Artificial intelligence for medicine needs a Turing test - STAT

In today's post from STAT I . have included pertinent comments from other readers

Speculation abounds about what artificial intelligence can do for medicine. It's time to put it to the test — perhaps an obesity-related Turing test.

Top 15 Promising AI Applications in Healthcare
By  Shailendra Sinhasane  In 



If you read high-profile medical journals, the high-end popular press, and magazines like Science or Nature, it is clear that the medicalization of artificial intelligence, machine learning, and big data is in full swing. Speculation abounds about what these can do for medicine. It’s time to put them to the test.

From what I can tell, artificial intelligence, machine learning, and big data are mostly jargon for one of two things. The first is about bigger and bigger computers sifting through mountains of data to detect patterns that might be obscure to even the best trained and most skilled humans. The second is about automating routine and even complex tasks that humans now do. Some of these could be “mechanical,” like adaptive robots in a hospital, and some might be “cognitive,” like making a complex diagnosis. Others might be a combination of the two, as in the almost-around-the-corner self-driving cars.

The idea of computers sorting through data and detecting patterns is of great interest for analyzing images like mammograms and colonoscopies, and for interpreting electrocardiograms. But is this really transformative or novel? An early version of digital image analysis and facial recognition was proposed by the polymath Francis Galton in the late 1800s. Likewise, machine reading of electrocardiograms has been occurring since at least the 1960s. There are, of course, issues with AI and machine learning like overdiagnosis and misreads, but the narrative is that eventually more data and technology will solve such problems.

Perhaps, though, IBM’s overselling of Watson to use artificial intelligence to identify new approaches to cancer care is a cautionary tale and reminds us that many things in medicine lack fixed rules and stereotypical features, and so will be hard for AI to solve.

Related: AI startups are racing into drug development. Here’s 5 burning questions about which will survive
Another hope is that AI could somehow rehumanize medicine by improving workflows and replacing the current tidal wave of screen time with face time with patients. Although that could happen, all of the data and associated analytics could also lead to an ever more oppressive version of medical Taylorism and a drive for “efficiency.”

It is possible that technology could free physicians and enhance their interactions with patients, but as the recent move to electronic health records shows, that is far from certain and the economic imperatives of corporate medicine to see more patients, capture more charges, and generate more throughput might just as easily predominate. Regulators will also likely weigh in. And while “Alexa, please refill Mrs. Smith’s statin prescription” seems simple enough, will we — or do we want to — get to “Alexa, please schedule Mrs. Smith with everything she needs for hip replacement”?

I think we need a Turing test for medical artificial intelligence. Such a test, proposed by British mathematician and computer scientist Alan Turing in 1950, can determine if a computer is capable of performing complex functions like a human being. For medicine, the test should be a problem that is currently hard to solve. Here’s one I think would be perfect: create a weight loss plan for patients with severe obesity (a body-mass index of 40 or more) that is as effective as bariatric surgery. This would be a classic non-inferiority trial, in which a new treatment isn’t less effective than one already in use.

Obesity treatment as a test of medical AI has the advantage of an easily measured outcome — all you need is a scale — and a condition that is potentially treatable by one or more interventions. Surgery is effective for sustained weight loss, and there are good data on the most effective surgical approaches. But it isn’t the only option — some people achieve long-term weight loss without surgery. Class 3 obesity is a common condition with plenty of downstream hazards — including increased risk of developing diabetes, heart disease, cancer, and arthritis, as well as trouble with activities of daily living — so the ability to recruit motivated participants for a randomized trial should be relatively easy.

All sorts of data are available that could be fed into “the computers” to generate individualized plans for participants. Beyond simple demographics, the plans could also synthesize genetic data, diet and exercise preferences, and information from wearables. Text messages could be sent to remind people what foods to avoid or when they needed to get in more steps for the day. Shopping for food could be automated, and certain foods and portions sizes at restaurants could be made electronically off limits. Even better, customized menus could be constructed on demand. All of this could be linked to financial incentive programs.

