Moonshots for Health Care

It sounds a lot like Star Trek's iconic statement, "Go where no man has gone before"

Paradoxically that is where we are at with health care, financially, technically and for access to care.

A strange coalescence of increasing needs, increasing elderly patients, and conflicting needs for financial resources has attracted investors, entrepreneurs to apply known and developing technologies across many disciplines ranging from biochemistry, genetics, material engineering, and artificial intelligence.

A Moonshot is, in the technology context at least, an ambitious, exploratory and ground-breaking project, normally undertaken without any near-term expectation of profitability, and without the full investigation of all potential risks and benefits to come further down the road.

Current Moonshots from Startup Health include supporting the U.N. Sustainable Development Goals for health and wellbeing by 2030 and a mission to improve the health of everyone on the planet by 2040.

Access to Care Today, healthcare is for the few, for those who live near more developed cities or towns, and for those with money. Fully half of the world’s population goes without needed healthcare. Lack of access to quality healthcare is a problem affecting billions of people across diverse economies in every corner of the globe. Access to care is about geography – is it a four hour drive to the nearest hospital? But it’s also about being able to afford the care once you arrive. To solve the access problem we’re building radical new solutions that address delivery, cost, geography, and technology. We will need to leapfrog legacy systems and dream up brand new ways of doing business.

Cost to Zero About 800 million people spend at least 10% of their household budgets on medical expenses, according to a 2017 report by the World Bank and WHO. That’s expensive enough to send 100 million people into extreme poverty. Mobile technology internet connectivity are flipping the cost of care paradigm. Telemedicine has dramatically lowered provider overhead. New population health startups are upgrading the way patients battle chronic illnesses, slashing costs. We’re on a moonshot mission to take costs from poverty- inducing all the way to zero. The only way that is going to be possible is for us to dismantle our understanding of health and rebuild the machine from the ground-up.

Cure Disease Heart disease. Cancer. Stroke. Obesity. Diabetes. Six in 10 U.S. adults have a chronic disease. These diseases, which accounted for tens of millions of deaths in 2016, are already within our power to treat or cure. Through basic apps run on smartphones, people can follow healthy diets and schedule recommended screenings. The bottom line: If a cure exists, it should exist for all, and health tech has the potential to be that democratizing ingredient. A moonshot to cure disease is about access, but it’s also about discovery. Groundbreaking advances in machine learning are increasing our capacity to understand the drugs we’re making, and how they will affect our bodies. This, in turn, is opening the door to faster cures and targeted medicines for rare diseases.

End Cancer Cancer claims the lives of millions, shattering families across every bracket of age, geography and economic status. By 2030, the number of new cancer cases per year is expected to top 23 million. Chances are, you know someone personally who has battled cancer. And if you don’t, you unfortunately most likely will. To defeat cancer once and for all, it is going to take true moonshot thinking. A global cancer moonshot is built on a level of collaboration we’ve never seen before. It’s going to require breaking down data silos between academic institutions, reaching across political aisles, and even sacrificing personal egos.

Women’s Health Being born a woman shouldn’t be a health risk factor. But in much of the world, it is. Achieving the Women’s Health Moonshot means widening the aperture on the definition of women’s health, focusing on issues that move beyond the current litmus test — sexual and reproductive health — to a standard of living well. This includes a women’s right to physical and mental health and wellbeing. According to the WHO, self-harm, including suicide, was the second leading cause of death globally among females, aged 15–29, in 2015. It means creating a world where individual women no longer have to shoulder the burden of advocating for themselves in order to get proper medical care, a world where they can rely on the medical system

Children’s Health  On one hand, we have cause to celebrate. Global annual infant deaths have been cut in half between 1990 and 2017. At the same time, we see massive opportunity for improvement. Every year more than 1.4 million children under five die of preventable environmental hazards like air pollution, hazardous chemicals, inadequate water, sanitation and hygiene. Nearly 100,000 kids under 15 die of cancer even though the vast majority of childhood cancers are potentially curable with existing treatments.

Nutrition & Fitness If we are what we eat, we’re a world of extremes, desperate for a healthy middle. On one end is hunger. According to UNICEF, in 2017 approximately 200 million children under the age of five suffered from malnutrition. Where malnutrition has been abolished, we’ve created an epidemic of excess. Obesity is now a primary cause of some of the world’s biggest killers, like heart disease, stroke and diabetes. Billions of people the world over are overweight, and 650 million are obese. Together we can create a world where all people have access to the foods they need to thrive, prevent disease, and stay healthy regardless of where they live. We also can build communities of support to help people control their weight and live healthy lifestyles.

Brain Health  With every new age has come startling, beautiful revelations about the human brain. How, like an intricate map, sections of the three pound mass can be tied to everything from speech to memory to personality. Yet the more we understand it, the less it appears like a map, and the more it opens up like an unexplored galaxy, full of mysteries and new frontiers. The Brain Health Moonshot means dismantling the old, siloed notions about basic neurology and searching its great depths to unlock its mysteries. No longer will we merely treat health challenges without connecting the brain to the solution. We will master the mechanisms of the brain in ways that will create new opportunities for health and wellness and then share them with the world.

Mental Health & Happiness  The DSM-5 tells us that there are approximately 300 mental disorders. We live in a world where 600 million people suffer from depression and an epidemic of loneliness threatens our elderly population. Advances in mental health research have shown us deeper and more nuanced ways of understanding how our chemistry and environments affect our brains, and our behavior. The Mental Health and Happiness Moonshot reimagines what it means to thrive, feeling whole inside and out. It means using telemedicine and smartphones to expand the reach of mental health services. It means gamifying healthy habits in a community of peers. And it means expanding our definition of happiness in ways that we can’t even fathom yet.

