by Tom Farley
The idea germinated in the summer of 2003, when Frieden read a study, published in The New England Journal of Medicine, that showed just how bad medical care in America really was. A group of researchers studying 6,700 medical records found that patients got recommended services at doctor visits only about half of the time. Low-quality medical care posed “serious threats to the health of the American public,” the authors wrote. The U.S. medical care system was, in Mostashari’s words, “leaving tens of thousands of lives on the table.”
The article bothered Frieden more than it did many in the world of public health. Later Mostashari told me that there was “a little bit of snobbishness in public health circles” about the limits of medical care. In the late 1970s, British doctor Thomas McKeown, in The Role of Medicine: Dream, Mirage, or Nemesis, had shown that the great improvements in health that occurred since the late 1800s had had nothing to do with medicine. The epidemics of infectious diseases had dried up with better plumbing and housing; McKeown attributed the rest of the gains to improved nutrition. Some public health people, including me, had written that even in the year 2000 medical care didn’t affect life spans much. Medical care typically treats people when they are already sick, we argued, when it is usually too late. It should be called “sick care” instead of “health care.” When we get sick, every one of us wants help from a good doctor. But if we hope to live longer, healthier lives, we have to prevent disease, not just treat it. That is what public health is about.
Frieden, on the other hand, was convinced that doctors could save lives by preventing disease on a grand scale—not with coronary bypass surgery or cancer drugs but with simple actions like counseling smokers to quit and treating people with high blood pressure, high blood cholesterol, and diabetes. The problem with medical care wasn’t that doctors didn’t take those simple preventive steps. It was that they were so unreliable. The key to saving lives through medical care was consistency. Preventing disease with medical care wasn’t a technical challenge; it was a quality improvement problem.
Frieden had pressed both Mary Bassett and Lynn Silver when he hired them: how could the health department get doctors to do a better job treating high blood pressure and counseling smokers? The two were more interested in promoting healthy behaviors and creating healthy environments than in improving medical care, but they were willing to try.
In the summer of 2004, they attempted a personal touch. Doctors are accustomed to “detail men” (and women) from drug companies appearing in their offices and delivering drug samples, brochures, and trinkets bearing the drug names. It is a horrible way for doctors to keep up with advances in medicine, because the drug companies are driving profits, not health, but it works; after detail men make the rounds, doctors prescribe more of their drugs. So Frieden, Bassett, and Silver tried “public health detailing”—sending into those same doctors’ offices health department workers. In the first wave of public health detailing, the staff passed out pamphlets on how to treat smoking and preprinted prescriptions for nicotine patches.
Over two months, the workers visited 150 doctors’ offices in the city’s poorest neighborhoods. It didn’t work. Only a third of the doctors claimed to be asking their patients if they smoked, and the others didn’t sound likely to start. Frieden realized that he was actually stuck with not one but two linked problems: doctors weren’t doing the simple preventive actions consistently, and no one—not Frieden, and not the doctors themselves—was able to measure any progress they might make.
Mostashari saw the problem from the point of view of doctors. They didn’t want to practice bad medical care—they were just pressed to do many things that felt urgent, and they were distracted. One day while visiting a community health center, he spotted a way to help. The center used computer software that reminded doctors to offer flu shots to patients over sixty-five. When the center turned on the reminder, the percent of seniors vaccinated jumped from about 5 percent to over 40 percent. At that time, fewer than one in five doctors in outpatient clinics in the United States used electronic medical record software, compared to more than half in the United Kingdom and 90 percent in Sweden. And the software they were using mainly just re-created paper systems for the computer screen; they weren’t “smart” systems that could help doctors make medical decisions.
Mostashari wondered if digital technology could fix the quality improvement problem. “I thought there was something there,” he recalled, “but I didn’t have the time to figure out what.” He proposed to Frieden that he take a six-month “sabbatical” to think about how software could help doctors prevent disease, especially for the city’s poorest patients. The civil service manual had no rule for sabbaticals, but Frieden agreed to let him do it anyway. Nothing he had tried with doctors was working, he told Mostashari. Figure this out.
