inaccurate or not up-to-date information within our charts rears its head when your medical information is needed for emergencies or you need it to qualify for other services. Have you ever tried to get life insurance? You can be denied life insurance or your premiums could be more expensive depending on your medical diagnoses. Also, it seems like identity theft is always in the news nowadays. Guarding your health insurance card is just as important as guarding your credit cards. Someone else’s diagnoses or allergies in your medical record could harm you, especially if you are unconscious or unable to communicate. On the plus side, with the implementation of the EHR, information is more accessible at the patient level. It is no longer a black box of unknowns. This in turn, allows the patient and their provider(s) to work together better as a team to make sure data is accurate. The next time you look at your medical record online, take a moment and read it.

 

 

Disclaimer: This Blog is for educational purposes only as well as to provide general information and a general understanding of the topics discussed.  The Blog should not be used as a substitute for legal advice and you are advised to seek additional information from your insurance carriers, Medicare and/or Medicaid agencies for additional criteria and regulations regarding these services.

Social Value of Online Communities

Social media might be taking precedence in our lives these days, but there is another form of online communication that we used to (and for some of us still) rely on for exchanging knowledge or receiving emotional support from strangers – the online forums or bulletin boards. For example, Stack Overflow features a Q&A platform for software developers to exchange coding knowledge. Slickdeals, a deal and promotion-sharing forum, on the other hand, has a typical forum structure that has threads, original posters, and responses to those original posters.

Various streams of research have been conducted on online communities, from motivations behind participants in contributing time and knowledge in helping strangers, to the economic value of such contribution. What is lacking is the social value of online communities. Scholars Goh, Gordon and Agarwal (2016) aim to bridge this gap by looking at how an online community addresses the health disparity of rural and urban populations. They are also the first to quantify the social value of online communities.

Their assumptions are as follows: there is limited access to resources such as specialized care, information, healthcare programs, and social support groups in rural areas, which creates significant disadvantages for rural patients. Therefore, rural patients tend to have decreased health status and health functioning, possess less health knowledge, and have lower health-seeking skills, beliefs and self-efficacy. Together with other health capability gaps, rural patients are more likely to have poorer health statuses and higher mortality rates than urban patients. Given rural patients’ disadvantage relative to the urban patients, these researchers suggest that online communities can reduce the health capabilities gap experienced by rural patients by enabling the exchange of social support, in the form of both health information exchange and emotional support. Moreover, to the degree that community interaction has a relatively more positive effect for rural patients, they hypothesize that online communities generate social value by reducing rural–urban health disparities.

To prove their hypothesis, they collected message data on a rare disease online forum posted by 111 rural patients and 527 urban patients from October 2005 through June 2009. They adopted a network methodology in studying the knowledge and emotional exchange among original posters and responses. To illustrate, each node in the network represents a patient who participated in the forum. There is directionality associated with support provisions such that a supportive tie between a patient who posts a thread and a response from another patient is represented by a directed dyadic tie, where the arrow points toward the originating poster and the arrow head terminating at the recipient (e.g., a patient whose initial post generates a reply in the thread would have a tie that is directed toward her).  If their hypothesis is correct, it should show that the rural nodes are more likely to be recipients and urban nodes are more likely to be providers of social support.

Their findings suggest the following: the probability of a node with an incoming tie is 7 percent higher for a rural node as compared to an urban node. In other words, all else equal, a rural patient is more likely to receive support compared to their urban counterparts. They also find that rural patients are less likely than their urban counterparts to provide support.

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The research suggests that support online flows in one direction

Taken together, these results show that the likelihood of an urban patient responding to a rural patient is higher than the likelihood of responding to another urban patient, all else equal, and therefore providing support for the claim that there is a net surplus of social support flowing from urban to rural users.