Addiction According to the National Survey on Drug Use and Health, close to 20 million American adults (aged 12 and older) battled a substance use disorder in 2017. What’s clear is addiction is no longer anonymous, like the sign at meetings suggests. Its cords are reaching into families everywhere, ripping at the fabric of our communities. The time is now to fight back, to radically alter our thinking about treating addiction and ending the opioid epidemic. It starts by rethinking what’s possible. Together, with a unified will, global collaboration, and innovative health treatments, we can create a world where addiction is a crisis of the past.

Longevity  The Longevity Moonshot is just as personal as it is technical. Where you live greatly impacts how long you live. What public health experts refer to as social determinants of health—think housing quality, access to fresh food, water and air quality—are thought to be among the most powerful influences on a person’s health. As more people live longer, we need the ability to scale senior care in a way that addresses both medical and mental health needs in this older population. We need smart solutions to improve injury recovery. We need support and accountability to adapt a preventative mindset when it comes to our health in order to detect diseases earlier.


The groups are not listed in terms of priority.  Behind each of these goals are people and companies already on their moonshot.

Present and previous moonshot companies have videos explaining their goals.


What is your Moonshot ?

   For those of us who like meetings, Startup Events are listed here





Startup Health is an internet driven organization whose purpose is to attract other high-minded entrepreneurs to health care as an investment opportunity.   We are all invited to join the effort.

Using CRISPR to edit eggs, sperm, or embryos does not save lives

Some scientists hail reproductive applications of CRISPR as potentially lifesaving and curative. That claim for CRISPR is mistaken and misleading.


This startling announcement by He Jiankui almost one year ago that he had created the first genetically modified human beings unleashed a torrent of criticism. It also brought to the surface common misunderstandings — even among scientists and ethicists — that reproductive uses of this genome-modifying tool have therapeutic value, will treat people with genetic disorders, will save lives, and will eradicate disease. None of those are true.

The twin girls that He helped create are publicly known as Lulu and Nana. Their father is HIV-positive. The scientist said he used CRISPR-Cas9 genome editing technology to disable a gene called CCR5 to mimic a naturally occurring gene deletion that appears to confer immunity against HIV.



In a recent publication, The  Journal of Bioethics the ethics and thinking behind this ill-advised experiment are viewed by another expert.

A major criticism from the scientific community, which has otherwise been generally supportive of advancing gene technologies, was that He did not use the technology to address a serious medical need. That criterion stems from a 2017 report by the U.S. National Academy of Sciences and the National Academy of Medicine recommending that, once the technology is ready and safe, genetic modification of embryos could be allowed when there is a “serious disease or condition” to be addressed and no “reasonable alternatives” exist.

IVF with pre-implantation genetic diagnosis is an existing alternative to CRISPR for preventing the transmission of genetic disease.

PHILIPPE LOPEZ/AFP VIA GETTY IMAGES

This scientific criticism of He’s experiment was on target: Although HIV infection is a serious disease, there are proven ways to prevent transmission of the virus from an infected father to his offspring, and later in life to prevent or treat the infection.

This act can be compared to the young child finding a gun and shooting itself because it did not understand what a gun does.  It's actions cannot be reversed....the genie is out of the bottle.

Careful consideration must be taken when designing and proposing gene editing using CRISPR or any other techniques which alter the 'germ line' of human and mammalian cells. We know so little about the long term effects of clipping out parts of the gene or adding snippets.  If there are other methods of treatment with known risks, they should always be used first. "primum non nocere" is one of the first things that medical trainees are taught.

Although we 'think' we know how genetics works and how DNA fits into programming protein manufacturing each year that goes by new surprises appear to disprove our theories.

CRISPR does offer a new tool for research in laboratory animals, bacteria, viruses.  Unique genes  can be inserted to use microorganism's machinery to manufacturer new drugs.

"Prime editing" is more precise and more efficient than CRISPR and could herald a new era of genetic manipulation.




Using CRISPR to edit eggs, sperm, or embryos does not save lives - STAT:

CMA to tackle four major issues at annual meeting

CMA physician delegates meet annually to establish broad policy on current major issues that have been determined to be the most important issues affecting members, the association and the practice o...

The 148th Annual Session of the California Medical Association (CMA) House of Delegates (HOD) will tackle four major issues when it convenes October 26-27, 2019, in Anaheim.

This year’s major issues are:

Augmented Intelligence: Technology continues to transform the way physicians serve patients, creating opportunities and exposing challenges that prevent quality, timely and affordable care. While CMA has adopted policies addressing telemedicine, electronic health records and interoperability, it’s time to explore pragmatic solutions that address medical decision-making, new liabilities and privacy concerns inherent with augmented and artificial intelligence. With few laws and regulations on the books, CMA needs to proactively develop new policy that keeps physicians at the center of health care delivery.

Cannabis: CMA has adopted extensive policies concerning cannabis use and regulation, including our 2011 white paper, “Cannabis and the Regulatory Void.” As the state’s legal cannabis industry continues to grow and evolve, CMA must continue to weigh in on pressing issues, including health impacts associated with cannabis use, public health protections, federal legalization, data and surveillance efforts, high-quality research, marketing and advertising practices, cannabis equity programs and more.

Homelessness: Physicians witness the homelessness crisis in emergency rooms, clinics and on the streets of our communities. The multi-faceted challenges of housing, case management, intervention programs and public health considerations require California’s physicians to weigh in on evidence-based solutions that address the health care and social needs of those at risk of or experiencing homelessness.

Adverse Childhood Experiences: When it comes to trauma-informed care, CMA supports efforts for data collection, research, and evaluation of screening for Adverse Childhood Experiences (ACEs), recognizing there is a growing need to increase familiarity on the what, when and how to incorporate ACE screening practices into routine care. California physicians need tools, resources and funding to address their patients’ cumulative ACEs, which has a strong correlation to numerous health, social and behavioral problems throughout their lives.