Related: IBM pitched its Watson supercomputer as a revolution in cancer care. It’s nowhere close
If you really wanted to stretch the limits, cars could be programmed to make it difficult to stop at fast-food restaurants. Or some sort of “pre-eating” aversive stimulus could be applied when the algorithm detected signals or subtle behaviors associated with an increased likelihood of excessive eating — depending, of course, on ethical committee approval.

In short, it’s entirely possible to develop a truly comprehensive weight-loss plan.

The fact that genetic data, diet preferences, wearables, and text messages don’t seem to have much impact on long-term weight loss in controlled trials are only minor details. There are also a host of issues with implementing artificial intelligence in the real world. But let’s not get distracted.

Enthusiasts of AI, machine learning, and big data should throw caution to the winds and craft a highly effective alternative to bariatric surgery. Such a demonstration would clearly tip the scales and show the skeptics what medical AI can do.

Or put more simply: It is time for medical artificial intelligence to go big or go home.

Michael J. Joyner, M.D. is an anesthesiologist and physiologist at the Mayo Clinic. The views in this article are his own.

About the Author
Michael J. Joyner
@DrMJoyner

Top 15 Promising AI Applications in Healthcare
By  Shailendra Sinhasane  In  Blog  Posted  June 17, 2019
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Donna Lemons
SEPTEMBER 6, 2019 AT 5:26 AM
Well written Michael!! AI has the potential to be applied in almost every field of medicine including drug development, patient monitoring, and personalized patient treatment plans. The healthcare industry is evolving rapidly with large volumes of data and increasing challenges in cost and patient outcomes. So, early adaptation of AI in the healthcare space is necessary. I have found some articles very informative on this topic these are: https://www.navedas.com/real-world-examples-of-ai-and-healthcare-in-action/ and http://sitn.hms.harvard.edu/flash/2019/artificial-intelligence-in-medicine-applications-implications-and-limitations/








Artificial intelligence for medicine needs a Turing test - STAT:

Predictions for Price Increases in Pharma for 2019

https://www.vizientinc.com/-/media/documents/sitecorepublishingdocuments/public/july2019dpf_slides_summary_public.pdf


https://www.vizientinc.com/-/media/documents/sitecorepublishingdocuments/public/july2019dpf_drugpriceforecast_public.pdf

One of the most driving forces for increasing health care costs in the United States is the cost of pharmaceuticals.  If you compare drug prices in the U.S. with the U.K. E.U., Mexico or South American countries there is a great disparity.

Increases in drug prices cannot be compared using overall global prices when there is actually much price variation when looking at specific drug classes. There are large fluctuations in price when pharma companies are merged, or purchased by venture companies who anticipate great demand for a product.  Some well-known brand pharmaceutical manufacturers have disappeared from the market place.  Not all companies make huge profits.  Some companies barely make a profit, if any.

There are many orphan drugs on which companies lose fortunes. Then there are companies in the news which make huge profits. such as Purdue, the manufacturer of Oxycontin.

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The expansion of smart health communities |

Industries are catching on to the inefficiency of data silos.  Health care is its own silo. Expanded connectivity and the exponential growth of technology are enabling smart health communities, which could offer a modern take on community-based well-being and disease prevention.

Five core components industry and government stakeholders can consider in the shift to health and well-being

Expanded connectivity and the exponential growth of technology are enabling smart health communities (SHC), which could offer a modern take on community-based well-being and disease prevention. 

HISTORICALLY, health care was delivered in the community. Physicians made house calls; birth and death happened inside the home. As the modern hospital developed, health care migrated inside its walls. Meanwhile, the concept of health became increasingly medicalized, and separated from people’s daily lives.

One example of an SHC is the YMCA’s decades-old National Diabetes Prevention Program (DPP), which uses the community to encourage individuals to proactively manage their weight and exercise with a coach in a group setting based at a local YMCA. While successful, these programs have had limited reach since they are tied to brick-and-mortar locations and require individuals to participate in person. 

THE FIVE KEY ELEMENTS OF A SMART HEALTH COMMUNITY

Digital technologies have the potential to significantly bring these programs to scale, thus increasing their impact. The widespread use of smartphones—which are prevalent even in lower-income communities—can increase the potential for virtual programs to scale widely. Apps on these phones can incorporate concepts from the behavioral sciences, such as nudges and gamification, to help people stay on track with their health care goals. 

