This month’s episode of “News You Can Use” on HealthcareNOWRadio features news from the month of August 2024
News You Can Use with your Hosts Dr Craig Joseph and Dr Nick van Terheyden
The show that gives you a quick insight into the latest news, twists, turns and debacles going on in healthcare withmy friend and co-host Craig Joseph, MD (@CraigJoseph) Chief Medical Officer at Nordic Consulting Partners and myself, where every diagnosis comes with a side of humor. We hope you stay curious, stay engaged, and keep seeking the truth in healthcare in a world that thrives on information.
Buckle up as we dive into the ER of excitement, the ICU of irrationality, and the waiting room of wacky wisdom in this month’s show that features a review of:
- Systemness and Round Trips
- The Epic UGM
- Payer management and rent controls
- Epic research Cosmos and Heart Disease
- EMR voter registration
A Conversation Starter, Not a Conclusion
This month we delve into the latest findings from Epic’s research on the Cosmos study, specifically focusing on heart disease among aging populations. We both acknowledge our own experiences as “aging old boys”, and discuss the nature of this data and the results that are published from this. As we point out – this is more of a conversation starter and not peer-reviewed research. We take issue with their summary and conclusions noting this is at best correlation.:
Patients with an average LDL below 90 mg/dL have an increased likelihood of being diagnosed with a myocardial infarction (MI) compared to those with an average LDL of 100-109 mg/dL.
Patients prescribed statins whose average LDL is below 80 mg/dL have an increased likelihood of coronary artery disease (CAD), while those without a lipid-lowering medication prescribed have an increased risk when their LDL is below 100 mg/dL. All studied patients, regardless of statin use, have an increased likelihood of an MI or a CAD diagnosis when their average HDL is less than 50 mg/dL, compared to patients with a higher average HDL level.
Craig reviews the recent Epic UGM meeting and some of the interesting announcements and even more on the Cosmos data and the percentage of the population now with a record in the Epic EMR database
We review the recent lawsuit by 8 states focusing on price fixing in rents for landlords with the product from RealPage, noting this sounds a lot like the way Multiplan works in healthcare for the pricing of clinical procedures
And we close dispelling more fake data surrounding the kerfuffle of EMR’s facilitating illegal voter registration with Not-ER (they are not)
We hope you enjoy our take on the latest news and developments in healthcare and want to help you keep untangling the web of information, dodging the sensational pitfalls, and emerging victorious, albeit a little dizzy, on the other side. In the end, the stories we uncover, and the discussions we ignite, all shape the narrative of our shared future. We want to hear from you especially if you have topics covered or questions you’d like answered. You can reach out directly via the contact form on my website, or send a message on LinkedIn to Craig or me.
Until next week keep solving healthcare’s mysteries before they become your emergencies
xx
Listen live at 4:00 AM, 12:00 Noon or 8:00 PM ET, Monday through Friday for the next week at HealthcareNOW Radio. After that, you can listen on demand (See podcast information below.) Join the conversation on Twitter at #TheIncrementalist.
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Raw Transcript
Nick van Terheyden
Nick, welcome to the month of August. I’m Dr Nick,
Craig Joseph
and I’m Dr Craig. This week, we will be dissecting
Nick van Terheyden
the latest healthcare news, unraveling the twists and turns and making sense of the debacles. Just
Craig Joseph
remember, life’s a lot like a breaking news story, unpredictable, often absurd, and occasionally leaves you wondering if it’s all just a cosmic prank.