CMA to tackle four major issues at annual meeting:

The number of transplant physicians is dwindling. That's a problem - STAT

Over the past few years, applications for training fellowships for transplant physicians has been on a decline, even as the need for them is increasing.

By DAVID WEILLOCTOBER 17, 2019

As the need for organ transplants grows, the number of transplant physicians dwindles

At any given time in the U.S., about 120,000 people are waiting for the call that they’ve been matched with a donor for a new lung, heart, liver, or kidney. That number will continue to rise, but the number of doctors to take the 2 a.m. call that a donor has been found for their patient and perform the transplant is dwindling..

About eight years ago, while directing the lung transplant program at Stanford University, I began noticing a sharp decrease in the number of applicants for the transplant fellowship program — a requirement to become a transplant physician — even though we had the oldest and best-established lung transplant training program in the world. Typically, I’d see five to six applicants a year, but in recent years I haven’t seen any. In my current role as a consultant to major transplant centers around the country, I’ve learned that this wasn’t specific to Stanford, and there has been a noticeable decline in the number of physicians committing to the transplant field, regardless of organ type.

Most Americans probably aren’t aware of the decline in the number of individuals training to become transplant physicians and how it will affect the future of medicine. Neither are the 2020 presidential hopefuls, all of whom have policies they believe best provide health care coverage for Americans without acknowledging or calling attention to the fact that soon there may not be enough doctors to do the work once more people are insured. We need a plan for that.

Our most vexing challenges in medicine right now are twofold: attracting young people to the field and keeping them there. These challenges are even more acute in transplantation. I have 12 months to teach fellows to be proficient at organ transplantation. It’s not enough time, so I work them hard. Throughout the history of medicine, training has been characterized as a “grand bargain” in which trainees make personal sacrifices with the expectation of a better life once they are practicing physicians. But that’s a deal many don’t accept anymore.

Physician wellness is a major factor. Up to half of physicians experience anxiety, depression, insomnia, and poor interpersonal relationships. Things may be worse for transplant physicians, as many view this field as unstructured with few boundaries to the physical work and, more importantly, one that requires a huge emotional commitment. In essence, transplantation is seen as a sure path to physician un-wellness. So, while many think about training in the field, most ultimately pursue other options.

Fifteen years ago, a lung transplant center would be considered large if it performed 40 transplants a year. Now the largest centers perform nearly 100 lung transplants a year (sometimes more) without concomitant increases in staffing. Harried transplant physicians care for an increasing number of patients, all the while under pressure from hospital administrators to do more transplants and pressure from regulatory bodies and insurance companies to produce better outcomes.









The number of transplant physicians is dwindling. That's a problem - STAT

“Things Providers and Patients Should Question.”

The mission of "Choosing Wisely" is to promote conversations between clinicians and patients by helping patients choose care that is:

Supported by evidence
Not duplicative of other tests or procedures already received
Free from harm
Truly necessary

Beginning in 2012, national organizations representing medical specialists have asked their members to identify tests or procedures commonly used in their field whose necessity should be questioned and discussed. This call to action has resulted in specialty-specific lists of  “Things Providers and Patients Should Question.”

The original list was compiled the American Academy of Family Physicians

Don’t do imaging for low back pain within the first six weeks, unless

red flags are present.

Red flags include, but are not limited to, severe or progressive neurological deficits or when serious underlying conditions such as osteomyelitis

are suspected. Imaging of the lower spine before six weeks does not improve outcomes, but does increase costs. Low back pain is the fifth most

common reason for all physician visits.

Don’t routinely prescribe antibiotics for acute mild-to-moderate

sinusitis unless symptoms last for seven or more days, or symptoms

worsen after initial clinical improvement.

Symptoms must include discolored nasal secretions and facial or dental tenderness when touched. Most sinusitis in the ambulatory setting is due

to a viral infection that will resolve on its own. Despite consistent recommendations to the contrary, antibiotics are prescribed in more than 80

percent of outpatient visits for acute sinusitis. Sinusitis accounts for 16 million office visits and $5.8 billion in annual health care costs.

Don’t use dual-energy x-ray absorptiometry (DEXA) screening

for osteoporosis in women younger than 65 or men younger than

70 with no risk factors.

DEXA is not cost effective in younger, low-risk patients, but is cost effective in older patients

Don’t order annual electrocardiograms (EKGs) or any other cardiac

screening for low-risk patients without symptoms.

There is little evidence that detection of coronary artery stenosis in asymptomatic patients at low risk for coronary heart disease improves health

outcomes. False-positive tests are likely to lead to harm through unnecessary invasive procedures, over-treatment and misdiagnosis. Potential

harms of this routine annual screening exceed the potential benefit.

Don’t perform Pap smears on women younger than 21 or who have

had a hysterectomy for non-cancer disease.

Most observed abnormalities in adolescents regress spontaneously, therefore Pap smears for this age group can lead to unnecessary anxiety,

additional testing and cost. Pap smears are not helpful in women after hysterectomy (for non-cancer disease) and there is little evidence for

improved outcomes.

– Nine leading physician specialty societies have identified specific tests or procedures that they say are commonly used but not always necessary in their respective fields. Patient advocates are calling the move a significant step toward improving the quality and safety of health care.