Their results yield implications for policy makers and practitioners concerned with meeting patient needs and overcoming disparities in medical access. Entities responsible for resource allocation decisions, such as governments, community agencies, and public health facilities should leverage the powerful role that online collectives can play. Online communities can serve as a low cost alternative to or as a complement to existing health programs. For instance, healthcare entities can have professional nurses or doctors participate in these communities by providing information in addition to regular patients. Such information shouldn’t replace necessary office visits. Rather, it can guide the patients in the right direction and serve as a conduit towards further examination.

 

Reference:

Goh, Jie Mein; Gao, Guodong (Gordon); and Agarwal, Ritu. 2016. “The Creation of Social Value: Can an Online Health Community Reduce Rural-Urban Health Disparities?” MIS Quarterly, (40: 1) pp.247-263.

Disclaimer: This Blog is for educational purposes only as well as to provide general information and a general understanding of the topics discussed.  The Blog should not be used as a substitute for legal advice and you are advised to seek additional information from your insurance carriers, Medicare and/or Medicaid agencies for additional criteria and regulations regarding these services.

Bad Apples and Sour Grapes

Healthcare fraud is a consistent problem that is ever evolving and adapting to the regulations and restrictions put in place to hinder it. Once one avenue is stopped, those individuals that were cashing in are likely to move to another area and begin anew. So the question I wanted to address here is how Value-Based Healthcare will impact an industry that is rampant with fraud.

In a VBH model the focus on collaboration of providers and coordinated care means one very important thing that is missing from a volume based model, communication. Currently a large portion of fraudulent claims to healthcare payers are made by solo providers that are only one part in the chain of treatment. In a VBH world the chain becomes a web and lots of people suddenly see what procedures have been done, what drugs are prescribed, what tests have been performed and treatments administered. Even my 4 year old will tell you that when someone is watching… you shouldn’t do something you know is wrong.

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If I can’t see them, they can’t see me, right?

This is even more important when a group of providers can all benefit from the administration of high quality and cost-effective care to their patients. It is as simple as peer pressure. “My friends made me do it” is a pretty weak excuse except when what they made you do is not commit a crime.

Now I don’t want to make it seem that all avenues of fraud are closed by a VBH system. In fact existing schemes can still flourish it just might be a little more difficult to pass some things by your colleagues. That is unless your colleagues all want to cash in too. So now what you have is a web of providers all collaborating to coordinate care and defraud the payers. If a large portion of the group is “in” on it then there is really not much that can stop them from cashing in… except that quality is being measured by external reference frames. What I mean is that the metrics that have to be reported in order for the assessment of quality to be made are also being reported by lots and lots of other provider collaborations and groups. That assessment of quality and the subsequent payment are therefore being evaluated rather guaranteed and a group of coordinated fraudsters could in fact lose money if their quality and cost measures fall below acceptable levels.

So the system of quality review and measurement is self-correcting right? Sure, in many cases it would be. That is of course (see I told you they always find a way) unless the quality measures are being fabricated as well. What you have now is a group of providers, institutions and patients all working together to get money out of the system. The trouble is that this would be terribly complicated and probably difficult to organize. Unfortunately I am constantly surprised as how innovative and devious people that have been convicted of healthcare fraud can be. Is it out of the realm of possibility? No, certainly not. Is it likely? I would put it at a low or medium-low risk.  The ways a scheme like that could fall apart are too numerous to count so in my opinion it just wouldn’t be worth the effort to make a few extra percent on an episode of care.

So this brings me to my closing. Right now what healthcare fraud really looks like is a number of bad apples all hanging out in the barrel making it all look bad.

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Fraudster in fruit form

VBH would do a great deal to pick those out and throw them away. The only trouble then would be the groups of sour grapes that spoil the system. Fruit metaphors aside I think I have made my point. The trouble today with fighting healthcare fraud is that it’s often very difficult to weed out the bad from the good, like I said they are really good at hiding. VBH can go a long way to shining light into the dark places but I certainly don’t think it will go as far as painting red arrows that say “Fraud This Way”.

