In writing about OpenNotes last summer, I argued that the practice of sharing clinicians’ notes with patients had moved beyond the question of whether it was a good idea (the landmark study published in Annals of Internal Medicine was pretty clear on that) to questions of how best to implement it.
As more organizations adopt the practice, it’s clear that we’re now in a phase of implementation, and experimentation with different approaches and learning. Tom Delbanco, MD, one of the project leads, often compares open notes to a drug — it does have some side effects and some contraindications for some people and some circumstances — and we all need to understand those nuances.
To make it easier for health care organizations to offer the service to their patients, the OpenNotes project team has just released a new toolkit.
The toolkit focuses on two challenges: helping organizations make the decision to implement open notes and helping organizations with all the steps involved in implementing open notes.
It includes a slide deck that lays out the results of the study and makes the case for implementation, a video profile of how a patient and her doctor have used the practice, profiles of the implementations at the pioneering sites, FAQs for clinicians and patients, and tips for clinicians on how to write open notes.
Please check it out and tell the OpenNotes team what you think: is it valuable? How could it be better?
Continue reading “The OpenNotes Toolkit”
Filed Under: Tech, THCB
Tagged: Electronic Medical Records, OpenNotes, Patient Notes, RWJF, Steve Downs
Mar 10, 2014
Since HIPAA entitles virtually all patients to obtain copies of their complete medical records at any time, it is always best to write notes with the assumption that patients may read them.
However, as electronic portals provide patients with easy access to their records, clinicians may feel new pressure to be more mindful about how they write their notes. They may alter their approach to or even omit sensitive information to avoid worrying patients unnecessarily. They may try to balance clinical and non-technical language to avoid confusing patients; they may feel they need more time to write notes that patients can read.
They may be concerned about how patients might choose to share their notes, including posting a clinician’s note on Facebook, medical forums, or other social media.
Most doctors in the OpenNotes study found that they generally didn’t need to change how they wrote their notes. Patients did not expect doctors to write notes aimed specifically at them and were grateful simply to have a window into their medical record.
However, a minority of doctors reported that they changed how they documented potentially sensitive topics. These included mental health, obesity, substance abuse, sexual history, elder, child or spousal abuse, driving privileges, or suspicions of life-threatening illness. These are not new dilemmas, but they gain urgency in an era of shared visit notes.
Unless you believe a conversation might harm your patient, a good rule of thumb is to write about things you discussed with your patients (and conversely, to talk about content you will write about). Many clinicians already follow this practice, and some choose to dictate notes with their patients present.
When documenting sensitive behavioral health issues, we recommend trying to describe behaviors descriptively, rather than labeling them or suggesting judgments. We also suggest highlighting the patient’s strengths and achievements alongside his/her clinical problems. This can help the patient gain a broader context within which to consider his or her illness and tackle difficult behavioral changes.
Continue reading “The Open Notes Toolkit: Writing Fully Transparent Notes”
Filed Under: Tech, THCB
Tagged: OpenNotes, personal health records, RWJF, Transparency
Mar 10, 2014
By ANDY ORAM
HIMSS has opened and closed in Florida and I’m in Boston with snow up to my rectus abdominis. After several years of watching keynote pageants and scarfing up the amenities at HIMSS conferences, I decided to stay home this year.
Writing articles from earlier conferences certainly called on all my energy and talents. In 2010 I called for more open source and standards in the health care field. In 2012 I decried short-term thinking and lack of interest in real health transformation. In 2013 I highlighted how far providers and vendors were from effective patient engagement. In general, I’ve found that my attendance at HIMSS leads moaning and carping about the state of health IT. So this year I figured I could sit in my office while moaning and carping about the state of health IT.
In particular, my theme this year is how health IT is outrunning the institutions that need it, and what will happen to those left behind.
The scissors crisis: more IT expenditures and decreasing revenues
Although the trade and mainstream press discuss various funding challenges faced by hospitals and other health providers, I haven’t seen anyone put it all together and lay out the dismal prospects these institutions have for fiscal health. Essentially, everything they need to do in information technology will require a lot more money, and all the income trends are declining.
