Morning in Maine

I’m working on the front porch this morning, sipping from a hot cup of coffee while the rain beats on the roof above, falling in fat, heavy drops along the drip line in front of me. A hundred yards out, a loon quietly paddles by, immune to the rain cascading down all around it, cocking its head when I move too quickly from the door to the sofa along the house’s outer wall.

The sky and bay are nearly the same color of grey this morning. The demarcation between the two is barely visible along the horizon line, called out by the dark shapes of islands crowned with pine trees and ringed with granite and knotted wrack.

It’s these quiet early morning moments in Maine that I tend to remember most when I’m surrounded by people, planes and tumult over the course of the year, immersed not in the sound of thousands of rain drops hitting leaves and weathered shingles but rather machines and men, their voices raised in anger, happiness, frustration and joy on the course of whatever task or journey that day’s course sets before them.

For now, it’s enough to simply be, disappearing into the words of a past interview, drinking deep of the cool, clean air and thinking of an older world that has long ago disappeared into the annals of a quieter age.

Notes on Dr. Atul Gawande’s talk at the Health Data Palooza [LIVEBLOG]

[Editor's note: these are live, rough notes from my iPad, and should not in any way represent a 100% accurate transcription. I missed far too much. Caveat lector. My comments are in brackets. You can find Dr. @Atul_Gawande's bio & writing at the New Yorker. Update: I've posted video of Dr. Gawande below.]

GAWANDE: A fascinating part [of the Health Data Palooza]: the idea that we’re putting together people from government, healthcare systems, people from outside who have knowledge about data and tools. This is quite different from the normal models: regulatory or laissez faire.

We have a healthcare system that’s fundamentally broken. The most common complaints from patients seem to be no one you can count on. If you’re paying, you have no sense that there is anyone who can help it costs be under control.

Where to start to fix that? We have recognized that there is enormous variation in cost, depending on whet you go. There is enormous variation in cost, depending on where you go. The two don’t have anything to do with one another. So there’s hope. [Good news.]

Some of the best places to get care are the least expensive. [In healthcare,] positive deviants are the ones that look the most like systems.

Examples from war and lessons within lethality

GAWANDE: Start by looking at performance of doctors in war and their teams. In the war in Iraq/Afghanistan, lethality below 10%. That doesn’t reflect intensity of conflict but improvement in care.

How did we do it? It was the not discovery of new tech that transformed survival but ability to use existing tech far better, in a system that works.

1) Kevlar. Got soldiers to wear it, operationally.
2) Speed to operating table. Improved forward mobile operating theaters.

We achieved the best survival rates in history. How? They changed the way they did surgery. Looked at data, realized needed to stop bleeding, stop contamination, under resource restrictive conditions. No X-rays, needed to learn 19th century techniques for finding fractures by feel.

They adopted “damage control surgery”: Do what you could during 2 hours. Ship and add a note: here’s what I’d did, what’s needed. That helped stimulate development of simple EHR. Average time from wounded on the battlefield, to getting care in the field, Baghdad, in Germany, in us, is less than 3 days. Less than 36 hours for some.

Soldiers can find better care for some conditions in Iraq than in a US city, with fewer resources. How? Alignment of finances, incentives. They weren’t “fee for service soldiers.” Everyone is on the same team: focused on saving life, maintaining health.

Within 48 hours of the wounding or death of soldier, posted on the DoD website. [DCAS: Defense Casualty Analysis System] The public accesses that data, but doctors & nurses access it the most.

One more example: soldiers not wearing protective eyewear. They called them ‘Granny goggles.’ The DoD contracted with a designer, made cool ones. Now wearing. Needed data and research to understand. [Stories matter.]

Affordable Care Organizations (ACOs) have done financial alignment. They’re committing to doing more project at a time. They’re committed to better health within an environment.

To get there, folks in war needed data useful to frontline decision makers. [The same is true at home.]