 The lists include things to question such as:

Do patients need brain imaging scans like a computed tomography (CT) or magnetic resonance imaging (MRI) after fainting, also known as simple syncope? Probably not. Research has shown that, with no evidence of seizure or other neurologic symptoms during an exam, patient outcomes are not improved with brain imaging studies. (American College of Physicians)

Do patients need stress imaging tests for annual checkups? Not if you are an otherwise healthy adult without cardiac symptoms. These tests rarely result in any meaningful change in patient management. (American College of Cardiology)
Should patients going into outpatient surgery receive a chest x-ray beforehand? If the patient has an unremarkable history and physical exam, then no. Most of the time these images will not result in a change in management and has not been shown to improve patient outcomes. (American College of Radiology)

Do patients need a CT scan or antibiotics for acute sinusitis? Most acute rhinosinusitis resolves without treatment in two weeks and when uncomplicated is generally diagnosed clinically and does not require a sinus CT scan or other imaging. (American Academy of Allergy, Asthma & Immunology)

Should dialysis patients who have limited life expectancies and no signs or symptoms of cancer get routine cancer screening tests? These tests do not improve survival in dialysis patients with limited life expectancies, and can cause false positives which might lead to harm, overtreatment and unnecessary stress. (American Society of Nephrology)

Should women under 65 or men under 70 be screened for osteoporosis with dual energy x-ray absorptiometry (DEXA)? No, research has shown that in patients with no risk factors, DEXA screening is not helpful in this age group. (American Academy of Family Physicians)

Since 2012 when the list was established it has grown substantially and many common tests performed regularly are on it.  This by no means that those tests should not be done. They must be considered in a larger framework of history, family history, physical examination and some routine blood tests.


To help patients engage their health care provider in these conversations and empower them to ask questions about what tests and procedures are right for them, patient-friendly materials were created based on the specialty societies’ lists of recommendations of tests and treatments that may be unnecessary.

The choosing wisely list was compiled by a large number of medical specialty societies.

Note: Choosing Wisely recommendations should not be used to establish coverage decisions or exclusions. Rather, they are meant to spur conversation about what is appropriate and necessary treatment. As each patient situation is unique, providers and patients should use the recommendations as guidelines to determine an appropriate treatment plan together.


The list has been duplicated and disseminated by numerous consumer oriented publications

Ref:  Choosing Wisely.

Nobody Wants a Waiting Room

With his nose buried in a binder full of specifications for standardized outpatient

clinics, the architect asked, “Where do you want your waiting rooms?”

“I don’t think anyone wants a waiting room,” came the earnest reply.

Chuckling, the architect persisted, “Yeah, you’re probably right, but let’s figure out

where they’re going to go in this building.”

“Actually, we’re not going to have waiting rooms. Nobody wants a waiting room.”

The room grew quiet, and a few people shifted uncomfortably. The architect,

sensing no jest in the exchange, looked up and gently closed his binder. “But

everyone has waiting rooms . . .”

Health Reform cannot take place only in the Digital Health Space, but also the physical space, we call our offices or clinics.  A twenty minute wasted time at the very beginning wastes a lot of patient time, and if we really want to be patient-centric we cannot ignore the patient's needs.

This initial conversation would be the spark for a series of struggles over the next 2 years as we attempted to establish a new model of care, with a service blueprint and an environment to enable it.

In the summer of 2015, as the new Dell Medical School at The University of Texas at Austin began planning for the launch of its specialty clinics, the school’s embedded Design Institute for Health was asked to assist in the design of both the service model and the physical layout of the clinic.

The possibility of eliminating waiting rooms represented one opportunity to transform the patient experience. For patients and family, the feeling of wasted time, alongside others who were ill, was a source of frustration and anxiety, and reinforced the prioritization of the system’s needs over the patient’s. We felt it was impossible to address these drawbacks, no matter how many amenities were included, and waiting rooms wasted valuable floor space

This concept produces a windfall of cascading improvement in patient satisfaction. While at first it may be disorienting to patients and staff the learning curve will be swift, in fact much quicker than the transition to electronic health records.

The possibility of eliminating waiting rooms represented one opportunity to transform the patient experience. For patients and family, the feeling of wasted time, alongside others who were ill, was a source of frustration and anxiety, and reinforced the prioritization of the system’s needs over the patient’s. We felt it was impossible to address these drawbacks, no matter how many amenities were included, and waiting rooms wasted valuable floor space

Nobody wants a waiting room, and no one needs a waiting room

“But I need a waiting room. Where else will I get my patients from?”

A clinical leader at the medical school, when told that we wouldn’t be building waiting rooms, insisted quite sincerely that the clinic wouldn’t be able to operate efficiently without a ready supply of patients at hand. The concern reflected a “factory” metaphor that is almost universal in traditional clinics paid on a fee-for-service basis.

The waiting room is nothing more than a temporary stock room, or intermediate warehouse for patients with billable conditions that feed exam rooms every 10–15 minutes, ensuring the unbroken stream of billable encounters demanded by RVU targets or other measures of productivity. No health care provider I know actually views patients as a packaged revenue opportunity, but the fee-for-service system has incentivized this warehousing behavior.

Rather than delivering patients serially to one exam room after another, each owned by a different provider, we made the patients the owner of their own rooms, and instead, circulated the providers to the patients.”

All of this is well and good if you are building out a new space or as leasehold improvements. But what about your office that is already built out.  How can you improve your space to make it more pleasant?

Enter the office:

Snack Bar

 The Concourse

The Boarding Pass

Open Office Concept

Here are some relevant sources:

https://www.accentoffice.com/five-ways-to-make-waiting-rooms-more-welcoming/

https://www.btod.com/blog/2017/02/01/the-best-colors-for-an-inviting-waiting-room/

http://www.digitalsignbuilder.com/adslide-medical-waiting-room

https://www.nuemd.com/news/2017/03/03/5-tips-making-your-medical-practice-more-inviting

https://www.careinnovations.org/resources/14-ideas-to-transform-your-waiting-room/

https://www.patientpop.com/blog/running-a-practice/6-strategies-turn-waiting-room-asset/

https://www.warehouse-lighting.com/articles/Lighting-for-Hospital-Waiting-Rooms

Remember that the modifications to your physical space can produce a return on investment in produdctivy with increased number of patients and improved staff and patient satisfaction.