Certainly the long-term payoff for the investment in information technology could be cost reductions–but only after many years, and only if it’s done right. And certainly, some institutions are flush with cash and are even buying up others. What we’re seeing in health care is a microcosm of the income gap seen throughout the world. To cite Billie Holliday: them that’s got shall get; them that’s not shall lose.
Here are the trends in IT:
Meaningful Use requires the purchase of electronic health records, which run into the hundreds of thousands of dollars just for licensing fees. Training, maintenance, storage, security, and other costs add even more. The incentive payments from the federal government come nowhere near covering the costs. EHR providers who offer their record systems on the Web (Software as a Service) tend to be cheaper than the older wave of EHRs. Open source solutions also cost much less than proprietary ones, but have made little headway in the US.
Hot on the heals of Meaningful Use is ICD-10 compliance, a major upgrade to the diagnostic codes assigned to patient conditions. Training costs (and the inevitable loss of productivity caused by transitions) could be staggering. Some 80% of providers may miss the government’s deadline.The American Medical Association, citing estimated prices for a small practice of $56,639 to $226,105 (p. 2), recently urged the government to back off on requiring ICD-10. Their point of view seems to be that ICD-10 might have benefits, but far less than other things the providers need money for. Having already put off its deadline, the Department refuses to bend further.
Continue reading “HIMSS Unplugged”
Filed Under: THCB
Tagged: analytics, Beyond Core, bundled payments, Health Fidelty, HIMSS 2014, ICD-10
Mar 10, 2014
Late last week, House Republican leaders declared their intention to bring H.R. 4015, the bipartisan, bicameral SGR repeal measure, to the floor for a vote.
Good news, you’d think, for doctors and the broader healthcare system, that we might finally be rid of the SGR’s broken machinations and perverse cycle of congressional intervention.
But House leaders added a footnote: the measure would be paid for by delaying the individual mandate, which CBO opined last week would save money through reduced enrollment in Exchanges and Medicaid. To cover the approximate $150 billion cost of the SGR measure, the mandate would probably need to be delayed by at least 10 years.
While sparing us a rehash of the individual mandate debate here, suffice it to say that the Obama Administration, the authors of the Affordable Care Act, and most healthcare insurers and providers consider it to be a linchpin of the health reform regime.
Without it, most agree, the consumer protections established by the ACA would precipitate spiraling premiums that would quickly destroy the market.
In other words, the House measure is DOA in the Democrat-controlled Senate and White House, which House leaders know all too well. In a move whose political deftness is hard to quibble with, they are coupling two very popular measures into a single package that they know the vast majority of Democrats can’t support.
Good politics? Probably. Good for enactment of SGR repeal? More like the opposite.
But don’t blame House leaders for the demise of SGR repeal. This move is a symptom, not a cause, of its end. As previously reported, the well-intentioned negotiators were having difficulty finding common ground on the so-called extenders package that would be included, and were miles apart on the offsets that would be used to fund it.
This train had already come off the tracks.
Continue reading “The Death of SGR Reform”
Filed Under: Physicians, THCB
Tagged: Billy Wynne, Congress, Obama administration, SGR repeal, sustainable growth rate (SGR)
Mar 9, 2014
Quality improvement (QI) and patient safety initiatives are created with the laudable goal of saving lives and reducing “preventable harms” to patients.
As the number of QI interventions continues to rise, and as hospitals become increasingly subject to financial pressures and penalties for hospital-acquired conditions (HACs), we believe it is important to consider the impact of the pressure to improve everything at once on hospitals and their staff.
We argue that a strategy that capitalizes on “small wins” is most effective. This approach allows for the creation of steady momentum by first convincing workers they can improve, and then picking some easily obtainable objectives to provide evidence of improvement.