The recently relaunched WW International (formerly Weight Watchers International), which now uses a technology platform to create a virtual community focused on weight loss and wellness and is informed by the science of behavior change, is an example of an SHC that is leveraging technology effectively.

A significant body of research shows that about 80 percent of health outcomes are caused by factors unrelated to the medical system. Our eating and exercise habits, socioeconomic status, and where we live have a greater impact on health outcomes than health care.

The pendulum is now swinging back to the community. Nontraditional players, including public, nonprofit, and commercial enterprises are establishing “communities” focused on prevention and well-being. These communities can be geographically based local initiatives, virtual communities with a global presence, or hybrids of the two.

The Deloitte Center for Health Solutions and the Deloitte Center for Government Insights interviewed over a dozen leaders from prevention and well-being initiatives outside of our traditional medical system to learn about the characteristics that are essential to their mission. These interviews have contributed to the development of a concept we call smart health communities (SHCs), which we define as containing some or all the following core features:


They empower individuals to proactively manage their health and well-being;

They foster a sense of community and belonging;

They use digital technology and behavioral science;

They use data to meaningfully improve outcomes; and

They create new and innovative ecosystems.

The dramatic changes reshaping health care today are driven in part by the intersection of Metcalfe’s Law and Moore’s Law. 

Metcalfe’s Law describes how the value of a network escalates dramatically as membership increases. Moore’s Law describes how computing power doubles roughly every two years. In tandem, these two phenomena will likely allow SHCs to grow and become more sophisticated, interconnected, and influential over time. 

                                  Metcalfe's Law

As this happens, the impact of community-based health interventions could be brought to scale, while becoming more personalized. Looking 20 years into the future, technology and other factors may allow more health care to migrate out of institutions and for SHCs to become more integrated into our daily lives, allowing for more preventive and personalized health interventions that can exist alongside—and perhaps even in collaboration with—our existing health care structures.

Smart health communities and the future of health

The expansion of smart health communities | Deloitte Insights:

UnitedHealthcare to Begin New Site of Service Policy

UnitedHealthcare has announced it will begin site of service medical necessity reviews for certain surgeries when surgery is performed in an outpatient hospital setting. In California, the reviews will begin Dec. 1.

The site of service policy is not unique to UHC, and Oxford, Cigna Anthem, and others use the same protocol.

The policy limits the circumstances in which UnitedHealthcare will pay for certain surgeries performed in a hospital outpatient setting, determined by the insurer whether or not the site of service for the procedure is medically necessary. Other states that will see reviews starting on or after Dec. 1 are Colorado, Connecticut, New Jersey, and New York. The policy will not apply to providers in Alaska, Kentucky, Massachusetts, Maryland or Texas.

"Medical necessity reviews for the site of service occur during our prior authorization process and are only conducted if the surgical procedure will be performed in an outpatient hospital setting," UnitedHealthcare said, according to Becker’s Hospital Review. "We utilize our Outpatient Surgical Procedures – Site of Service Utilization Review Guideline to help make our site of service medical necessity determinations. Site of service medical necessity reviews are currently being conducted for certain surgical procedures and will apply to additional surgical procedures beginning on Nov. 1, 2019, for most states."

The number of outpatient facilities jumped from 26,900 to 40,600 (51%) from 2005 to 2016, according to a report from CBRE, a commercial real estate services and investment firm. Along with it, rent has shown a similar trend, setting a record high in the second quarter of 2019, rising 1.4% per year to $22.90 per square foot.

Making services more convenient and more affordable is what it comes down to, said Christopher Bodnar, vice chairman of CBRE Healthcare Capital Markets, according to Modern Healthcare.

"That strategy moves along the entire continuum of care for providers. It's front and center for their real estate strategy as well," Bodnar said. "We are seeing health systems look to decompress their main campus and look to move more services to an outpatient setting."

Hospital outpatient settings typically cost more, due to their increased overhead as a component of an acute hospital

With the outpatient surgery policy, the insurer said it hopes to reduce healthcare spending by guiding patients toward ambulatory surgery centers, where care may be cheaper when there isn't a substantial medical reason for the surgery to be performed in a hospital outpatient setting..