Nick van Terheyden
This week, we take a look at systemness, hmm. Wonder what that is round trips and the epic UGM,
Craig Joseph
and we also dive into payer management and rent control and voter registration. I’m sorry. I’m sorry. Dr nickett, we’re we’re talking about voter registration today. Yes,
Nick van Terheyden
we are. But first off, this week, we’re going to dive into epics research on cosmos and heart disease. So picking up from recent publication from the cosmos, we saw a note come out that I think both you and I have been fans of some of the content that comes out, but this one, I think, tickled us both in a slightly different way, in part because we’re aging old boys. Just gonna say, Well, they say, I speak for myself, maybe, oh
Craig Joseph
no, you’re you’re correct. I will not, I will not correct you. There you this is accurate. We are aging old boys,
Nick van Terheyden
and I what happens to aging old folks is they die of the, I don’t know, is the four horsemen. I don’t know how many horsemen there are now, but one of them is cardiac disease. And, you know, we face that off and try and combat that. I know you certainly are doing that. I certainly have, I think I’ve been pretty public about some of the things that I’m trying to manage as part of that. But in this particular instance, the cosmos database, as we put it, had a different view of what might be the appropriate therapy, and came out with something. Do you want to tell us what we saw? Yeah,
Craig Joseph
so just if we take a step back, Epic is a big vendor of electronic health records, and many of the very largest healthcare systems in in this country and in many other countries use epic and and many of them, I think the majority of them, contribute de identified data to a big database, and epic calls that cosmos. And so if you contribute to it, then you can leverage it. We’re going to talk about that a little bit later. But one of the ways that epic tries to leverage all of this information on hundreds of millions of people is by putting out research. And I’m, I’m putting that in air quotes, even though this is a podcast, and you can’t see that it’s, it’s, it’s not peer reviewed. Oh, behave. It’s not. This is not research that you know is of the quality that would be in a journal. It’s basically there to kind of pique your interest and to show trends. And if someone’s interested in the academic world, they can go and follow up and do a more thorough job. Anyway, this piece of interesting information, at least the way it was presented, and you and I interpreted, was looking at the levels of HDL, which we usually call the good cholesterol, and there
Nick van Terheyden
is no good and bad guys. I like to channel a little bit of my Peter Attia podcast. There is no anyway. Go on. Sorry,
Craig Joseph
all cholesterol is evil, but HDL is less evil than LDL? Yeah, and so LDL is usually the one that most of us, if we have a cardiologist or a primary care doctor who’s interested in that, they want that LDL to be low. And we know why. Of course, the lower Well, at least once you get to a low point with LDL, your risk of having a heart attack or other cardiac problem goes down. We know this to be true. And the question that the epic, a couple of epic researchers, asked was, well, what happens? And again, they have data. They have hundreds of millions of patients. Can is, can you go too low. And let’s specifically talk about, you know, LDL, once it gets below a certain point, does your risk of having a heart problem increase? Which is really a question I’ve never, I’ve never thought of, because it’s very difficult to get it at least very, very low, in my experience and there and again, I don’t I think calling it researchers more than they would want, but, but they’re look at the data seem to indicate that there are numbers with LDL specifically that if you get lower than you know, some number, your risk of having a heart problem goes up. So. And and I commented to you privately when we when I first read this that my cardiologist would like, I think my LDL to be negative 10, yes, yeah, zero and me both. It’s not low enough for my my cardiologist, yeah, keep going. He wants me to be spitting out, uh, cholesterol, cholesterol, yeah, yeah, or coming out of my skin or something. So I and we never really got a good answer as to as to why it would be. You know, looking at some of their graphs for coronary artery disease, specifically, it seems that once you get below, I don’t know, 8060, it’s, your risk of having coronary artery disease goes up based on their data. And so it was a little weird. And you and I kind of tried to get more clarification via social media, but really didn’t get very far. I just, I thought it was interesting. As you know, we regularly bring up this information that that this research, and because it’s interesting, it’s interesting, I would say it’s interesting, but not actionable, right? Like, you’re not going to, no one’s going to change what they’re doing based on this information. You’d want a formal study.