National Quality Improvement Initiatives
Our qualitative team is participating in two large ongoing national quality improvement initiatives, funded by the Agency for Healthcare Research and Quality (AHRQ). Each initiative targets a single HAC and its reduction in participating hospitals.
We have visited hospital sites across six states in order to understand why QI initiatives achieve their goals in some settings but not others.
To date, we have conducted over 150 interviews with hospital workers ranging from frontline staff in operating rooms and intensive care units to hospital administrators and executive leadership. In interviews for this ethnographic research, one of our interviewees warned us about unrealistic expectations for change: “You cannot go from imperfect to perfect. It’s a slow process.”
While there is much to learn about how to achieve sustainable QI in the environment of patient care, one thing is certain from the growing wisdom of ethnographic studies of QI: buy-in from frontline providers is essential for creating meaningful change.
Frontline providers often bristle at expectations from those they believe have little understanding of the demands of their daily work.
Continue reading “The Dangers Of Quality Improvement Overload”
Filed Under: Physicians, THCB
Tagged: AHRQ, Burnout, Catherine van de Ruit, Charles Bosk, hospital acquired conditions (HACs), Hospitals, Joanna Brooks, Ksenia Gorbenko, Patient Safety, Providers, Quality improvement
Mar 9, 2014
March 2nd through the 8th were National Patient Safety Awareness Week – I don’t really know what that means either. We seem to have a lot of these kinds of days and weeks – my daughters pointed out that March 4 was National Pancake Day – with resultant implications for our family meals.
But back to patient safety and National Patient Safety Awareness Week. In recognition, I thought it would be useful to talk about one organization that is doing so much to raise our awareness of the issues of patient safety. Which organization is this? Who seems to be leading the charge, reminding us of the urgent, unfinished agenda around patient safety?
It’s an unlikely one: The Office of the Inspector General of the Department of Health and Human Services. Yes, the OIG. This oversight agency strikes fear into the hearts of bureaucrats: OIG usually goes after improper behavior of federal employees, investigates fraud, and makes sure your tax dollars are being used for the purposes Congress intended.
In 2006, Congress asked the OIG to examine how often “never events” occur and whether the Centers for Medicare and Medicaid Services (CMS) adequately denies payments for them. The OIG took this Congressional request to heart and has, at least in my mind, used it for far greater good: to begin to look at issues of patient safety far more broadly.
Taken from one lens, the OIG’s approach makes sense: the federal government spends hundreds of billions of dollars on healthcare for older and disabled Americans and Congress obviously never intended those dollars pay for harmful care. So, the OIG thinks patient safety is part of its role in oversight, and thank goodness it does.
Because in a world where patient safety gets a lot of discussion but much less action, the OIG keeps the issue on the front burner, reminding us of the human toll of inaction.
Continue reading “What the Work of the Inspector General Tells Us about Patient Safety…”
Filed Under: THCB
Tagged: Adverse Events, Ashish Jha, Never Events, OIG, Patient Safety, skilled nursing facilities, To Err is Human
Mar 9, 2014
Kudos to the New England Journal for providing a tidy summary of the latest Republican healthcare reform proposal. Up until now, your correspondent was only vaguely aware of the GOP’s evolution from the political party of “no” to one of “go,” albeit with lots of caveats.
It seems the Senate Republicans no longer want to repeal Obamacare and are OK with keeping many of its more popular reforms. Instead, they’re focusing on undoing selected provisions, such as repealing the minimum benefit, returning some aspects of medical underwriting and resurrecting the “block for Medicaid.
But one of the more interesting wrinkles in the proposal is “auto-enrollment.”
Those of us from the bygone days of “disease management” may recall the debates over the merits of “opt-in” versus “opt out” participation in our programs. The former required persons to actively chose to be entered into nurse coaching, which had the advantage of committing resources to a highly motivated population. The latter approach assumed all patients with a condition were enrolled and, only if they specifically requested it, would they allowed to stop the coaching phone calls. Unfortunately, “opt-out” usually gathered many patients who never answered the phone and were “engaged” in name only.