Attribution: https://catalyst.nejm.org/nobody-wants-waiting-room/

Patients Eligible For Charity Care Instead Get Big Bills |

Nonprofit hospitals admit they sent $2.7 billion in bills over the course of a year to patients who probably qualified for free or discounted care.  When Ashley Pintos went to the emergency room of St. Joseph Medical Center in Tacoma, Wash., in 2016, with a sharp pain in her abdomen and no insurance, a representative demanded a $500 deposit before treating her.

Health Care Finance Bullying.

She said, ‘Do you have $200?’ I said no,” recalled Pintos, who then earned less than $30,000 at a company that made holsters for police. “She said, ‘Do you have $100?’ They were not quiet about me not having money.” But Pintos, a single mom with two kids who is now 29, told state officials St. Joseph never gave her a financial aid application form, even after she asked.

Pintos said she was examined and discharged with instructions to buy an over-the-counter pain medication. Then St. Joseph sent her a bill for $839. When she couldn’t pay, the hospital referred the bill to a collection agency, which she said damaged her credit and resulted in a higher interest rate when she applied for a mortgage.

Not many people talk about this despicable standard of care in some hospitals.  About 56% of American community hospitals have nonprofit status, which frees them of paying most taxes and allows them to float tax-exempt bonds. In return, they are supposed to provide community benefits including free or discounted care for patients who can’t afford to pay.

The IRS leaves it up to each hospital to decide the qualifying criteria. A comparatively generous hospital may give free care to people earning less than twice the federal poverty level — around $25,000 for an individual and $50,000 for a family of four — and may provide discounts for people earning up to double that.

For those who do not qualify, hospitals often offer payment plans. But they can turn to aggressive tactics if bills are not resolved. Patients can be pestered by debt collectors, and some hospitals sue them or try to garnish their wages. Medical debt can damage credit ratings — one study calculated Americans had $81 billion in collections in 2016 — and forces some people into bankruptcy.“

While some hospitals say they write off the debt of poor patients without ever resorting to collection measures, several hospitals whose practices were highlighted in news reports this year for aggressively suing patients admitted to the IRS they knew many unpaid bills might have been averted through their financial assistance policies. 

Analysis of Debt Process

Patients Eligible For Charity Care Instead Get Big Bills | Kaiser Health News: Nonprofit hospitals admit they sent $2.7 billion in bills over the course of a year to patients who probably qualified for free or discounted care.

Social Determinants of Health in the Digital Age: Determining the Source Code for Nurture | Health Disparities |

Previously on a routine history taking there were several categories of organization, ranging from chief complaint, present illness, family history, past medical history, review of systems.and social history I remember memorizing those categories and the questions in each category.  Regardless of what a patient complained about it was standard to perform this standardized method of taking a history.

In today's world the Social determinants of health include socioeconomic, familial structure, health insurance coverage and other sociological factors, religion, community, social networks and more.

Remarkable advances in medical science, clinical care, and therapeutics over the last 60 years have established the current understanding of the “nature” side of disease. The “nurture” components of disease also have been explored, revealing strong associations between social support and health outcomes. However, prior investigations into social determinants have often been limited by self-reported information based on reductionist instruments with standardized responses. Moreover, social determinants are complex, and entail networks and behaviors that are best revealed by what actually occurs in life, rather than the perception of these complex relationships. Individual and network data available within social platforms therefore have the potential to elucidate the understanding of social determinants of health and could offer measurable, actionable insights into how disease can be prevented. To date, only limited direct links between medical and complex social network data have been made.

Corresponding Author: Freddy Abnousi, MD, MBA, MSc, Facebook Inc, 1 Hacker Way, Menlo Park, CA 94025 (abnousi@fb.com).

In this Viewpoint, Harlan Krumholz and colleagues discuss the promise that social media data hold for helping researchers better understand social determinants of health, and the challenges that must be overcome to reliably link social network data to clinical and health outcomes.

Leveraging the Social Determinants of Health: What Works?

The roots of interest in social determinants of health can be traced back in part to the World Health Organization (WHO), which, in 1946, notably defined health as “complete physical, mental, and social well-being.”3 Since then, a number of national and international efforts have increased awareness of the field, such as the WHO’s Commission on Social Determinants of Health and initiatives by the MacArthur and Robert Wood Johnson Foundations.4-6 From a research perspective, numerous studies have shown associations between social determinants of health and life expectancy.  While these studies reflect the overall importance of social determinants of health in relation to health outcomes, an important limitation of current research on social determinants of health is that many of the identified factors, such as income and education, cannot easily be changed.8 This is in part because of a lack of granularity in understanding the person and his/her community, compounded by the potential flaws introduced by survey self-reported social/behavioral variables as opposed to observed factors. Access to information that captures the habits, behaviors, and networks of individuals has been limited in the existing body of work as these parameters relate to health outcomes. As such, it is not surprising that actionable variables continue to be elusive.

Better approaches are needed for accessing information about observed habits, behaviors, and networks to foundationally understand their relationship with health and health outcomes. Despite the exponential increase in the role of social media in the daily life of individuals around the world over the last decade, most studies have not directly evaluated social variables from social network sources in relation to clinical outcomes.

Evaluating social network data in combination with increasingly available digital health care data (such as from large, national clinical registry programs or electronic health records) could lead to novel, more nuanced understanding of social and behavioral variables that account for the interplay of the individual and the network in relation to health outcomes. These may transform the traditionally held social determinants of health, including education, income, housing, and community, to encompass a more granular tech-influenced definition, ranging from simple factors, such as numbers of online friends, to complex social biomarkers, such as timing, frequency, content, and patterns of posts and degree of integration with online communities. With data related to millions of users, network effects may amplify the total range of patterns and associations.