 

Disclaimer: This Blog is for educational purposes only as well as to provide general information and a general understanding of the topics discussed.  The Blog should not be used as a substitute for legal advice and you are advised to seek additional information from your insurance carriers, Medicare and/or Medicaid agencies for additional criteria and regulations regarding these services.

Under the Hood

Shhhhhhhhhh……..

Lean in a little closer…closer…whoa, not that close!

I’m speaking (writing) in hushed tones because in this special sort-of-but-not-really-post-post Halloween episode we’re discussing the dark side of AI.

Imagine this nightmare scenario: One day in the not too-far-off future, you’re on the way to work. It’s a beautiful day. The sun is shining, the birds are chirping, your self-driving car is doing all the work while you relax and sing along with your favorite rap-opera-country song. auto car

Suddenly and for no apparent reason, your car violently lurches to the left and drives straight into an artificial tree! Stunned, you emerge a few moments later. The car’s safety features have spared you any physical injury, but the horror slowly sets in that your pumpkin spice latte is gone forever. The EMT robots arrive and begin probing you with instruments you don’t understand as your head clears and you start to wonder what happened.

“Did my constant singing finally drive the car to suicide? Surely my voice isn’t that bad.”

It is, but that probably wasn’t the cause. A short while later a group of software engineers gathers around the crash site to search for a cause. The last strains of Carmen Wrecked My Pickup for Shizzle crackling through the damaged speakers. They mumble to each other in an incomprehensible jargon, reminiscent of an ancient forgotten tongue. After a few moments of silence, some head scratching, more silence, they give each other a knowing glance.

In the morning, they’ll blame it on the hardware.

And now many of you are thinking, “That’s just silly. My mechanic, Bunky, can plug a thing into the car now and find out what’s wrong with it.” Yes, that’s true today, but, on a side note, why are all good mechanics only known by their nickname? Bunky, Cooter, Skeeter…it’s like they’re part of some secret society or something. Or maybe their nicknames hide their real identities so you don’t call them at 3 a.m. when you can’t sleep because your car made a noise on the way home and it’s probably nothing but you’re thinking the car may be possessed by the spirit of Mikhail Baryshnikov because you saw this show on the Discovery channel where…

Sorry, getting off track there. Long story short: I recently had to switch mechanics.

Anyway, cars today are relatively simple compared to the fully autonomous vehicles of the near future. And it’s that complexity that will make it practically impossible to figure out what finally drove your car over the edge. As problems become more complex, rather than programming computers to solve the problem directly, we have to teach them.  I know that sounds silly, but board games may help illustrate what I mean.

When Deep Blue from IBM beat the world chess champion in 1996, it was able to do so basically using brute force. There are only about 220 possible board configurations in chess, and the computer could check all of them in order to determine the best move. It was vastly different last year when AlphaGo, a computer built by Google, beat the human GO champion. GO is an ancient Chinese board game where there are about 2.08 X 10170 possible board configurations. I tried to think of an example to help us get our heads around that number, but I’m afraid I’m just not that creative. Grains of sand on a beach? Not even close. Cat hairs on your favorite sweater? Nope. Number of times your weird uncle has embarrassed you during the holidays? Warmer, but still not there. If you had a million weird uncles and you were all there for every holiday in every country from the beginning of time? Still not enough.

You see my dilemma. It’s just a really, really huge number. So how then did a computer beat the human champion? The engineers let it learn by watching the moves from thousands of human matches. Then, after the AI had a rough grasp of the game, the engineers employed what’s called reinforcement learning. Basically, the computer played millions of games against itself until it was amazingly good.

So, you can begin to see the issue. Start with an incredibly complex problem. Create a very complex AI system, and then let the AI learn on its own how to solve the problem. The result is that we have no idea why the AI is making the decisions it is. And so we may never know what happened with the car in the scenario above. Maybe your Toyota became self-aware like Skynet from The Terminator. dark tech(I realize for most of you “from The Terminator” is superfluous there. It’s obviously not Skynet from Sense and Sensibility. Not saying it’s a bad movie, just a little lacking in the killer robot department. Maybe in the sequel.)

