Why we die early

America’s healthcare system stands out in the world for juxtaposition of two conflicting facts: it is the world’s most expensive healthcare system in a country with one of the developed world’s lower life expectancies. Many people ascribe this problem to inefficiencies in the system, economic forces, failure to ration care. However, there is a much simpler reason, whose only problem is that it is very difficult to accept: the abundance of food in America is changing us for the worse. It’s killing us.

A simple thought experiment will illustrate why evolution would result in life that lives fast and dies young in times of plenty. Imagine two islands. Each island is populated with two species. The first, species A, has a three year lifespan. The first year, animals of species A grow from helpless infants to adulthood, and at the end of the first and second year, the animals each produce two offspring. In their second and third year of life, the adult animals raise their babies to adulthood. Then they die. In times of plenty, animals of species A grow large and dangerous.

Species B lives for 15 years. In the first five years of life, the animals of species B mature from infants to adults, produce two children at some point between years 5 and 10, and dedicate the next 5 years to raising them. After their children reach adulthood and before dying in year 15, the animals of species B can assist in raising their grandchildren, or whatever else interests them. In times of plenty, the animals of species B might have a second litter of cubs.

Both animals are equally intelligent, but Species B, with a slower maturation and longer life, learn more during their childhood. As adults, they are more knowledgeable than those of species A. Living beyond their required lifespan for childrearing, adults of species B can help their offspring through challenges or to prepare for future ones.

Here’s the experiment: Island 1 is rich with easily accessible food, pleasant weather, and raw materials for nests or burrows. Island 2 has some fruit bearing plants, but their production depends on good weather, which on island 2 may be variable. Forage for food and nesting materials is more difficult. Put two animals of each species on each island.

It’s not difficult to think about what might happen. On island 1, the animals of species A rapidly multiply, filling the island and crowding out species B. On island 2, the animals of species A multiply slowly, and are less susceptible to periodic famines. Over time, the animals of species B survive and those of species A fail.

The interesting thing is that humans are both species. Evolution has made us live fast, reproduce, and get out of the way when living is easy, and live slowly, reproduce opportunistically, and stick around to help the young survive when times are tough.

Research has shown that most animals live dramatically longer when subjected to what is essentially a starvation diet. More than this, many people once thought that early puberty in children was related to hormones in milk. Today we know that it is very likely obesity that triggers early puberty: it seems the more food available, the earlier our bodies prepare for reproduction. Other facts conform with this theory: for example, women experience amenorrhea from stress, low body weight, and excessive exercise. Doesn’t this seem like signals that it was not a good time to have children during the evolution of the modern human?

Could the problem with America be that we are killing ourselves with abundance? As manufacturing, technology, and even services are increasingly being delivered abroad, America is increasingly specializing in two things: feeding its population and combating the effects of this with medical technology.

Could the solution to Americas health care crisis be so simple as to stop eating so much? We ask for medicine to furnish more and better chemicals to counter the influence of the chemicals we put in our bodies. Why don’t we just cut back on these chemicals? We’ve all heard pitchmen advance the benefits of anti-oxidants, but why don’t we just stop consuming so many oxidants?

Let’s be species B, living slowly by our wits. Species A is bigger and stronger than Species B but stupider, lazier, and shorter lived. The nations that are out-competing us in the industrial, technological, and, increasingly, intellectual arena are composed of lean, mean, species B, while we Americans gorge ourselves on corn and fat.

We have two hopes: we could stop this, cutting our caloric intake and re-gaining our intellectual edge. Alternatively, we could export our easy, fat complacency.

Tylenol’s Maximum Daily Dose Lowered

Every year, acetaminophen overdoses send 56,000 people to the emergency room, cause 26,000 hospitalizations, and take more than 450 lives from liver damage, according to the FDA.

This news has prompted Johnson & Johnson, the makers of Tylenol, to decrease the maximum daily dosage of products containing acetaminophen to 3000 mg/day. This move was made because too many people are not following the recommendations, which in part is due to so many products containing acetaminophen including cold and flu medicine, prescription medicine such as percocet, and others.

Advocates of this industry decision are hopeful that other companies will follow in Johnson & Johnson’s footsteps, and is overall a good public health effort to reduce the amount of overdoses on acetaminophen.

The Healthcare Bubble

We just got through a couple of financial bubbles.  There’s another one, harder to see, in healthcare.

There are two basic criteria for a bubble.  First is a disconnect between value and price, with price exceeding value.  Second is for that disconnect to increase rather than correct.