These aspects lean toward 'population health' measures.  this kind of research also harbors potential risk and clear challenges. As was done for the Human Genome Project, the first step will be to establish the legal and ethical framework for this endeavor. Social network data raise unique challenges to deidentification beyond the typical demographic identifiers. For example, when an individual posts a simple phrase, the exact composition of words used can become a form of identification in its own right; developing the techniques to de identify this kind of data will require thoughtful approaches. In addition, a combination of physical and software-driven isolation needs to tightly control access to the data. Concurrently, investment in research towards the creation of “synthetic data sets” (ie, data sets that maintain associations but have the original data removed) may serve to advance security and privacy for the next iteration of this research.Some authors have even suggested the use of social media as a measure for social determinants. For those not familiar with the standards of health care professionals this would be a dangerous measurement.

Facebook has had serious privacy violations in the breast cancer group Thousands of women who carry mutations in the genes BRCA1 and BRCA2 and joined ‘private’ Facebook groups recently learned that their groups were vulnerable to a Chrome plug-in that allowed marketers to discover group members’ names and other private health information.  That Chrome plug-in has since been removed from this, and apparently all other private groups, but has left a deep scar in the BRCA community’s trust in Facebook. 

Safeguards have been put in place for Facebook which include removing the chrome extension grouply.io.  This extension allowed for mass harvesting of group members data.

The bottom line is that these methods are not yet ready for prime-time and should carefully be investigated until ethical and legal matters are addressed and codified.

Social Determinants of Health in the Digital Age: Determining the Source Code for Nurture | Health Disparities | JAMA | JAMA Network:

Waste in the US Health Care System: Estimated Costs and Potential for Savings | Health Care Policy | JAMA | JAMA Network

ECO- HEALTH .   CAN WE GO GREEN ?

Author

Can we become Green doctors and patients?  Our current focus on  health reform has been to make it more efficient and less costly.  Our country shares two statistics that are shameful.  . We suffer with the highest costs globally, and we are one of the most polluting country in the world.


Audio click .   William Shrank .
 

The term "eco-health' also refers to  the effect of our environment on personal well-being.

The United States spends more on health care than any other country, with costs approaching 18% of the gross domestic product (GDP). Prior studies estimated that approximately 30% of health care spending may be considered waste. Despite efforts to reduce overtreatment, improve care, and address overpayment, it is likely that substantial waste in US health care spending remains.

This review used the framework of 6 domains of waste that guided previous work (failure of care delivery, failure of care coordination, overtreatment or low-value care, pricing failure,  fraud and abuse, The estimated annual savings from these interventions ranged from $22.8 billion to $30.8 billion.) administrative complexity)2,3 and added estimates of the cost of low-value care to the “overtreatment” domain (Table 1).

Low-value care was defined as services that provide no or minimal benefit to a patient in a specific clinical situation.15 In addition to new evidence on the cost of waste, evidence regarding cost-saving interventions was reviewed to provide estimates of potential waste reduction in each domain if those successful interventions were scaled. 

Two articles addressed cost of waste from administrative complexity (Table 2), and no articles were identified that addressed savings from interventions. The estimated total annual cost of waste in this category was $265.6 billion.

This review of the current literature of the cost of waste in the US health care system and evidence about projected savings from interventions that reduce waste suggests that the estimated total costs of waste and potential savings from interventions that address waste are as high as $760 billion to $935 billion and $191 billion to $282 billion, respectively. These estimates represent approximately 25% of total health care expenditures in the United States, which have been projected to be $3.82 trillion for 2019.

Patients and providers alike must learn about and question why their physician orders a test or a treatment. Both are subject to commercial marketing practice and competition amongst laboratories, imaging services, hospitals, clinics and pharma for their share of the marketplace.

68 of the greenest hospitals in America | 2018

In addition to financially going Green, a focus on minimizing pollution, increasing recycling, and improved energy efficiency are of paramount importance. While other industries are giving attention and resources to these issues, health care has not.  Cogeneration and alternate sources of energy have been ignored by hospitals and large medical clinics. There is little competition from medical device manufacturers about energy efficiency of their products.

Waste in the US Health Care System: Estimated Costs and Potential for Savings | Health Care Policy | JAMA | JAMA Network: This Special Communication uses a systematic literature review to update previous dollar estimates of waste in the US health care system attributable to failure of care delivery and coordination, low-value care, price inflation, fraud, and administrative complexity.

CMA President Responds to Trump Administration’s Executive Order on “Protecting and Improving Medicare for our Nation’s Seniors.”

CMA President David H. Aizuss, M.D., issued the following statement in response to the Trump Administration’s new executive order on “Protecting and Improving Medicare for our Nation’s Seniors”

By issuing an Executive order the administration intends to bypass Congress's powers for health care just as he did for border and immigration. His order includes 'sweeping" changes many of which could effect America's healthcare. It is a carrot and stick approach to gain acceptance by physicians and patients.  It would reduce massive bureaucracy and regulation and at the same time drastically reduce reimbursement to providers.

“Since Day One, this administration has worked to undermine access to care and quality of care for patients. The president’s latest Executive Order suggests changes regarding scope of practice that would also have disastrous effects for patients. We must ensure that every American, regardless of age or economic status, has access to a trained physician who can provide the highest level of care. We agree that medical professionals should be able to practice at the top of their license but care must be supervised by a physician who is highly trained and ultimately responsible. Expanding access to care should not come at the expense of patient safety and we will not support unequal standards of care for patients from different economic backgrounds.”

It strips away a differential reimbursement algorithm which pays physicians differently than nurse practitioners or physicians assistants.  The new regulation would pay a uniform amount to a second level provider equating their expertise with that of a an accredited licensed M.D. (or a specialist).

It merges  disparate functions of the FDA and HHS in an attempt to legislate increased efficiency and decrease reimbursement.

It would prohibit any legal action by a person or organization to hinder the implementation of said executive order.

Para: 12:3 in General Provisions.

  "This order is not intended to, and does not, create any right or benefit, substantive or procedural, enforceable at law or in equity by any party against the United States, its departments, agencies, or entities, its officers, employees, or agents, or any other person."