The scary part of all this is that advanced AIs are being implemented in more and more settings where it would seem important to know the why behind the decisions.  Such as: who gets what healthcare treatment, who is admitted to which school, who should be paroled, and, of course, which TV shows should be renewed for another season?  Also, these systems are often trained using existing data sets.  If the data is already tainted with human biases, we’ll need some way to make certain those biases aren’t being carried over into the AI decisions.  Unfortunately as AI systems become more advanced, there will be less insight into what’s going on under the hood. That’s why you may hear them referred to as “black boxes”, we can’t see inside.

All is not lost, however; at least not yet. Very smart people at Google, Microsoft, and other places are working on the problem as part of the larger issue of AI ethics. (This is a good article about the current state of AI ethics if you’re interested.)

Well, that’s it for this episode; I hope it wasn’t too frightening. Remember, if you can’t sleep tonight you can always call your mechanic (if you know their real name). As always, if you have any questions about AI or Machine Learning, or need some movie ideas, drop me a line.

Thanks!

 

Disclaimer: This Blog is for educational purposes only as well as to provide general information and a general understanding of the topics discussed.  The Blog should not be used as a substitute for legal advice and you are advised to seek additional information from your insurance carriers, Medicare and/or Medicaid agencies for additional criteria and regulations regarding these services.

The Lost Art of Face-to-Face Conversation

Imagine you are in a restaurant and at the next table over you see a family of four. There appears to be a father, mother, and two children. However, no one is talking, laughing, or making eye contact with one another. Instead, they are all looking down at their smart phones. Now imagine you are visiting a healthcare office or hospital and the provider is doing the same thing. This has become a recurring scenario in many health care settings. Doctors, nurses, even therapists interacting with computer screens more than they do with their patients is pretty much the norm. According to a Forbes article, this is known as the “iPatient” phenomenon1.

“i” (iPad, iPhone), has been marketed by Apple® since 1998. Created by Steve Jobs, the “i” in iMac stood for Internet. These days, anything associated with technology, often has either an “i” or an “e” (i.e. eRecords) in front of the word. By putting an “i” or “e” in front of patient, does that take the “human” out of patient and make the “human” more like a “thing”?

Stepping back a second, why are we discussing experiences about less eye contact between patients and healthcare professionals? Oh yes, now I remember, the implementation of the EHR. Technology designed to streamline patient care, produce legible records for other providers caring for patients, and to help health professionals be able to “see” the whole patient (i.e. know what tests have been performed, diagnoses already ruled out, medications tried and determined not to be effective). checklist-2077023_1920It is also supposed to help decrease healthcare costs by reducing redundancy in services by multiple providers and improve healthcare outcomes by allowing the sharing of information across disciplines. All great goals, but are we losing the care in healthcare?

As we grow increasingly reliant on computers to help make decisions, today’s healthcare professionals spend more time in front of the monitor charting and examining tests results and less time meeting the real live person. Remember the days before digital when you could actually hold “data” in your hands? Radiologists used to go over chest films with the medical team. Now a radiologist may be reviewing films at home in the evening alone. Provider rounds are slowly disappearing, along with the time allowed for clinicians to be able to think collectively about what something may mean. Is technology causing us to make decisions faster without giving our human brain time to think and rationalize? Humans are not computers and everything is not according to the textbook or black and white.

Nurse friends of mine that still provide direct patient care in today’s environment state that charting via the “old” paper way actually took less time and gave them more time with the patient. Time with the patient was what they enjoyed and why they became a nurse. E-paperwork was not the care they wanted to provide.  From their perspective, valuable information that they could gather from direct human-to-human contact has suffered. Bedside skills appear to have dropped in inverse proportion to the technology available as evidenced by hospitals having to implement Medical/Surgical Skills Day to ensure that staff remember how to correctly perform basic tasks learned in nursing and medical school.

