Health for life

This is the first of a series of blog posts in which I will recount my adventures at Stanfords Medicine X, Conference: An experience which has changed my life, and I will not soon forget. :-) 

The Palo Alto Westin Hotel is a small hotel tucked into the Palo Alto scenery, and spitting distance from Stanford University. Warm, and welcoming, employees genuinely seem to care about ones lodging needs. As I checked in (having completed a journey that began 9 hours before, at 2:00 AM, in Ames, Iowa), I gave the attendant $50 of my last $71, for a security deposit. I really hadnt planned on THAT, so I was hoping the rest of the day wouldnt require any more money from me. (I also hadnt planned on everyone, and their mother, requiring a tip from me.)

After settling in, I went about the business of trying to find out what I was supposed to do next. I was a little outside of my comfort zone... Okay, a lot outside my comfort zone. Okay, "The Village" level outside of my comfort zone. I hadnt traveled anywhere in 5 years; heck, I hadnt even left my small town to go anywhere in the nearby vicinity, in 5 years. When you have no car and minimal financial resources, the world sort of closes in on you. Social media, and walking everywhere, are about the few things you have.

I was in the most expensive city in America, where I knew no one, where I had $21 left, where I didnt know how to use my loaned smartphone, and where I had planned to attend a session in 15 minutes in some supposedly nearby street. "Just turn right on University Avenue, up ahead," said the bellhop. Except, there was a train running through it. Yes, a train. Before I had a chance to wonder much farther, two gentlemen who seemed about equally lost -- but who knew how to use their smart phones -- asked me if I was going to the Stanford startup session. "Yes, I said," so I followed them. And follow the leader is what I did... all weekend, pretty much.

What is the Angry Type 2 Diabetic doing in Palo Alto, you ask? Attending Stanford sessions, nonetheless? Well, in case you missed it (which I almost did), last Spring I was selected (among many applicants) for a scholarship to attend Stanfords Medicine X Conference, in Palo Alto, California. I had applied at the suggestion of a friend, and quickly forgotten about it. :-)

At the time I didnt know much about Medicine X... but my curiosity was piqued. I knew the things I believed in: the patient, the patients ability to quantify their experience, and social media to glue it all up together... and now Stanford University, via Medicine X, seemed to want to address all those things. Nothing makes one feel better than when the crazy things one rants about get acknowledged by large institutions.

So, I took them up on their offer. I was, and am, confident that this is the future of medicine. It is, in my mind, one of the only ways to guarantee the patient has a voice. A voice that isnt clouded by the need to see 30 patients or more a day, 6 minute doctor sessions, and clinicians who are hell bent on not deviating from anything they learned back in 1976. A way to circumvent the little treatment and education patients with type 2 diabetes are receiving. A way for patients with limited resources, to make the most of their health situations.

But... after a week of being stranded at home, with the flu, and not being able to work, the little savings I had for this event disappeared in the form of medicines and bills. So I almost didnt make it out there. Almost. I have my family to thank for making this event happen for me. For believing in this little wild adventure on which I was about to embark.

And boy was it an adventure.

I really wasnt sure what to expect... and thinking Id immediately see many of my fellow diabetes advocates, I had worn my fun-loving shirt "Diabetics Luv Pricks," for my travel day. It really made me an attention magnet, in ways I didnt want to be one. hehe "So what are YOU doing here?," "What exactly are you going to bring to MedX, with what you do?," "Whats your role in MedX?," "I thought this conference was just for startups," etc.

People were really proud of being startups of their own companies (even if it was just a company of 1 or 2), and people were really... PROUD of being in the center of the universe, as it was put to me more than once. And... it was a bit unnerving, to be honest.

Just like I did on my first day of college, I called home, and cried, and begged to leave. And just like on my first day, thank goodness I didnt.   :-) Culture clashes can be rough things.

A CAT scan. Wheres that big spleen?

Years ago, the Disease Management Care Blog ordered an abdominal CAT scan for one of its patients. The study was reassuringly normal except for the unexpected - and most likely benign - finding of an enlarged spleen. In the absence of any other worrisome findings, the interpreting radiologist recommended that another CAT scan should be done in six months to make sure it wasnt getting bigger. The patient agreed. The DMCB then fired up the electronic health record (EHR), scheduled the CAT scan order for six months, closed the encounter and moved onto the next patient.