Correlating with this emphasis on freestanding ambulatory surgery centers the number of outpatient facilities surges as industry values more convenient, affordable care  systems are looking to keep pace with mergers like CVS Health and Aetna and Optum's continued push into the market, drawing patients away from the hospital into a retail setting, closer to where people live and shop to fulfill the demand of more accessibility. 

The number of outpatient centers increased by 51% from 2005 to 2016, a trend that shows no sign of slowing.  The number of outpatient facilities jumped from 26,900 to 40,600 between 2005 and 2016, according to a new report from commercial real estate firm CBRE. Rents have followed. They reached a record high in the second quarter of this year, rising 1.4% year over year to $22.90 per square foot, driven by areas with low vacancy rates like Louisville, Ky., Seattle, Nashville, Manhattan, and Indianapolis.

It mainly comes down to two things: making services more convenient and more affordable, said Christopher Bodnar, vice chairman of CBRE Healthcare Capital Markets."Technology is also changing so fast that providers can bring care to the consumer quicker and in a different way," Mark Lamp, executive managing director of healthcare at CBRE said. "Providers recognize that they need to deliver care differently than they have in the past."

Some hospitals partner with other real estate ventures to lower cost and add value.

Rush University to outsource facility management, illustrating a trend

Source:  https://tinyurl.com/y4mtfajz

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UC Irvine Medical School gifts Butterfly handheld ultrasounds to its whole class of 2023

The University of California, Irvine presented each member of the class of 2023 a handheld/smartphone portable ultrasound device.  This represents a considerable upgrade for the stethoscope treasured by so many neophyte physicians.  No longer would the treasured stethoscope hanging from the neck of students, nurses and nurse practitioners be the status symbol.

Ultrasound machines are usually those large instruments wheeled around from room to room with a large display.  It required a  physician order to have an ultrasound technician to perform the test.  Now the ultrasound will become ubiquitous.  For most diagnostic purposes it will be carried in a pocket by the physician for immediate use.  And for most studies, it will be adequate.  If a more advanced ultrasound is needed it can be ordered.  In 90 % of cases, it will be used to rule out serious problems in an emergency department, urgent care center, nursing home or even at home.

Normally $2,000, the devices were free for the 104 newly-minted members of the class of 2023.

In 1966 when I was a junior at George Washington University School of Medicine we were gifted a Welch Allyn Diagnostic set in a zipper case.  It was a moment like that I am sure the UCI medical students experienced.  This gift measures the strides we have taken since 1968. Very few would imagine a hand-carried ultrasound would take the place of the 'stethoscope' which had become an icon about physicians.

Nine years ago, the University of California at Irvine Medical School became the first medical school in the country to equip each of its 104 incoming students with their own iPads.

This month, at the same White Coat Ceremony where that announcement was made back in 2010, Dr. Michael J. Stamos, the school’s dean, surprised the class of 2023 with another gift: Butterfly handheld ultrasound devices.

The devices are the students’ to keep, and it's no small investment on the school’s part — each device retails for just under $2,000.

“When our faculty director caught wind of Butterfly coming into existence, we had talked about this being a big game-changer for us,” Dr. Warren Wiechmann, UCI’s associate dean, told MobiHealthNews. “Historically, we had been using a lot of laptops and cart-based ultrasounds, which are technically portable but they’re not handheld and they are still a little bit limiting for our students. So when we heard about Butterflies, that really opened up the possibility that we could move toward this idea of having every student with an ultrasound machine in their pocket.”

An additional important feature of this device is that images can be uploaded to a cloud and also interface with the electronic health record for permanence. Incorporated in the network software is a provision for reimbursement coding (CPT) and diagnostic information. (ICD)
WHY IT MATTERS

Butterfly Network’s device, which secured FDA clearance two years ago, uses a novel ultrasound-on-a-chip technology to make handheld portable ultrasounds cheaper and more accessible. The mission is not just to make it easier to use ultrasounds in the ways they are already used, but also to change the status quo — using ultrasounds in areas of medicine where they might be useful but formerly would have been impractical.