• • •
Nearly a year later Frieden came up with his own idea. It was in late October 2005, in the heat of Bloomberg’s second mayoral campaign, with the election just a couple of weeks away. “It suddenly hit me,” he told me later, “that election season is when you get money.” The mayor was making campaign promises that would require funding in the second term. The health commissioner wanted to add a pledge by Bloomberg to transform medical care.
Farzad Mostashari was making progress. He thought he saw a way for the health department to offer doctors software with features that both reminded doctors to provide the kind of preventive services that saved many lives, and helped them do so. “The way I looked at this,” he told me later, was “how do we have Tom Frieden at the shoulder of every doctor in New York?”
That Friday night in October, Frieden called Mostashari and told him he was going to ask for money to do it. The two worked furiously through the weekend on a plan. They made spreadsheets on “how much exactly is it going to cost, and exactly how long, for exactly how many doctors,” said Mostashari, when in fact they had no idea what it would cost. They settled on a plan to get a thousand doctors in the city’s poorest neighborhoods to use a new “prevention-oriented electronic health record” by the end of 2008. Frieden hoped to sell the idea, based on his boss’s background selling computer terminals to Wall Street, as “the Bloomberg in health.” They landed on a request for $27 million to cover both the software and the staff to help doctors trade their paper charts for it. By improving medical care, Frieden claimed wildly, it would save $100 million in health care costs.
On Monday morning, Bloomberg made the promise. The message, Frieden later said, was that “it was really exciting, and it was gonna be high tech, and it was for poor people, it would save lives, it would improve medical care, and it would reduce medical costs.” In the frenzy of the last days of the campaign, with fanciful promises and dubious charges flying back and forth by the hour, the newspapers all but ignored the idea. But after the election, Frieden got his $27 million for what they called the Primary Care Information Project.
A small company called eClinicalWorks beat out much bigger competitors for the contract. Mostashari and his team spent the next ten months developing the software with them. The software would be smart, and it would think like people in public health. It would remind a doctor based on a patient’s characteristics—like age, blood pressure, and presence of diabetes—what sort of tests or treatment each patient should get to save the most lives citywide. In tech jargon, it was a “clinical decision support system,” but to Mostashari, it was Frieden hovering at the doctor’s shoulder.
The final version of the software had forty reminders, including counseling smokers to quit, treating high blood pressure, screening for depression, testing for HIV infection, and giving flu shots. The software also could easily create “registries,” or lists of patients with a specific chronic health problem (like diabetes or hypertension) who needed checkups. And it automatically calculated measures of the quality of care, like the percent of patients with diabetes whose A1C level the doctor had tested within six months, so that doctors could measure their progr
ess across their entire practice.
And now in February 2008, Mayor Bloomberg arrived at a doctor’s office in a converted house in the state’s poorest borough to demonstrate these smart features to the world. “Of course, the thing doesn’t work!” Mostashari remembered. “It was crashing!” Coders revised it furiously to get Bloomberg through the press conference.
Standing beside a computer loaded with the new software, Bloomberg told reporters he was going to revolutionize medical care. “Think about it,” he said. “You get notices for preventive maintenance from your dentist, your pet’s veterinarian, even your auto mechanic. Why not your doctor?”
Big clinics could afford electronic medical record software on their own. But in the city’s poor neighborhoods, doctors often worked alone or in small group practices without tech support. Bloomberg repeated his campaign pledge to install the software in a thousand doctors’ offices by the end of the year and added another promise: that 2,500 doctors serving two million patients would be using it by the end of 2010. Even though the prevention features were still buggy, the mayor advised the rest of the country to follow him. Going national with this software would cost the medical care system $20 billion over five years, he said; that sounded expensive but it was only a tiny fraction of the $2 trillion the country paid for health care annually. “We all deserve treatment when we’re sick,” he said, “but we’ll be far better served by a system that’s designed to keep us healthy.”