Approximately one year later the patient returned for an appointment. Thats when it was discovered that the CAT scan had never been scheduled. The DMCB was later told that the EHR wasnt configured to schedule tests 6 months in advance.*

Its on behalf of patients like this and their physicians that the DMCB welcomes this Institute of Medicine report on Health IT and Patient Safety. It recognizes what most front-line EHR-using physicians have known for years:

"The evidence in the literature about the impact of health information technology (IT) on patient safety, as opposed to quality, is mixed but shows that the challenges... involve people and clinical implementation as much as the technology. The literature describes significant improvements in some aspects of care in health care institutions with mature health IT.  For example, the use of computerized prescribing and bar-coding systems has been shown to improve medication safety. But the generalizability of the literature across the health care system may be limited. While some studies suggest improvements in patient safety can be made, others have found no effect. Instances of health IT–associated harm have been reported. However, little published evidence could be found quantifying the magnitude of the risk." (bolding from the DMCB)

In other words, selective reporting involving best case scenarios fail to account for the reality that the old safety issues of a paper-based system are being displaced by new safety issues of an IT system and, whats worse, we dont know the extent of the problem.

Here are the IOMs (paraphrased) recommendations to Health and Human Services (HHS):

1. HHS, working with the EHR vendors, should develop a health IT surveillance plan.

2. HHS should foster the free exchange of information and address the "legal clauses" in contracts that shift liability from the vendors to the doctors (The AMA has erred to these as "hold harmless" clauses).

3. Data is needed that allows health IT users to publicly compare and share experiences among multiple vendors.

4. "A Health IT Safety Council" that assesses and monitor health IT safety should be established.

5. A public register of all health IT vendors should be established.

6. Its time to specify those processes that reduce risk and make the vendors adopt them.

7. Health IT related deaths, serious injuries and unsafe conditions need to be centrally reported.

8. An independent federal entity should be established that is empowered to any investigate deaths, injuries or unsafe conditions.

9. HHS should report annually on its progress.

10 More cross-disciplinary research is needed to improve the design, testing and use of health IT.

Bravo says the DMCB, bravo!



*many of the facts are changed, but you get the gist

Health for human | My first experience of a little story that I experienced on my idap disease is Coronary Heart Disease (CHD), at the age of 33 years old I had a heart attack while driving in the car. This is how I feel without any specific complaints in advance but, in fact my sudden shortness of breath with the cessation of breathing a few seconds (do not reach 1 minute) followed by back pain and a cold sweat off his entire body, I had time to panic I thought dying will fetch me, but Praise God still protects and gives me the opportunity to live in the moment. Because pain and shortness of breath that does not stop a few hours, my wife and I decided to go to one of the private hospital of international standard in Bandung (Bandung happened to my people)

at that time I dealt with the ER doctor. The doctor asked me what happened to my wife, immediately take action also in the stomach and given injections of drugs that have been opened recently placed under the tongue that I knew it was to thin the blood also to dilate coronary blood vessels in the heart, then installed the tool ECG in ECG after I tested positive for CHD, because my wife did not believe I am finally on the ECG is the second time, and the results remain positive CHD.

To further make sure I was rushed to the ICU for treatment and better outcomes. After blood was taken in the laboratory, but the result showed very high levels of total cholesterol where LDL levels (bad cholesterol) and high levels of HDL (good cholesterol) is very low, normal triglycerides, CKMB levels are very high anyway. These results are enough to prove that I am suffering from CHD.

My doctor advised me to dikateterisasi for the pairs of ring (ring) in the blood vessels are blocked, at that time in 2008 for the cost of a drug ring plus have to pocket 35 million dollars, because my curiosity dikateterisasi proceed with above instructions your doctor if the blockage is less than 40% then no need to be installed simply by taking the drug ring and a healthy lifestyle. My guess would be missed if the blockage of blood vessels that I experienced there was a five-point with each - each 90% in fact there are already 100%. Automatic immediately anyway I thought about trying to multiply it cost 35 million dollars multiplied by 5 rings to be paid, instead of calm even so stressed I had to pay 175 million dollars plus the cost of care has not been long in the hospital, I finally decided not to proceed with its own mounting ring (the ring) had been at the heart of assuming a very large cost and outage I havent enough money for it all.