Based on my own recent office visit, less direct human communication levels started when I walked up to the front desk to check in for my appointment. I was handed an electronic tablet and told to review and sign the documents and make corrections for any data that is wrong. Soon afterwards, my name was called and I headed back to an exam room. My Provider entered the room and went directly over to the computer, pulled up my records (that I just put in) including the reason why I was at the office in the first place. comicNot taking her eyes from the computer, she asked me questions of what brought me there. As I was explaining my symptoms, I noticed that my provider was not even looking my way. She was concentrating on her computer screen and clicking boxes. Yes, being a healthcare professional myself, I understand why she has to do that and yes, I appreciate that it is important that she does it; however, I thought to myself, was my provider even listening to what I was saying.

Back when I was growing up and again later, when I was in nursing school (before computers, as my son would say, “old”), I was taught that if you are not looking at the person that is speaking to you, then you are not listening. Experience has taught me that active listening involves more than the ears. To really understand what a person is telling you, you have to see their facial expressions. It feels like yesterday when I was taught this, but in technology time, it was a lifetime ago. Technology time changes quickly and more frequently. What was here today is gone tomorrow. My Provider did a quick hands on examination, ordered a diagnostic test, and a prescription that was directly sent to the outpatient diagnostic office and pharmacy of my choice according to my healthcare plan. I did not have to do a thing. I was taken completely out of the picture. Almost like I was never even there.

 

What’s your experience?

 

Disclaimer: This Blog is for educational purposes only as well as to provide general information and a general understanding of the topics discussed.  The Blog should not be used as a substitute for legal advice and you are advised to seek additional information from your insurance carriers, Medicare and/or Medicaid agencies for additional criteria and regulations regarding these services.

The Invention of the Minivan

Imagine, if you will, a country where everyone moves from place to place in single person combustion engine vehicles. A country where all the laws, expectations, and infrastructure is built to support only single person vehicles. In this world of singular travel, the population realizes that it is inefficient and that all of these single person vehicles are burdensome not only in terms of space but of pollution and traffic. In order to change their ways and improve the acceptable methods of travel they begin to make laws requiring change and the creation of… the minivan.

minivan
Minivan coolness may vary

This new multi-person vehicle is more efficient, produces less pollution per person, and is superior to the single person vehicles in almost every way. This leap in progress does not come without its drawbacks. For example, many roads have not been created for a vehicle as wide as a minivan and often cause traffic jams where they once never existed. Revenue from tolls suddenly begins to drop. The same amount of people are passing the tollbooth but the number of vehicles has reduced as the person per vehicle ratio has risen. This hypothetical place becomes polarized over the issue and people are suddenly either a SP (single-person) supporter or a MV (minivan) activist. Political turmoil abounds as debate and discussion stifle change and the issue only becomes more perplexing when someone invents the 4-door sedan.

I imagine that you have only continued to read so far because you are curious what my point is… Well you are in luck. I will likely tell you what I am up to in the next few sentences. Or maybe not. In either case here is a picture of my cat Finnegan as a reward for getting this far.

Finnegan
Finnegan

The hypothetical circumstances I described above are an allegory for the healthcare industry in the U.S. In case you hadn’t guessed it yet, the “multi-person vehicle” is really this newfangled idea I’ve been blabbering on about for the last few months. My point was to illustrate an instance where a complex system was built to function one specific way. This situation can hamper change, and sometimes progress, because the underlying infrastructure is not equipped to adapt. Not necessarily because someone wants it to stay the same but simply because the system has never had to change.

So, if you are still with me here is the whole point (I told you it was coming). Value Based Healthcare is such a profound change from the current way of doing things that the infrastructure and legal framework for healthcare in the U.S. is not completely equipped to handle the change.  In fact, there are a few legal establishments that are barriers to adopting a value-based payment model.  Anti-fraud laws that exist today were designed for a fee-for-service model in a world where doctors often worked for themselves instead of for larger healthcare groups. The Stark Law and the Anti-Kickback law have been specifically indicated by the American Hospital Association as major blockers to the adoption of the value-based initiatives put forth by the MACRA legislation. These laws inhibit hospitals from being able to initiate collaborative and coordinated care for patients without the possibility of legal ramifications. The MACRA legislation even states that the Department of Health and Human Services must make legal exceptions and changes in order to allow for easier pathways to success for new and innovative payment models.