Later, when Frieden visited one doctor’s office, he saw the system’s potential—and glimpsed a problem that the software wouldn’t solve. “A lady came in for [prescription] refills and because her thighs hurt,” he told me. The doctor ordinarily would have just dealt with her immediate problem. But the computer’s software was rife with reminders. Frieden told the doctor, “She doesn’t have Pneumovax, she hasn’t had influenza vaccine. You haven’t checked her A1C in eighteen months, and the last time you checked, it was twelve. Her blood pressure is out of control, her lipids are probably out of control as well, she’s on the wrong medications, she hasn’t been HIV-tested, you didn’t check her for alcohol or depression. She doesn’t smoke—that’s good, but you didn’t check her for unsafe sex . . .” It took the doctor about an hour to clear all the reminders.
I asked Frieden what the doctor’s reaction was. “I think he was in shock. Farzad told me afterward, ‘You know, he gets twenty-four dollars for that visit.’”
• • •
Meanwhile the antitobacco program kept winning. The 2007 telephone survey showed smoking rates falling to 16.9 percent, a drop of 60,000 smokers from 2006 and 300,000 smokers from 2002. By Frieden’s simple one-third estimate, the decline since 2002 would save 100,000 lives.
The cigarette tax had worked so well that the tobacco team wanted to raise it again. Frieden proposed a fifty-cent increase in the city tax. Antitobacco advocates outside the health department, though, bolstered by the state medical society, organized around a $1.50 increase in the state tax, directing much of the money to the Medicaid program to pay for health care. They ran radio and television ads promoting the idea and lobbied legislators. Frieden wrote to Bloomberg, “From an NYC public health perspective, this would be fantastic. It would reduce the number of smokers by nearly 60,000 in NYC (vs. nearly 20,000 with the 50-cent tax we proposed), preventing about 20,000 deaths (vs. about 6,000 with the 50-cent tax).” The campaign worked. With the state running a huge budget deficit and Governor Eliot Spitzer rejecting an increase in the income tax on the rich, the legislature raised the tax another $1.25, bringing the price of a pack of cigarettes in New York City to about $8.50.
The tobacco team kept hitting New Yorkers with tough ads. Ronaldo, the man with a hole in his throat, had another run, as did Marie, the woman who had lost her fingers and toes. The health department also reran its grisly Cigarettes Are Eating You Alive ad. Then they tried an Australian ad called Separation. In the ad, a mother is holding the hand of her toddler in a bustling train station. The mother then lets go and disappears into the crowd. The camera zooms in on the toddler who now can’t find his mother, his face going from confusion to fear to anguished crying. The voiceover says, “If this is how your child feels after losing you for a minute, just imagine if they lost you for life.”
The health department was flooded with complaints. How could the director have been so cruel as to make the little boy cry? But an advertising executive on NBC’s Today show loved the sucker punch of the smoker making his children suffer. Maybe the director had made the kid cry, the ad man said, “but if it saves 20,000 lives for five seconds, I’ll take it. . . . Finally, somebody’s getting it right.”
The 2008 telephone survey showed that smoking rates had dropped another percentage point to 15.8 percent, meaning a decrease of another 50,000 smokers.
• • •
Frieden might have sold his electronic medical record software to Mayor Bloomberg, but Farzad Mostashari still had to sell it to doctors. He hired a team of young eager staff who mailed out pamphlets, attended Medical Society dinners, cold-called doctors, and showed up unannounced in their offices. The doctors were reluctant because the change was traumatic. The switchover meant shutting down their practice for up to two weeks, after which the doctors had to reconfigure nearly every office task, and then the software required more of everyone’s time than paper did. The simple task of writing a note or filling out a form suddenly became data entry, and as with all electronic medical records, the software didn’t accept data the way many doctors’ or nurses’ brains worked. Of the doctors who signed up, some later abandoned the system in frustration.