Coming home from the hospital I was advised consume the drugs doctors prescribed which must be redeemed approximately 1.5 million for each month. I spent the days are heavy with patience, and keep remembering tawakal also closer to the Almighty Creator. My situation is not improved even continued to decline from day to day for a bowel movement I just have to consume the drug in order to smoothly let alone to walk up the stairs to the second floor I could not because my breathing is quite crowded.

Because there is not much activity the end I often read books and go to the internet related to coronary heart disease problem, which is quite surprising is the danger of the negative effects of the drugs that I normally consume with my determination to stop consuming drugs did cause long-term effects I received an impact that will cause other serious illnesses. I consumed drugs in the period was only 2 months, the effect is very pronounced indeed that is the condition of the body should be able to defend against a disease that we suffer so that the pain in the chest and shortness of breath I felt almost a year.

Ok to get a lot of knowledge from books and the internet and advice - advice from friends and people around me, I tried alternative medicine by applying the knowledge I gained life squad a day - day.

Here are some tips that I will share to you the following (I will not detail the presentation, but by and large just as I do)

1. Diet diets eating the rainbow of vegetables and fruits (rainbow colors green, yellow, red, etc.) every day at least two times two servings (2-3 colors) processed without being fried, since any kind of cooking oil or even unsaturadfat the unsaturadfat poly kalo is heated at high temperatures will turn into trans fats are quite dangerous for the body is the greatest contributor to cholesterol.
2. Consumption of fish contain enough omega 3 to avoid seapood (clams, squid, shrimp, crab, and the like)
3. Avoid foods that contain totally bad fats, contains a lot of instant cooking spice in cooking should be natural spices especially shrimp.
4. Who used to eat white rice is advisable to switch to brown rice because it contains lots of fiber, or switching to wheat or barley,Also avoid processed foods that contain flour and the like.
5. Avoid foods and drinks containing processed sugar consumed the recommended 2 tablespoons of pure honey before the morning meal and 2 tablespoons before bed 1-2 hours after dinner.
6. Avoid over dinner at 7 mlm, ideally sleeping 9 hours max mlm organs begin to work again after a day beraktipitas reshes.
7. Consuming omega-3 supplements if you can that contain squalen also min 2x a day 500 mg - 1000 mg depending on serving size persoftjel, his usefulness to dilate the arteries and lowers cholesterol (before eating)
8. 1 tablespoon olive oil 2x a day before meals, the efficacy of raising HDL cholesterol levels
9. 1 tbsp sunflower oil 2 times a day, the efficacy of the blood to thin pieces and decrease total cholesterol (before eating)
10. 2 eggs habbatsauda (black cumin) 2x a day before meals contain many properties of the amino acids needed by the body to replace damaged cells.
11. Consuming drinks of mangosteen rind 2 x day / 200 ml glass, how to make it that after washing, immediately cut 2 mangosteen fruit, boiled in 4 cups water over medium heat and do not use media from a metal made from Pyrex or recommended use of the land clay to the boil and the remaining 2 cups, drained and then filtered and ready to drink. Because mangosteen is a fruit that is quite rare in the market, so that mangosteen peel can be stored for a long time should be cut and thrown away the hard outer skin of the past in sliced ​​and then dried in the sun to dry for about 3 hours and boiled according to the estimated dose above was when it dried, could add 2-3 tablespoons of honey and 2-3 grains of dried flowers rossela. Efficacy contain 17000-20000 oxygen radical absorbance capacity or equivalent 80-10 oranges its anti-oxidant content.
12. It is advisable to drink plenty of water at least 8 glasses per day, so toxins can be removed from the body through urine or sweat to the fullest.
13. Wake up early morning pull out a deep breath while stretching the muscles of the body approximately 10-15 minutes. Do a few minutes bending over like someone who is bowing to the circulation of blood-borne oxygen to the brain smoothly do every day.
14. Do the exercise at least 5 times a week for 20 -30 minutes walk enough heating or stretching the body should be used for 10 minutes, for the sick heart is still heavy do it gradually bit by bit.
15. avoid stress and be reasonable.
16. Perform or recreation or a time to walk along with the family for a reshing atmosphere of each month.
17. In addition to the above tips are still a lot I want to say but too long if I posted here including cupping therapy combined with suction leech therapy, acupuncture, and lexology.