Attribution is given to FDA, HHS, CMA. Statements outisde ".." are those of the author and do not represent any other organizational entities.  The author has no financial interest in other health care entities and owns no shares of medical, Pharma or business corporations












CMA President Responds to Trump Administration’s Executive Order on “Protecting and Improving Medicare for our Nation’s Seniors.”:

Why Are Hackers Targeting Hospitals? - ReferralMD

attrib: Shutterstock

 Why do hackers target healthcare data? Hospitals need to spend more and pay attention to cybersecurity in order to prevent data breaches.

Did you know that more than 25 percent of all data breaches that occur in a given year affect hospitals and healthcare facilities? Why is healthcare data a target for hackers?

Research from 2018 suggests that health data is the second most at-risk type of information after social security numbers.  In 2019, there have been more than 25 million patient records affected.

It’s also very important to point out that out of all hospital data breaches, 53 percent originated within the establishment itself. What’s even more troublesome is the fact that for most hospitals, more than a month passed from the initial hack attack/breach to its detection.

Why are healthcare facilities vulnerable and what makes hackers target such institutions? Why are health security challenges becoming more difficult to address every single year?

The conclusion reached was that hospitals were severely lacking in data security measures due to the lack of funding, the lack of appropriate staffing, no employee training pertaining to the best data security practices, improper organizational structure, the overall lack of a security policy and the lack of security audit procedures.

Why Do Hackers Target Hospitals?

The research quoted in the introduction suggests that over 15 million patient records were breached in 2018. The number of affected records has nearly tripled over the course of a single year – from slightly over 5.5 million records in 2017 to over 15 million records in 2018.

There are several reasons why hackers are so keen on accessing healthcare facility and patient information.

Patient data can easily be sold off, which is the number one reason why healthcare facilities are subjected to so many hack attacks.

Health records and other patient-related information are hugely demanded on the black market. In some instances, hackers are even capable of selling the information back to the hospital itself. Needless to say, they generate massive profits from such “transactions.”

In essence, hackers can make money from patient data through blackmail or by selling such records to the highest bidder.

Hackers can also utilize the information of high profile patients. In 2017, for example, hackers breached the network of a major plastic surgery clinic in London. It was a high profile case that included information from numerous celebrity clients. That information consisted of pictures, medical records, addresses, and even sensitive financial data. Such information can easily be applied to fraudulent activities, stalking, and harassment.   Finally, hackers target medical facilities because they lag behind in the introduction of security measures. Bank and financial networks, for example, are heavily protected. This isn’t the case for medical facilities. Many of them don’t have the resources to introduce the latest safety measures and to make sure that patient information is properly protected.

Ways in Which Hospital Data Breaches Occur
A hospital’s database can be breached in several distinctive ways.

The first and easiest available option is the so-called social hacking. It involves getting credentials (user names and passwords, for example) from one of the individuals that have legitimate access to the network.

It’s very easy for someone to impersonate an IT company rep who needs to do maintenance, hence is looking for credentials information.

The second and a bit more challenging option involves the use of brute force to access the network in a completely unauthorized way.

Security experiments show that the second data breach method isn’t that difficult to utilize.

Healthcare Data Protection: Best Practices

Data security solutions are becoming more readily available today. Cloud-based technologies are scalable and cost-efficient. They allow for better protection through encryption, access monitoring and the logging of unusual activity.

A shift in mindset is needed for healthcare facility managers and administrators to see the cost-efficiency of database safety solutions. Until recently, these were perceived as too costly and only attainable within the framework of a large medical facility.

Educating staff members is even more important. As already illustrated by some of the examples, many hack attacks and security breaches are the results of negligence or complete unawareness of safety protocols.

Any IT security program within the healthcare framework should have a big focus on staff training. Many people are still unaware of how hack attacks occur, what’s phishing, malware or ransomware. When such threats become easy to identify, they also become easy to circumvent.

Good hospital data protection practices should also focus on the establishment of a secure wireless network, the encryption of portable devices and even the introduction of physical security controls like locking file cabinets (to protect paper-based data) and installing security cameras.

Hospital Security Necessitates a Thorough Approach. Workforce training and management is a requirement for all covered entities under the HIPAA Security Rule.

Making hospital data more secure isn’t about the introduction of a single measure. A thorough approach will be required to eliminate vulnerabilities from the network itself and to reduce the risk of human error.

Such measures, however, are long overdue.

Top 5 Healthcare Data Security, Infrastructure Threats

Ransomware, external threats, and advanced persistent threats are a few of the key healthcare data security and healthcare IT infrastructure dangers.

1. Ransomware
2. Outside Threats (human)
3. Advanced Persistent Threats (APTs) – Theft of IT and Corporate Data
4. Distributed Denial of Service (DDoS) Attack

The importance of information management in the healthcare context cannot be underestimated. While digitization is simplifying the management of larger information volumes than ever before, it also contributes to potentially disastrous security risks. The need for healthcare-focused security solutions and staff training courses is only going to grow in the years to come. While current statistics don’t pay an optimistic picture, technological advancements and higher levels of awareness will hopefully change the situation for the better in the near future.

Training Employees to Avoid Healthcare Data Security Threats

Healthcare employees must undergo regular and comprehensive training so organizations can better avoid potential data security threats.

Eighty percent of health IT executives and professionals said that employee security awareness is their greatest data security concern, according to a survey conducted by HIMSS Analytics and sponsored by Level 3 Communications, Inc.

There is a shortage of adequately trained cybersecurity experts. There are over 300,000 job positions available that remained unfilled A variety of solutions have been suggested, from retraining already employed personnel in cybersecurity, to Filling Healthcare Security Staffing Gaps with Virtual CISOs, Students.  The staffing shortage has hit the healthcare sector hardest: 79 percent of healthcare organizations find it difficult to recruit security staff, Ponemon reported. 