Nick van Terheyden
Yeah, so I think you’re right that it’s not actionable, in part because it’s not a formal study. There’s no randomized, you know, fishing out of a database. But that said, the publication of it has a tendency to sort of stimulate folks to say, Oh, I shouldn’t, I should not do, or I should do, you know, the following as a result of that, because, gosh, I’m seeing it. And, you know, this is correlation, causation at its core. There’s, you know, a bunch of reasons why that particular instance troubled both you and I, not least of all from the personal standpoint, where we’ve got somebody else telling us something completely different. Let’s be clear, I’m I, I’ve been if I can, I clearly don’t want it at zero, but I certainly want it to be as low as possible, because I buy the published research and where we are in terms of that. And you know, I think it did what it was expected to do based on how you described the outline, which is generate a conversation which is good, albeit in this particular instance, I’m going to say the conversation is no but what worries me a little bit is that maybe there are other folks, I don’t know. I think anybody can sign up for this. So if you’re receiving that information, and you receive that, and that becomes an actionable activity that worries me. I’ve got to say a little bit, because I think it’s, you know, it worries me not as much, but along the same lines as advertising for pharmaceuticals, and I feel like that’s the only adverts that I ever see. And I don’t see a lot. I skip through them, but that’s almost all I ever see. And I worry a lot about that, because it just, it’s not doing anybody any favors. I think the epic research, or Cosmo, I’m not sure what to call it now, now that you’ve called out the research piece, but I think it offers value, but it needs to come, you know, does it have a disclaimer? I’ve never really looked I read it with, you know, everyone that shows up, not all of them, but they’re good. Maybe it should come with a disclaimer. But is that enough? I don’t know. I’m I’m struggling with this particular instance. Yeah,
Craig Joseph
I you know, it’s got some words in there, and it’s certainly available. They’re English words, and they they have nouns and verbs and stuff. They got all the kinds of words in there. Yeah, you know, this is information that’s available to anyone. I think it’s ideally focused on healthcare practitioners and again, not to take action yet, just to spur conversation, and then to have someone say, well, we should maybe think about looking, you know, looking into this more formally. So, yes, your point’s well taken. I do wish that there were some, you know, some way that, some organized way. And maybe this is a suggestion, if anyone from Epic is listening, that we could put comments and kind of have a back and forth individual things, so that, because we let’s acknowledge that you and I are not experts in research or statistics or any of that we are experts in our own cholesterol levels and our experiences with our own cardiologist. I’m not
Nick van Terheyden
even sure that I am an expert, given how bad it’s been at times. All
Craig Joseph
right, that’s fair. That’s fair. So, all right, yeah, well,
Nick van Terheyden
moving on. We’re staying with epic because the UGM just took place. Space. And I, you know, I certainly saw some materials coming out of it. I didn’t personally attend, but always a focal point. A lot of interest. You know, everybody gets into the spaceship that’s underground, and it’s, it’s a big setting now compared to how it used to be.
Craig Joseph
I, you perhaps I went more. No, I actually, I actually attended this year. I was lucky enough to go into that spaceship.
Nick van Terheyden
I, you know, I’m still struggling with this. How the hell do they let you in? It’s just is nobody watching the doors or the gates. Here I
Craig Joseph
wear a disguise. Dr, Nick, mostly I it’s, I can’t get into any more details, but I wear a disguise. Also, I have certain technologies around me to make me invisible to cameras. And so there’s a lot, there’s a lot, there’s ability cloak. I don’t want to really get into it right now, but let’s just go with that. I attended epics user group meeting. That’s what UGM is. And yeah, it was, it was great fun, and I it’s a three day event. At least this year, used to be four days where and again, Epic’s a vendor, that software vendor that that creates the electronic health record software tools that almost, I think it’s now above 51% of hospitals and healthcare systems with respect to how many patients they take care of now use so most of us, most of us have probably, actually, I think that’s clear. The majority of of Americans have, have a record in epic somewhere at some time, whether you whether you know it or not. Anyway, there were two things that I wanted to call out that I thought were pretty, pretty amazing. One was artificial intelligence, or AI. And epic announced that certainly they’ve been working on AI, as has everyone, but that they’ve got over 100 projects, over 100 projects in flight. That’s a lot for them, that that leverage AI from finding out, giving you a better idea about when the next appointment can be, you know, and not just asking you a ton of questions or having a scheduler ask you those questions. But hey, we noticed that this person always likes to schedule on Tuesdays in the afternoon. Maybe that’s the first suggestion that we’ll make. Is Tuesday in the afternoon. No one has to tell it that. It just kind of learns that. And again, reminds me, if you have Tuesday afternoons off, that’s when you’re going to make your doctor and dental appointments. And so that kind of thing, which many of us don’t really think of AI, but I think that that can be very helpful. Just one example. Another one that we’ve talked about a lot is, is ambient listening in the office setting. So in you go to see your doctor, and in the in the in the exam room, there’s a microphone. There might just be a phone, actually, and with your permission, it records the voices of everyone in the room, and then generates a lot of cool things. This is actually so it certainly generates a note for the doctor. A question is, how good of a note is that? How much work does the doctor have to do? I think that’s getting better and better to they it actually works today that if I’m in the exam room and I say so, Nick, we’re going to order an LDL cholesterol and an HDL cholesterol, and I’d like to go up on your rusuva statin from 20 to 30 milligrams a day, and we’ll get you a 90 day supply of that with three were you listening
Nick van Terheyden
into my last console? I do.