“From the very beginning, it’s an affirmation of this device and the role it could play in the transformation of healthcare,” Dr. John Martin, chief medical officer at Butterfly, said. “If you look across the practice of medicine, two-thirds of medical dilemmas can be solved with simple imaging devices. In the past, I had to order that test. Now, as a physician I don’t have to order that test; the test is in my pocket. I can communicate with my patients, I can share that information with them instantly, I can make rapid decisions, and that puts this school far out front of others across the country.”

Martin and Wiechmann hope that students will take the technology and treatment methodologies it enables with them after they graduate.

“The fundamental purpose of good medical schools and good residency programs is they help people develop the knowledge and skills and then seed the rest of the planet with those people and then they take that knowledge to those institutions,” Martin said. “I’m pretty confident that’s what’s going to happen.”

THEIR TAKE

Members of the class of 2023 said they are excited at the prospects of the device for patient engagement and for bringing care to lower-income, lower-infrastructure parts of the globe.

“I think it’ll help me connect with my patients, which is pretty much essential to establishing continuous care of a population,” Leonardo Alaniz, an incoming student, said. “It will enhance my abilities as a physician, and it will also give me the opportunity to share what I see. Patients aren’t always committed to sticking with the health plans we put them on, and I think that [better communication] ultimately can lead to better outcomes.”

“I’m looking at doing a program for ultrasound initiatives, global outreach around the world, in the summer between first and second year,” said Christina Grabar, another student. “I think having my own Butterfly and being able to use it well before the program starts is not only going to enhance my research but then when I’m going to teach other physicians about this technology, I’ll feel even more comfortable with it.”

THE LARGER TREND

UCI’s cultivated reputation for training the next generation of digital-savvy doctors goes beyond iPads and ultrasounds. The school has also experimented with Google Glass and AliveCor’s ECG device, as well as investing in high-fidelity simulations.

In 2013, the school boasted that the first class to receive iPads saw a 23% boost in their test scores.


“I think it’s important that we prepare our students to become the best 21st-century physicians and not necessarily be held to the classic constructs of how medicine is practiced and how medicine’s delivered now,” Weichmann said.

First hint that body’s ‘biological age’ can be reversed

In a small trial, drugs seemed to rejuvenate the body’s ‘epigenetic clock’, which tracks a person’s biological age.

A person’s biological age, measured by the epigenetic clock, can lag behind or exceed their chronological credit: Patrick McDermott/Getty

A small clinical study in California has suggested for the first time that it might be possible to reverse the body’s epigenetic clock, which measures a person’s biological age.

For one year, nine healthy volunteers took a cocktail of three common drugs — growth hormone and two diabetes medications — and on average shed 2.5 years of their biological ages, measured by analyzing marks on a person’s genomes. The participants’ immune systems also showed signs of rejuvenation.

The results were a surprise even to the trial organizers — but researchers caution that the findings are preliminary because the trial was small and did not include a control arm.

“I’d expected to see slowing down of the clock, but not a reversal,” says geneticist Steve Horvath at the University of California, Los Angeles, who conducted the epigenetic analysis. “That felt kind of futuristic.” The findings were published on 5 September in Aging Cell1.

“It may be that there is an effect,” says cell biologist Wolfgang Wagner at the University of Aachen in Germany. “But the results are not rock solid because the study is very small and not well controlled.”

Marks of life

“I’d expected to see slowing down of the clock, but not a reversal,” says geneticist Steve Horvath at the University of California, Los Angeles, who conducted the epigenetic analysis. “That felt kind of futuristic.” The findings were published on 5 September in Aging Cell1.

“It may be that there is an effect,” says cell biologist Wolfgang Wagner at the University of Aachen in Germany. “But the results are not rock solid because the study is very small and not well controlled.”

Marks of life

The epigenetic clock relies on the body’s epigenome, which comprises chemical modifications, such as methyl groups, that tag DNA. The pattern of these tags changes during the course of life, and tracks a person’s biological age, which can lag behind or exceed chronological age.