The real estate bubble was built on two consumers and an intermediary.  One consumer was homeowners.  Homeowners are usually fairly unsophisticated, and make decisions irrationally: I love this house, someone else is bidding for this house, my realtor tells me it is good.  The other consumers were purchasers of debt securities: they wanted to invest their cash in securities that paid better than government debt.  The intermediaries were the realtors and the banks, who took a percentage of every deal.  We knew that real estate was a bubble because one could buy substantially the same asset for very different prices, and yet many assets were sold at the higher price.  (If buyer A and buyer B both wanted the same house and A was paying with cash while buyer B was paying with a no-money down subprime 2-year NINJNA ARM, buyer B was paying a much, much higher price for the house.)  Finally, real estate did not self-correct because it was a positive feedback system: every participant gained from inflating prices.

Healthcare is the same.

Several studies have shown that good health outcomes are not a function of the cost of care.  McGlynn at RAND showed that many patients receive unnecessary care and don’t receive recommended care.  Jack Wennberg and his Dartmouth Atlas Project showed that many people pay as much as 60% more for the same or worse results than others — and it’s not just pricing differences, they receive 60% more care.  Patients, physicians, hospitals, and insurers collude to keep the bubble inflated.  Many patients feel that more care is better care.  Care is complex, but patients usually like to get it.  There has been a lot of work on the placebo effect, and it’s clear that most people believe that care is helping them, and that more care helps them more.  Physicians, who are usually paid for the care they deliver more than the results they achieve, have a financial incentive to recommend that care.  Hospitals are in the same position.  (It should be noted that many, many physicians do not deliver unnecessary care even though it might be profitable to do so.  This is demonstrated very simply by noting that Wennberg’s atlas uses real care to identify the low-cost regions–those physicians who do not over-treat their patients.)  Many people think that private insurance companies profit by limiting care, but the reverse is true: insurers make their profits from a percentage of the care delivered.  If healthcare costs rise predictably, insurers price insurance accordingly and draw their profits from that amount.  Just looking at the math (and not at insurers), it is the unpredictable denials that drive profitability, where the insurance was priced assuming something was covered but then it wasn’t.

Just like with housing, we have a disconnect between the cost of care and the value of care: the best way to assign a value on health care is by looking at the minimum cost to achieve the best health outcomes.  The Dartmouth atlas shows this disconnect.  Just like housing, we have pressure to increase the this disconnect: the best health outcome is rarely perfect health.  Given this, people will often pursue better outcomes through seeking more care.  Further, providers are compensated for giving it, even if that care does not actually improve health.  This drives inflation.

Just like real estate in 2007, healthcare is in a bubble.  If everyone received the care delivered in the most efficient regions identified by Wennberg, 20% or more of health costs could disappear.  Note that Wennberg’s most storied finding was related to Medicare, the largest single health program in America and run by the government.  These savings could be more than all the interest paid on all the government debt put together.  If this happens fast, companies will collapse and hospitals will go bankrupt: they couldn’t afford the loss.  Even if it happens slowly, the end result will look very different from what we are used to seeing.

How will we recognize when this is about to happen?  I’m guessing that this will be a long, slow road.  If America adopts sensible health policy, this bubble will deflate all at once.  If policy remains the same, it is likely that soon, so many people will lose coverage that there will be a market opportunity for providers who promise only sensible care.  (This would also require policy change, especially with regard to shield laws for malpractice, but less radical.)

The key to understanding the bubble is recognizing what won’t pop it.  Health IT will not pop the bubble.  Universal coverage will not pop the bubble.  Medicare is part of the bubble, so expanding Medicare won’t pop the bubble.  The policy change that will pop the bubble would target services directly, either by using capitation or salary based models for physician payment.  Remember, pay for performance initiatives hold out only a tiny portion of the total payment for performance.  If I can get reimbursed for 60% more care but get a 5% penalty for doing so, by accepting the penalty I still get paid 52% more.

Like housing in 2005, much of healthcare is sustainable–in fact, it only survives–in an era of rising costs.  Flat or decreasing costs will hurt the system as much as they did housing and the banks.  For bearish investors, keep an eye out for another bailout–probably insurer and provider equity shorts would be better than shorting the debt, however think about GE, Siemens, and similar vendor-financing equipment vendors if hospitals are allowed to pass through bankruptcy.

Native iPad Application Lets Patients Do Own Onboarding

We are a technology company located in the heart of Silicon Valley dedicated to bringing innovative product and design to our nation’s healthcare system.

Currently we offer four points of access to our platform:

1) Web-Based Practice Management/Billing Software found on drchrono.com

2) Native EHR Application for the iPad found in the Apple App Store

3) Native Scheduling Application for the iPhone found in the Apple App Store

4) Native Android Scheduling Application found in the Android Market

All four of these portals work in conjunction with one another to facilitate an intuitive workflow between the doctor and their office staff.  As a doctor is on his iPad creating a set of clinical documentation and billing encounters the front desk automatically receives that data on drchrono’s Web-Based Practice Management and Billing Software.