V-CISOS

Virtual CISOs, or vCISOs, are quickly becoming a sound method for effectively closing security staffing gaps. These cybersecurity leaders are offsite and are commonly shared between several organizations. On the surface, the move could seem risky: the leader is off-site and shares security time with other providers.

Those concerns are valid. But for smaller organizations that may not need a full-time security leader or that may reside in an area where it’s difficult to attract top security talent, a V-CISO can be more than effective at providing the necessary security policies, procedures, and support.

Synoptek, CynnergisTek, Pivot Point Security, and a host of others offer these virtual roles, which can be tailored to meet the needs of an organization.

Hospitals often struggle to find and retain security leaders who have the skillset to manage the complexity of the healthcare environment, Hewitt explained. Even with outside recruiting, there’s a moderate amount of movement in CISO roles. Resources also add to the challenge, as many can’t afford to retain top talent. VCISOs can fill that gap, while providing elements a traditional CISO cannot.

 “For mid- to small-sized providers, you can clearly see that a vCISO may be an advantage because, number one, they probably can’t afford additional training. But they can take that money and go with a vCISO, which will be shared across two to five hospital districts or providers. There’s an economy of scale.”

What should an employee do if they suspect a breach in cyber security 

Attribution is given to the following publications and/or organizations for the content herein.

Health and Human Services
exTelegent Healthcare Media

Fat Shaming does not reduce Obesity

Obesity is very difficult to cure or treat.  Research is exploring the road to being overweight. New concepts are emerging

My own concepts and observations led me to believe it was highly associated with lower-income populations.  This may be falsely attributed to my analysis that Walmart provides low-cost food and other household items. The two ethnicities I have observed are Hispanic and African-Americans specifically and not all people of color.  My demographic is based upon "The Walmart demographic" I have been to Walmart's in many regions of the United States, and it seems to be true in all regions.

We have all been faced with the aisle jams caused by people who take up an inordinate amount of floor space.

Update on the Obesity Epidemic

How and why weight stigma drives the obesity ‘epidemic’ and harms health

The obesity epidemic continues relentlessly across the globe, despite the increasing attention being paid to it. The latest CDC statistics (as of 2016) show that 39.6% of adult Americans are obese, with every state having a rate of >20%. This is an increase from 2011 – 34.9%. In fact, the trend has accelerated. The same is true worldwide. As of 2016, there were 650 million obese adults worldwide. This is no longer a problem of just industrialized nations, and obesity can occur alongside malnutrition. The figures have tripled since 1975.

A 2019 study published in Nature

Despite these alarming numbers, there remains a fringe of “obesity denial”, which I first discussed in 2011. There are two main elements to this denial. The first is the notion that people are not really getting fatter, that it is just a trick of statistics. This is clearly not true, as the trends over the last 8 years further demonstrate. Second, there is the notion that overweight and obesity may exist, but are not in and of themselves unhealthy. This is also not true but takes a bit more data to unpack.

The counterclaim is that obesity correlates with other things that are unhealthy, such as a poor diet, lower socioeconomic status, and less access to health care, but is not an independent risk factor for the disease. This is the “fat but fit” hypothesis. This has always been a minority opinion among experts, but a plausible interpretation of the data, resulting in some controversy. This is because the data, by necessity, is observational. You cannot make people get fat to see if they are more likely to die from the disease. Correlational data leaves the door open for multiple interpretations of cause and effect.

At this point, however, I think we can say that the data is in. The “fat but fit” hypothesis is all but dead. Multiple large studies have reasonably isolated obesity as an independent risk factor. A 2018 study in the European Heart Journal looked at almost 300,000 people prospectively. They first evaluated them for their metabolic health – diabetes, blood pressure, cholesterol – and then tracked their health over four years. They found that waist size was an independent risk factor for heart disease and strokes. Further, there was a “dose-response” effect – the bigger your waist, the higher your risk.

Brain cells -- not lack of willpower -- determine obesity, study finds

Further, being overweight is an independent risk factor for other things which themselves carry a further risk – such as sleep apnea, diabetes, certain cancers, and arthritis.

A recent study also shows this risk extends to younger age groups. Specifically, tracking of cancer rates over the last decade show a shift in obesity-related cancers to younger age groups.

In this cross-sectional study of 2,665,574 incident obesity-associated cancer cases and 3,448,126 incident non–obesity-associated cancer cases from 2000 to 2016, the percentage of individuals diagnosed with incident obesity-associated cancers increased in younger age groups, with some of the greatest increases observed for liver and thyroid cancers (all sex- and race/ethnicity-specific strata), gallbladder and other biliary cancers (non-Hispanic black men and women and Hispanic men), and uterine cancer (in Hispanic women in the 50- to 64-year age group).

We show that, contrary to the dominant paradigm, more than 55% of the global rise in mean BMI from 1985 to 2017—and more than 80% in some low- and middle-income regions—was due to increases in BMI in a rural area

The one thing about which there is general agreement is that the epidemic cannot be understood simply through the lens of individual behavior. This is a public health issue, relating to societal factors. A lot of blame focuses on the fast-food industry. Over the last 30 years, the average calorie content of a fast food meal has increased (along with salt and fat content). There is also a focus on “food deserts” – locations that lack sufficient access to fresh fruits and vegetables. There is some debate about the role of a sedentary lifestyle, although it seems the evidence supports the conclusion that obesity is largely due to excessive caloric intake.

Overweight and obesity is a complex behavior problem without a known consistently effective solution. The primary problem may be that we evolved in an environment that was calorie-restricted and now we have access to calorie abundance. The food industry competes with increasingly tasty products, and that means more calories. Health and dieting fads have apparently not been helping.

What is likely necessary is a significant change in the culture of food, but that is not something that is easily changed, or really in the power of any one organization or institution to change. That is why we debate endlessly about the causes and solutions to the obesity epidemic, while the numbers continue to worsen and even accelerate.