Scientists construct epigenetic clocks by selecting sets of DNA-methylation sites across the genome. In the past few years, Horvath — a pioneer in epigenetic-clock research — has developed some of the most accurate ones.

Steve Horvath, PhD

The latest trial was designed mainly to test whether growth hormone could be used safely in humans to restore tissue in the thymus gland. The gland, which is in the chest between the lungs and the breastbone, is crucial for efficient immune function. White blood cells are produced in the bone marrow and then mature inside the thymus, where they become specialized T cells that help the body to fight infections and cancers. But the gland starts to shrink after puberty and increasingly becomes clogged with fat.

Evidence from animal and some human studies shows that growth hormone stimulates regeneration of the thymus. But this hormone can also promote diabetes, so the trial included two widely used anti-diabetic drugs, dehydroepiandrosterone (DHEA) and metformin, in the treatment cocktail.

The Thymus Regeneration, Immunorestoration and Insulin Mitigation (TRIIM) trial tested 9 white men between 51 and 65 years of age. It was led by immunologist Gregory Fahy, the chief scientific officer and co-founder of Intervene Immune in Los Angeles, and was approved by the US Food and Drug Administration in May 2015. It began a few months later at Stanford Medical Center in Palo Alto, California.

Fahy’s fascination with the thymus goes back to 1986 when he read a study in which scientists transplanted growth-hormone-secreting cells into rats, apparently rejuvenating their immune systems. He was surprised that no one seemed to have followed up on the result with a clinical trial. A decade later, at age 46, he treated himself for a month with growth hormone and DHEA and found some regeneration of his own thymus.

In the TRIIM trial, the scientists took blood samples from participants during the treatment period. Tests showed that blood-cell count was rejuvenated in each of the participants. The researchers also used magnetic resonance imaging (MRI) to determine the composition of the thymus at the start and end of the study. They found that in seven participants, accumulated fat had been replaced with regenerated thymus tissue.

All of this work required the collaboration of many disciplines, genetics, statistics, biochemistry, immunology, and mathematics.

While the clinical evidence is still limited by the small size of the trial, the science is real. Perhaps soon there will be a test to measure your biological clock.

Rather than being viewed as a fountain of youth, there are other important motivating factors to research anti-aging. Source:  Reversal of epigenetic aging and immunosenescent trends in humans Population aging is an increasingly important problem in developed countries, bringing with it a host of medical, social, economic, political, and psychological problems

The first hint that body’s ‘biological age’ can be reversed: In a small trial, a cocktail of drugs seemed to rejuvenate the body’s ‘epigenetic clock’.

Cleveland Clinic Institutes Ambitious Plan to Double Patient Volume

by Greg Slabodkin Managing Editor, Health Data Management

Last year, the Cleveland Clinic cared for more than 2 million patients—an unprecedented number. However, president and CEO Tom Mihaljevic, MD, says it’s a small fraction compared with what the health system can and should be doing.

“The care that we deliver today is of paramount importance to those in need,” Mihaljevic told an audience this week at the Cleveland Clinic’s 2019 Medical Innovation Summit. “What we strive to do is to touch as many people as possible with the highest quality care.”

Mihaljevic said the Cleveland Clinic has an “ethical mandate to grow” and a moral obligation to relieve human suffering. However, he acknowledged that the provider organization “touches far fewer lives than what our brand recognition, our reputation would suggest.”

According to Mihaljevic, the Cleveland Clinic’s market share in the United States is only half a percent. As a result, the Cleveland Clinic has an ambitious plan to double the number of patients that the healthcare organization serves over the next five years—and health information technology is at the core of its strategy.

Adding more facilities and increasing the number of caregivers is not enough to meet this goal and the growing demand for the Cleveland Clinic’s services, according to Mihaljevic.

“We understand that we have to change the way that we deliver care—but we also have to change the tools that we use for care delivery,” he said.

As Centers for Excellence in many specialties both Cleveland Clinic see large numbers of patients.  Mayo Clinic is often compared to Cleveland Clinic in terms of excellence.  By comparison, Cleveland Clinic sees twice the volume of Mayo Clinic and appears to be hard-pressed to see this volume.  Yet they seek to double that volume.