Our OnPatient application is the next chapter in drchrono’s points of access.  We noticed that although we were doing an incredible job of making the doctor’s life easier  we were literally taking the office manager/staff’s day to day operations and turning them upside.  With this on-boarding tool the staff will no longer need to hand the patient a clipboard when they enter the waiting room.  They will be handing the patient an iPad (or they will use an iPad Kiosk). The patient will then be entering their own demographics, personal, insurance, and “custom” information forms made by each practice. They will even be signing off with a stylus feature on their HIPAA consent forms.

Our development team will be releasing this application to Apple’s App Store on Monday.  It will need to go through the arduous Apple Review Process and will be released to the public shortly after.  So, in about two weeks, you will be able to go right to the app store and download your free native patient onboarding application for your drchrono EHR, Practice Management, and Billing Software.

Thanks to the continual support and guidance from our current user base we are quickly becoming one of the most disruptive/innovative technology companies in the medical space.

Custom iPad EHR Notes

How to Make Your Own EHR Custom Note Template
From Dr. John Giacalone

In my humble opinion, one of the most powerful features of drchrono is that you can produce an extremely quick and efficient note without taking away from the doctor-patient encounter and without losing your unique personality in each and every note. Many of us have spent many years developing a specific style that we favor while writing our SOAP notes — a style that we are comfortable with; one that meets medical necessity expectations.

Instead of detailing every single option for making a custom template, I will focus on the {{value}} variable and discuss the most important aspects that will be sufficient for 95% of everyone using drchrono.  Additionally, what I am about to cover will empower the other 5% to explore the omitted options and master them through trial and error.

Before you begin to make your own custom templates, drchrono has many wonderful preset features and I suggest that you use them first.  Get to know each and every preset note template.  What this will do is provide you with a glimpse of the power of drchrono and it will also give you a few ideas on how you can fine-tune drchrono to sound exactly like you.

The first step in customizing your notes is to reverse engineer what you consider to be your finest patient note.  Working from the whole to form the individual parts will allow for a smoother overall experience.  Trial and error is inevitable but with repetition and fine-tuning, your custom note will evolve into a work of art.  To help illustrate the process, I have taken the liberty of creating a very general patient note using the Medicare-based PARTS format.  I will also make that note available to each of you so that you can have the basic framework to play with.  If you do nothing else but start with this template, you will have a complete note that shows medical necessity in the eyes of Medicare.

Now that you have your finest patient note, the next step will be to identify two different portions of the note: the concrete portion and the variable portion.  The concrete portion consists of the parts of the note that never change.  No matter who the patient is and the circumstances of their visit, these key parts will remain the same.  The variable portion is unique but predictable.  For example, not every patient will have the same region of the complaint, but every patient has the same exact regions.  So, while the complaint will be unique, you can still predict the possible regions.

Once you have finished identifying what is concrete and what is variable, you are ready to log in to drchrono.  Go to “Clinical Tools” and choose “Custom Workflow Editor.”  Welcome to your custom note laboratory.  Having this screen in front of you will be necessary for the final paragraphs.

Fortunately for you and me, you do not need any experience with programming to program your own custom note template.  You are intentionally limited to a few very well constructed pre-made variables in the top left corner and truthfully I typically use only one, {{value}}.  The “allowed values” box is where you will always list the variable portions that you found in your finest patient note.  Where you place the {{value}} variable in the SOAP sections will dictate where the “allowed values” appear in your generated SOAP note.  For 95% of doctors, the “SOAP note line item type” will always be set to “Field”.  “Field” allows you to place the variables of your finest patient note into the blank “Allowed values” box.  If you would like to select multiple variables at once, simply choose the option “allow for one or multiple values”.  You may find this valuable for sections like pain quality where the patient lists multiple descriptors instead of just one.

Now for a valuable tangent.  I want to emphasize the following point: it is completely acceptable to enter absolutely nothing into the “allowed values”.  What this will do is allow you to type whatever you want when you reach this box in your custom template note from your iPad.  This is very powerful because sometimes it will take more time for you to go through a list of 100 items neatly typed into the “allowed values” box than it will for you to simply type the name of the two items in question.  For example, it will be easier for you to simply fill in the blank for the appropriate subluxation complex than it is for you to type every possible variable into the “allowed values” box and then scroll through the options to select the appropriate subluxation complex.  This principle will carry through for many circumstances where you find yourself wasting time searching for the appropriate option.

Now choose a name for your custom template, set aside a little time and let the creative juices fly.  Employ the tips I have shared with you and even use the template I created to help illustrate the reverse engineering process from my original patient note.

Click here to copy Dr. John Giacalone’s template into your own drchrono EMR/EHR account.

Don’t have an account yet? Easily create a free drchrono EMR/EHR account by clicking here.