At this time Alhamdulillah my health condition is normal and gradually be

activity returned as usual, yet I still manage and maintain health with no excessive activity. We are sorry if there are words or writing that is not acceptable. May be useful to our brethren who have the same disease as I have suffered, humans can only sought but only Allah is the Almighty Creator decisive. Do not despair there is still the spirit of every difficulty there then there will also ease if we are patient in living healing InsyaAlloh sure we get. Good luck.

Enshrining a term only an actuary could love, the Affordable Care Act sets health insurance coverage on the basis of "actuarial value" (AV).  A good summary can be found in this Consumers Union Health Policy Brief.  As the Disease Management Care Blog understands it, AV is the percent of typical medical expenses that a health insurance policy will cover for a typical population.  In other words, some individuals will have no out of pocket expenses (deductibles, coinsurance and limits) while other individuals will have end up paying for most of their services.  When those expenses are rolled up over thousands of persons and compared to total health care costs, the percent left over is the "AV."

Once the Disease Management Care Blog wrapped its head around the AV, it next tackled the ACA concept of the "essential health benefit" (EHB).  This is the minimum package of covered services (outpatient, emergency room, maternity, hospitalization, medications, rehabilitation and the like) that a health insurer must include in its coverage plan.  This will ultimately be defined in yet-to-be-determined federal regulations. 

Now that we have the jargon nailed down, plans that fail to meet at least 60% of AV on the EHB will be excluded from the exchanges and ineligible for federal subsidies.  60% is "bronze" coverage, while 70%, 80% and 90% are "silver," "gold" and "platinum," respectively.  This is important because not only did most members of Congress not understand AV (consumer costs) or EHB (coverage), but because both will determine the future cost of our nations health care bill. 

Enter the Institute of Medicine (IOM), which has just released a report on how the Feds should best determine the EHB.  A handy summary can be found here.

Bottom line? 

The IOM has backed into the EHB, not basing it on notions of optimum health coverage but on affordability.  It recommends that the basic affordable EHB be based on a survey of what is typically covered by an insurance plan that is purchased by a small business employer.  With that as the baseline, the EHB be further modified (based on scientific evidence and public input) so that the premium ultimately matches 70% of the small business AV.  According to John Iglehart writing in the New England Journal of Medicine, that could work out to be about $5000 per year for individuals and about $13,500 for families.

This is significant because the key underlying assumption of the ACA was that forcing everyone in the risk pool (with the Constitutionally suspect "play or pay" provision) with insurance rich in wellness, prevention and services like rehab, mental health and pediatric oral care would, by itself, drive down health costs.

The smart folks over at the Institute of Medicine respectfully disagree.  They believe the best approach is to figure out what is affordable first and then define the insurance coverage second.

Its finally happened.  While its not explicitly stated, the Federal deficit has noisily bumped into the Affordable Care Act. The IOM has given the ACAs supporters cover over the inconvenient intrusion of costs into coverage, affordability into access and reality into fantasy.  Even if the IOM recommendations fall on deaf ears, DMCB readers can expect the the Federal budgets problems to now and forever be part and parcel of the ACA.

What to do?  When the Disease Management Care Blog is flummoxed, it likes to break into song.  One song that comes to mind is Taxman......

The Battle of Thermopylae or an image of modern patient care?

What can the Battle of Thermopylae and The Simpsons teach us about patient centered medicine?

The Disease Management Care Blog says read on.

At one testosterone-laden point in the six-pack riddled fantasy movie "300," the Spartan narrator admires how some non-Spartan warriors made a "wondrous mess of things" at the Battle of Thermopylae.  It was professional warriors accommodating the pitchfork wielding non-professional farmers in the drive to victory.

And so it is with "patient centered medicine." When it read the New England Journal Perspective by Charles Bardes titled Defining "Patient Centered Medicine," the DMCB was reminded of a coming mess in health care.  That includes the doctor-patient relationship, payment and quality measurement, all of which promise to be scrambled by a decidedly non-professional, imprecise and radical notion: consumers are going to have a big role in what drives value in health care.