Craig Joseph
Well, I’ve, I’ve tunneled into your phone, but that’s a different conversation altogether. If I say those things, and if we have the software configured correctly, and if we have the electronic health record configured a lot of ifs there, but if those things are all in line, which they’re not a lot of the time, but if they are, then those orders are sitting there waiting for sign. Let’s be clear, if they’re not active orders that the you know, the AI is not sending them off, but they’re right there, queued up. For me, it’s amazing.
Nick van Terheyden
I think, you know absolutely great opportunity. You know automation, you know some of the drudgery. Let’s be clear. This is, you know, I know that’s what I want, but I gotta go then find hunt and click and whatever my question here is, you know, as I’m hearing you talk about that that feels like products. And you know, you specifically talk to ambient, that’s a product from a large organization now under Microsoft, and indeed, a bridge at least two and there’s several others. Is this competing directly with them? Or is this No,
Craig Joseph
no at this point, it’s integration. I asked that. Okay,
Nick van Terheyden
all right, so it’s a function that’s coming from other parts,
Craig Joseph
correct? They just interface in and we. Hmm, there are dozens and dozens of these, sometimes small, sometimes large. The biggest one you didn’t mention, which was nuance and now owned by Microsoft. So
Nick van Terheyden
I did. I mentioned Microsoft, but nuance is absorbed,
Craig Joseph
absorbed. Yep, there. Yes, you are correct. So there are big and small groups that are doing this, and I don’t believe Epic is doing it yet, but, you know, hold on, they tend to get into those things after a while they do. That’s true. So lot of cool and interesting things that will help both the patient and the physician and other clinicians and pay, you know, registration folks and scheduling folks and and revenue cycle folks, so a lot there. The other thing I kind of wanted to call, which we’ve already talked about, to some extent, but more leveraging of that Cosmos database. And again, as I mentioned, Cosmos is where many epic, many of Epic’s customers, not all, but many deliver de identified data into one single database that epic. And then can can kind of do crazy things with and so, just as an idea about how big this this is, there was an article that I read where a researcher said, Hmm, I would like to see how many down how many patients with Down syndrome are in cosmos. And came back and again. Let’s be clear, this is these are de identified data. So this researcher doesn’t get a list of names, just gets a just gets a number. And the number was about 100,000 and the comment from her when she first saw that, that I read in the article, was, well, we think there are 200,000 patients with Down syndrome in the US, and an epic has just identified half of them in its database. And again, not every epic customer is contributing well,
Nick van Terheyden
but that database jives with the number that you just you shared, in fact, that they have 51%
Craig Joseph
right? It’s just, I say these words, but it’s still, it’s spooky, yeah. And so, so they’ve started kind of leveraging it again as a starting point, as a jumping off point, like, is there some correlation between, you know, having Down Syndrome and this other thing? And they were actually interested in skin diseases, yeah, that. And so I think it’s just very, very helpful. Two new products, I think that are functionalities that Epic is coming out with. One is find patients like mine. So Nick, if you’re sitting there and
Nick van Terheyden
that’s a product, that’s a website, patientslikeme.com just saying, but go on.
Craig Joseph
But this has a lot more information, right? Because, yeah, right, so, so. And then saying, hey, patients like this, what do they seem to respond to? Right? And says, Oh, well, patients who had this lab that was abnormal was high, and now it’s gone low. Are on this kind of blood pressure lowering medicine. And again, no causation here, simply saying that these things seem to be correlated, Doctor, you should look into it. So pretty interesting and exciting. It’s really not ready for prime time yet, but moving on, it’s it’s going to get there.