By comparison, Cleveland Clinic is in a much more densely populated region with proximity to the east coast of major metropolitan areas and Pittsburgh.  Cleveland has a major international airport, a 19-minute drive to the clinic via Interstate 71.

The Mayo Clinic lies in a less populated region, and the airport is served by regional airlines with few connecting flights as compared to Rochester, MN. It can be accessed by Rochester's International Airpor (RST) or Minneapolis-St. Paul's Hopkin's (MSP) airport.

Adding more facilities and increasing the number of caregivers is not enough to meet this goal and the growing demand for the Cleveland Clinic’s services, according to Mihaljevic.

“We understand that we have to change the way that we deliver care—but we also have to change the tools that we use for care delivery,” he said.

Scaling an enterprise of this size can be daunting and requires methods of not just increasing or doing more with present facilities.  It will take a sea-change in facilities and technology to reach this very ambitious goal of 4 million patients a year. It will also require insurance companies, health plans transportation services and other support industries to match Cleveland Clinic's growth curve.

The Cleveland Clinic’s near-term plan calls for the implementation of digital platforms such as telemedicine, data analytics, and artificial intelligence, as the $8 billion healthcare organization looks beyond its core electronic health record system capabilities.

“The new digital and analytic tools and the new way that we process information for better servicing our patients will have a transformative effect on our industry,” added Mihaljevic, who noted that the Cleveland Clinic’s aspiration is to be the best place to receive care anywhere and also to be the best place to work in healthcare.

On Monday, at the Medical Innovation Summit, the Cleveland Clinic and telemedicine vendor American Well announced that they have formed a joint venture company—called The Clinic— which will offer virtual care by leveraging the Cleveland Clinic’s specialists through American Well’s digital health platform, providing patients with online access to care in their homes. American Well is focused on providing telehealth communications and also integrates with Cerner and Epic electronic health record systems.

“This new venture marks the first time that a major digital health technology platform has partnered with a globally recognized healthcare provider to deliver digital solutions for complex healthcare problems,” observed Mihaljevic. “This new digital health service will provide access to world-class Cleveland Clinic expertise and quality of care for patients in the U.S. and internationally.”

Cleveland Clinic's plan to expand its footprint using telehealth allows primary care doctors to access specialty knowledge as well as affording patients second opinions without traveling to Cleveland. 

Both Cleveland and Rochester are challenged by inclement weather restricting patient travel

Rather than a true partnership where both entities are at risk, it seems to be more of a client-vendor relationship.

Mihaljevic neglected to expand on internal functions for patient flow and reducing paperwork.  By comparison from personal experience, Mayo Clinic already implements patient registration, calendars for the patient on line, instructions for both pre-visit and post visit. The patient is aware of the plan and locations for their services.

Insurance companies aren’t doctors. So why do we keep letting them practice medicine? - The Washington Post

We know how important it is to have insurance so that we can get health care. As a physician, parent and patient, I cannot overemphasize that having insurance is not enough.

Physicians often prescribe expensive medications or tests for my patients. But for insurance companies to cover those treatments, I must submit a “prior authorization” to the companies, and it can take days or weeks to hear back. If the insurance company denies coverage, which occurs frequently, I have the option of setting up a special type of physician-to-physician appeal called a “peer-to-peer.”


Here’s the thing: After a few minutes of pleasant chat with a doctor or pharmacist working for the insurance company, they almost always approve coverage and give me an approval number. There’s almost never a back-and-forth discussion; it’s just me saying a few keywords to make sure the denial is reversed.


Because it ends up with the desired outcome, you might think this is reasonable. It’s not. On most occasions, the “peer” reviewer is unqualified to make an assessment of the specific services. They usually have minimal or incorrect information about the patient. Not one has examined or spoken with the patient, as I have. None of them have a long-term relationship with the patient and family, as I have.

 Some physicians dealt with this system from the patient side, as well. A daughter has a rare genetic disorder called Phelan-McDermid Syndrome, which causes developmental delay, seizures, heart defects, kidney defects, autism and a laundry list of other problems. She receives applied behavior analysis therapy, an approach often used for autism, and has been wildly successful in improving her skills and communication. But recently, our health insurer reduced the amount of therapy they thought she needed.