Legal barriers are only one part of the complex landscape that has to be tiptoed through in order for coordinated care partnerships to flourish. The connectivity of systems, equivalent health record formats, as well as organized and consistent billing for each episode of care from both institutional and outpatient providers are all necessary components for a complete VBH system.  While it is easy to put these down in words, it’s not so easy to overcome such hurdles. The reason? The minivan was just invented and not all fuel stations, mechanics or dealers are equipped to handle it.

The takeaway here? If we, as a population, want to make sure that concepts like VBH survive and take hold, we must do what we can to embrace the change. If positive sentiment from patients and legal backing from the government can support each other, more and more providers and payers will make the investment in change. I would say that VBH is already well on its way but even the best-laid plans can fall prey to unstable circumstances. I don’t think that will happen but in my experience it’s always better to be prepared and keep a watchful eye.

 

 

Practice Makes Perfect – But We’re Not There Yet

In my last blog, we looked at the ability to demonstrate meaningful use that includes specific objectives, milestones, and metric requirements to monitor use of health information. We discussed technology, the certified EHR, the tool to help demonstrate meaningful use by having a place to document health care data that can be easily shared across disciplines, thus, allowing healthcare professional to “picture” the entire patient, not just fragments of them. All this aims to demonstrate, through EHR data metrics, that healthcare costs are decreasing (or at least not rising so fast) and healthcare outcomes to the population are improving. It’s all because we are becoming more efficient.

files
Any nostalgia for paper charts out there?

Because we can “see” data real-time and it’s not stored in paper charts at some doctor’s office or in boxes in a storage facility. We can show through data that multiple providers are not performing the same diagnostics tests, less medical errors are occurring, and readmissions to hospitals are on the decline. Can the EHR really do this?

It is not as simple as it may sound to put this into practice and be able to get the metrics needed to demonstrate what’s being requested from the healthcare arena, or at least into today’s healthcare setting. Until recently, health care records were paper located at the individual provider’s office. Providers worked in silos, not sharing with others except by fax transmission or postal mail. Even the patients were not provided copies of their information until HIPAA came along and mandated that a patient be allowed to see and have their own information. But even then, the patient had to request it and pay for it. When a patient was referred to see a specialist, one still could not rely on the information getting back to the primary care provider or what did get communicated was just a summary (without all the details).

Even today, the EHR is not a comprehensive record for each patient. Clinical notes and tests ordered by a patient’s various health care providers cannot be viewed from a single record by all providers, nor is there one patient portal for the patient to access their comprehensive medical record. A patient cannot go to Walgreens® and request their pharmacy records from CVS®. As a result, this can provide an incomplete picture of a patient’s health and behavior. Becoming electronic does not prevent health records from being fragmented, which could affect milestones and metric requirements. In addition, the tool itself does not make the data for the measurements; it still takes a human to enter the data into the tool. At least for now (to learn more about that tale visit our Machine Minded blog). However, with little or no standards on data entry, accurate measurements are a challenge. The old saying still holds true, “garbage in is garbage out”.

On the more positive side, while the EHR is not perfect, we are heading in the right direction. It is still much better than paper and it’s a step closer in regards to being able to demonstrate meaningful use. Having a health record available in real-time to providers and patients is far more useful.

 

 

Disclaimer: This Blog is for educational purposes only as well as to provide general information and a general understanding of the topics discussed.  The Blog should not be used as a substitute for legal advice and you are advised to seek additional information from your insurance carriers, Medicare and/or Medicaid agencies for additional criteria and regulations regarding these services.

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