While DMCB readers are already familiar with the rhetoric of consumerism, empowerment and shared decision making, Dr. Bardes reminds us that full adoption of PCM will go far deeper. PCM is based in a "biopsychosocial model" that trumps illness over disease and caring over curing. Its rooted in 1960s style psychotherapy that involves a highly tailored, shared and special therapist-client relationship where the journey was no less important than the destination. Graft that onto modern notions of consumerism and medical "value" goes from being scientific, precise, quantitative and measurable to being subjective, shifting, qualitative and immeasurable.

This is important because it redefines the one-sided "special knowledge" that defines the doctor-patient relationship,threatens the business-as-usual payment methods and calls into question the use of measures like HEDIS and Medicares HospitalCompare.

This may be silly, but think about donut munching Homer Simpson and what this could mean for primary care.  While one would expect Homer to get a prescription to control his diabetes, generate a monthly management fee for his patient centered medical home and have an A1c (that would probably undermine his PCPs quality scores), that goes all away in PCM. What we have instead is empowered Homer ultimately deciding if he really wants to take any pills, payment that is based on his subjective satisfaction and quality measures that record whether Homer was allowed to make informed choice among several treatment options. Whether Marge gets a mammogram is not important; its whether Marge actively choses to get a mammogram or choses not to.

To Spartas credit and Hollywood fiction aside, the historical record shows Spartan King Leonides et al welcomed the help of their amateur Greek brethren in stopping the Persian invasion. So, heres a question for the the DMCBs professionals colleagues running the health care system: are we prepared to accept the participation of Homer and Marge in reshaping a dysfunctional health care system?  If the answer is yes, where in the battle can we use them and how much "mess" are we willing to put up with?

Critics look at employee wellness

Only the Disease Management Care Blog can link population health, a JAMA "Viewpoint" article on personalized medicine and a Wall Street Journal editorial on the alleged futility of worksite wellness.

The DMCB explains.

The JAMA article, written by Drs. Goldberger and Buxton, illuminates the cognitive dissonance over guideline-based vs. personalized medicine. 

The former represents the best care advice for a condition based on a published body of evidence.  Makes sense, but that evidence is typically based on multiple research studies involving populations that are both broad (able to generate statistically significant data) and representative (similar to other patients with the same disease). 

The latter describes tailored medical treatment that is suited to the individual characteristics (and personal preferences) of each patient.  This suggests that within the flow of "populations" that form the basis of a generalized guideline, there are circumstances for some persons that might make a particular treatment of greater or lesser benefit.

While Goldberger and Buxton use a complicated example involving implantable cardioverter defibrillator therapy to illustrate the conundrum, the DMCB has a simpler example.  Current guidelines support yearly mammography in every woman over the age of 50 years. Does that apply for the terminally ill woman in hospice or for a woman who, despite the advice from her physician, decides to forgo the test?

Intellectually reconciling competing policies of guidelines, such as "best practice," "reducing variation," "benchmarks" and "pay-for performance" on one side vs. personalized "informed consent," "patient empowerment" and "clinical judgment" involves subpopulations.  In other words, within any population-based study that shows an intervention is of benefit (mammograms save lives) there are subpopulations where the intervention is of little to no benefit (exceptions to every rule).

Which brings the DMCB to this provocative Wall Street Journal editorial condemning the entire worksite wellness industry. It recycles a number of tiresome criticisms, including outcomes tainted by regression to the mean, over-reliance on process-based outcomes, selection bias, employee discrimination, savings vs. program costs and overdiagnosis.  

Another criticism of the industry is the need for workforce-level (total) savings vs. per-participant savings. Since wellness programs typically focus on subpopulations of employees at greatest risk who are most likely to benefit and willing to participate, the observed savings can be limited to a few patients.  Unless those savings are culled from the large pool of total health insurance claims, they are otherwise invisible and critics will unfairly pounce.

Worksite wellness offers personalized care for limited numbers of patients.  That is its essential value proposition and its curse.  Until we can reconcile the total care via standardized guidelines vs. a more nuanced approach using personal care, it will continue to be criticized.