Many of those who made it over the hump didn’t like the “clinical decision support system.” They found the reminders annoying. There were too many of them. The doctors would rather use that space on their screens for information they found more useful, like a summary of the patient’s medical problems. And they sometimes disagreed with the reminders; the internists wanted to change the frequency that certain tests should be done—like every six months instead of every three—and the pediatricians wanted reminders about vaccinations, not smoking and high blood pressure.
But Mostashari was excited by the possibilities after he visited a doctor in Harlem operating a storefront clinic. An older woman, she wasn’t comfortable on a computer. It was slowing her down, but she was “soldiering on.” It being winter, Mostashari asked her, “What percent of your elderly patients did you give a flu shot to when they came in for a visit?”
She didn’t know but guessed about 80 percent.
He asked if she had ever clicked on a tab that produced a list of patients.
No, she hadn’t.
He clicked on it, and there were all her patients. “Now you can limit it to those who are over sixty-five,” he said, and put in the criterion and clicked again. Then he restricted it to those who had received a flu shot. It was only 20 percent.
That can’t be right, the doctor said.
“Now, for the first time ever, she could see for herself,” Mostashari told me. He told her, “Okay, let’s look at who has not had a flu shot.”
The doctor double-clicked on the first patient on the list, to open her progress note. “Yeah, I guess I didn’t give her a flu shot,” she said, reading her note. “Mmmm, but she was just here for a refill.”
She double-clicked on the second patient to open her progress note. “Oh, I’m working on her blood sugars.” She clicked on the third one, the fourth one, and the fifth one. After the fifth patient, she accepted it.
“It was that quick,” Mostashari told me later. “She accepted that she hadn’t given flu shots to eighty percent. Not eighty, not sixty, not fifty, not forty, not thirty!”
The doctor looked a little ashamed. “Can I send them a letter?” she asked.
“Yes you can,” he said. “Right here. Just click, and you can send them all a form letter.”
Years later he told me, “That was for me the ‘aha!’ moment, that we
can actually get normal docs in that normal storefront who are practicing independently to understand population health.”
The doctor’s reactions also explained a paradox in medicine. Every doctor believes he or she is delivering excellent medical care, but all the numbers say that medical care in America is abysmal. The discrepancy is that doctors have no idea what they are doing across their entire panel of patients. They remember the difficult diagnoses, the gratifying cures, the tragedies avoided, and the occasional mistakes, but they have a blind spot for the diagnoses, treatments, and counseling opportunities that they miss. Now a computer was filling in the blind spot.
8
“There’s no doubt our kids drink way too much soda.”
When I first came to the health department in the summer of 2007, Tom Frieden asked me what I thought he should do about obesity. Like Lynn Silver and Mary Bassett, I saw the source as a toxic food environment, especially cheap, calorie-dense, ready-to-eat foods and beverages, offered at arm’s reach everywhere from office vending machines to hardware stores. Calorie labels might help some people resist the Bacon Double Cheeseburger at Burger King, but they wouldn’t touch the rest of that smorgasbord. I didn’t have a simple solution.
Frieden surprised me by responding that he thought the single best action we could take was to put a tax on soda. And with that, he started down a course that would shape the nation’s response to the obesity epidemic.
Obesity researchers then were starting to eye sugary drinks with great suspicion. For decades, dietary guidelines had told Americans to cut back on fat. When it came to weight gain, most experts thought, a calorie is a calorie, no matter the source. Because dietary fat has more than twice as many calories per gram as carbohydrates or protein, people should avoid fat. Then in the 1990s, some nutrition experts—watching obesity rates surge despite that advice—started rethinking carbohydrates. During the thirty years of the obesity epidemic, Americans’ diets had grown by 200 to 300 calories a day, nearly all from carbs.