Nick van Terheyden
Yeah, unfortunately, we don’t have time to cover another aspect to this that I think I would love to know, and if, if somebody would like to comment, I’d certainly hear but de identification of data extremely challenging, having been to DEF CON and saw a specific presentation that essentially said between eight and 10 items that I need about you that I can uniquely identify, and I think it’s now down to six to eight, huge challenge, especially with medical data, let’s be clear, but we don’t have time for that. Unfortunately, moving on swiftly, recent actions on the part of the government to go after real page, which is a group an application that helps landlords. I’m going to say, set prices. I want to be careful that I don’t overstep the boundaries of what that means. But essentially, they have, there is a lawsuit now pending, suggesting that this is for want of another term, price fixing. And you know, that’s not medical. But what really struck me, and clearly some other folks that comment in this space, Mr. Histor, called this out, but I saw that as well, you know, very similar to products that do a similar kind of thing. In this case, multi plan for payers and says, you know, this is what you could get. This is what you should potentially discount. And you know, it always bothers me, this sort of, what I can only describe as surge pricing for abbreviation terms of, you know, procedures and activity. While there’s some variability, if you’re getting a medical procedure done, you should have some sense of the pricing. And you know, if they’re going after the rent activity, maybe they might start going after the payer controls, or payer fixing of prices, is the suggestion. Thoughts,
Craig Joseph
well, I It’s, it is a slippery slope, and let’s be clear, that the Department of Justice is going after someone doesn’t or a group doesn’t mean that they’re going to be convicted of anything, or, even more formally accused. So yeah, it’s, it’s, it’s concerning, and I think it’s an area worth exploring and watching, just like that. That company that says, hey, this is what we think the your rent should be. Hey, landlord, this is what we think based on all the information we have. But if they’re the ones giving everyone that information, if that then, yeah, they’re kind of setting the price, and then they’re also getting rewarded, right and and it’s not a flat fee, so they’re not the higher the rent, the more that they’re getting paid in the in the same way, the higher a third party says, Hey, for this as a as an insurance company, think you should, you should just offer them this, because they’ll probably take this, because we know a lot about them, whoever they are, it’s usually a hospital or a big reminds
Nick van Terheyden
reminds me a lot of ticket prices for concerts and some of that stuff that’s going on anyway, moving on. Unfortunately, we’re running rapidly out of time systemness and round trips. I gotta say, I was intrigued when you brought this up.
Craig Joseph
Yeah, it was just a short article from the Chief Medical Officer at atrium, and basically talked about the program where whereby patients were waiting for surgeries because they could only happen at the big mothership Hospital, which has all the kind of sophisticated equipment. But they were delayed because even though they had smaller hospitals out in the community, a little further away. They couldn’t do the surgeries there, and what they found is that they could safely and effectively and efficiently have the surgery at the big mothership hospital and then immediately put that patient in an ambulance and send them to one of the smaller hospitals, closer to their homes, closer to the patient’s home, where they could, where they could safely recover. And it sounds pretty easy and straightforward, but it gets really complicated really fast. You have to have the right folks and right equipment and right lab facilities.
Nick van Terheyden
The idea of an ambulance trip, long ambulance trip after some you know, major i mean, i Hey, I like the principle freeing up the resources, but I’d want some real comfort issues to be resolved. Certainly, my experience is in the back of ambulances. And to be clear, that’s not as a patient. I don’t think I’ve ever been, but I have, I’ve rode along, which I’m going to say, was a lot of fun for me. Yeah,
Craig Joseph
no, it has to be done, right? And, and they were, looks like they’ve kind of figured it out, at least for them, for the surgeries that they’re taking care of. So, yeah, you’re right. There’s a lot of you need to make sure pains under control and it’s safe, and all of that stuff.
Nick van Terheyden
All right. Final topic, we promised it voting, voter registration. There was a lot of fuss over this, or it would appear there was fuss over it, that the epic application was that EMR was encouraging, and actually encouraging illegal voter registration. Let’s just, I’m going to say it out the gate. That wasn’t what was going on. This was legitimate. Hey, we can register the same way that you can be registered at a driver’s license. It was facilitating. But any thoughts, closing thoughts on that,
Craig Joseph
yeah, this is absolutely an innocent attempt at a to try to get people to register, and in the same way that sometimes you can register in a shopping mall or at the at other places like you said, driver’s license or post offices, this was another opportunity. It had nothing to do with the EHR specifically. It was just a kind of reminder in the EHR person, someone pressed a button, and then they could go in and the patient, if they were there, and if they had time, could answer questions, and if the questions all aligned up, then they could put in their name to to register. Or if there was an online system that was offered by the state, they would be directly. They just directly went to that. So now this was, this was someone, you know, fake
Nick van Terheyden
news.
Craig Joseph
I’m just going to say, yeah, yeah, it’s, it’s Dear Lord making a mountain out of a molehill. There’s nothing there. Oh, well, all right, so
Nick van Terheyden
we find ourselves, as usual, at the end of another episode where we explored some of Healthcare’s mysteries before they became your emergencies. Until next time, I’m Dr Nick and I’m Dr Craig. You.