While I know what levers to pull from the physician's side, a patient’s options are completely unclear. I probably have better access than almost anyone else can get, yet the ability of my daughter’s providers to mitigate denials for services they deem appropriate is slow and often ineffective. A patient can languish for months or years not receiving care that every highly qualified person who treats her agrees she needs. While we wait, the window to give her a little bit more function, a little bit less suffering and a little better life get smaller.

Most likely the person evaluating the claim has a leaf book or now a computer with an algorithm that decides the decision by checking off any number of boxes in a flow diagram of yeses and nos to make a decision, without knowing the patient's history, or physical findings.

This sounds good, as most denials are related to specific provider choice or contractual issues, which are relatively easy to remedy (but a problem nonetheless). But other denials are a judgment of some test or treatment as “not medically necessary.”

Insurance companies know that many patients don’t bother to appeal at all. A smaller fraction asks for an internal review, and still fewer seek or even know about external review options available in most states. Of the cases that do end up under external review, almost a third of all insurer denials are overturned. This is clear proof that whatever process insurers have to determine medical necessity is often not in line with medical opinion. A study of emergency room visits found that when one insurance company denied visits as being “not emergencies,” more than 85 percent of them met a “prudent layperson” standard for coverage.

Some might argue that it makes sense to have two doctors discuss a case and then come to a consensus on the most cost-effective approach for an individual. That’s not what is happening. This is a system that saves insurance companies money by reflexively denying medical care that has been determined necessary by a physician. And it should come as no surprise that denials have a disproportionate effect on vulnerable patient populations, such as sexual-minority youths and cancer patients insurance companies will say this system makes sure patients get the right medications. It doesn’t. It exists so that many patients will fail to get the medications they need.  It also exists to save money for the insurance company. 
Transgender youth are at high risk for mental health morbidities. Based on treatment guidelines, puberty blockers and gender-affirming hormone therapy should be considered to alleviate distress due to discordance between an individual's assigned sex and gender identity. The goals of this study were to examine the: (1) prevalence of mental health diagnoses, self-injurious behaviors, and school victimization and (2) rates of insurance coverage for hormone therapy, among a cohort of transgender adolescents at a large pediatric gender program, to understand access to recommended therapy.

Case-study: An IRB-approved retrospective medical record review (2014–2016) was conducted of patients with ICD 9/10 codes for gender dysphoria referred to pediatric endocrinology within a large multidisciplinary gender program. Researchers extracted the following details: demographics, age, assigned sex, identified gender, insurance provider/coverage, mental health diagnoses, self-injurious behavior, and school victimization.

Results: Seventy-nine records (51 transgender males, 28 transgender females) met inclusion criteria (median age: 15 years, range: 9–18). Seventy-three subjects (92.4%) were diagnosed with one or more of the following conditions: depression, anxiety, post-traumatic stress disorder, eating disorders, autism spectrum disorder, and bipolar disorder. Fifty-nine (74.7%) reported suicidal ideation, 44 (55.7%) exhibited self-harm, and 24 (30.4%) had one or more suicide attempts. Forty-six (58.2%) subjects reported school victimization. Of the 27 patients prescribed gonadotropin-releasing hormone analogs, only 8 (29.6%) received insurance coverage.

Conclusion: Transgender youth face significant barriers in accessing appropriate hormone therapy. Given the high rates of mental health concerns, self-injurious behavior, and school victimization among this vulnerable population, healthcare professionals must work alongside policy makers toward insurance coverage reform.We can do better. If physicians order too many expensive tests or drugs, there are better ways to improve their performance and practice, such as quality-improvement initiatives through electronic medical records.

When an insurance company reflexively denies care and then makes it difficult to appeal that denial, it is making health-care decisions for patients. In other words, insurance officials are practicing medicine without accepting the professional, personal or legal liability that comes with the territory.

Insurance companies aren’t doctors. So why do we keep letting them practice medicine? - The Washington Post: To get access to health care, you don't just need insurance. You also often need to navigate all the hoops and hurdles of health plans.