Well, the Republicans are apparently proposing that states be allowed to “auto-enroll” persons eligible for premium payment support into an insurance plan or Medicaid without their up-front permission, just like the old “opt-out” disease management days. The tax credit would cover the insurance costs, no bills would be issued to the consumer and voilà! the risk pools would expand. Patient choice would be preserved, because persons could always just say no.
Your correspondent was always of fan of opt-in disease management. Not only were patients who wanted to be in the program more amenable to behavior change, it allowed the program to “flex” the nurses that we needed as the program grew in scope. However, when it comes to insurance, yours truly thinks the Republicans may be onto something with their opt-out insurance approach.
Count your correspondent as a fan.
Jaan Sidorov, MD, is a primary care internist and former Medical Director at Geisinger Health Plan with over 20 years experience in primary care, disease management and population-based care coordination. He shares his knowledge and insights at Disease Management Care Blog, where an earlier version of this post first appeared.
Filed Under: THCB, The Business of Health Care
Tagged: Auto-Enrollment, Disease Management, GOP Repeal, Jaan Sidorov, Opt out, Opt-In, Republicans
Mar 8, 2014
Lub-SHHRRR. Lub-SHHRRR. Lub-SHHRRR.
“Can you hear it?” she asked with a smile. The thin, pleasant lady seemed as struck by her murmur as I was. She was calm, perhaps amused by the clumsy second-year medical student listening to her heart.
“Yes, yes I can,” I replied, barely concealing my excitement. We had just learned about the heart sounds in class. This was my first time hearing anything abnormal on a patient, though it was impossible to miss—her heart was practically shouting at me.
Her mitral valve prolapse—a fairly common, benign condition—had progressed into acute mitral regurgitation. She came to the hospital short of breath because her faulty valve was letting blood back up into her lungs.
Though it was certainly frightening, surgery to fix the valve could wait a few weeks. But before doing anything, the surgical team wanted a picture of the blood vessels in her heart.
If the picture showed a blockage, the surgeons would have to perform two procedures: one to fix the blockage, and another to fix her valve. If her vessels were healthy, though, the surgeons could use a simpler approach focused just on her valve.
So she came to the interventional cardiologist who was teaching me for the day. Coronary angiograms are the interventionalists’ bread-and-butter procedure, done routinely to look for blockages and to guide stent placement. They involve snaking a catheter from the groin or arm through major blood vessels and up to the heart.
Under fluoroscopy (like a video X-ray), the cardiologists shoot contrast medium into the arteries, revealing the anatomy in exquisite detail.
The images are recorded electronically and accompanied by the cardiologist’s interpretation for anyone else who opens her medical record.
Though routine, these catheterizations aren’t trivial. Whenever you enter a blood vessel, you introduce the risk of bleeding and infection. Fluoroscopy is radiation, and contrast medium can damage the kidneys. And let’s not forget cost—reimbursing the interventional cardiologist, a radiology technician, and nursing staff costs Medicare almost $3,000 per case.
So I asked the cardiologist if such an invasive approach was really necessary.
Continue reading “Actually, High-Tech Imaging Can Be High-Value Medicine”
Filed Under: Tech, THCB
Tagged: angiograms, Costs, CTA, FutureMed, Imaging, Interventional cardiology, Karan Chhabra, MRI, Quality
Mar 6, 2014
The administration has confirmed that the individual policies that were supposed to be cancelled because of Obamacare can now remain in force another two years.
For months I have been saying millions of individual health insurance policies will be cancelled by year-end––most deferred until December because of the carriers’ early renewal programs and because of President Obama’s request the policies be extended in the states that have allowed it.
The administration, even today, as well as supporters of the new health law, have long downplayed the number of these “junk policy” cancellations as being insignificant.
Apparently, these cancelled policies are good enough and their number large enough to make a difference come the November 2014 elections.
As a person whose policy is scheduled to be cancelled at year-end, I am happy to be able to keep my policy with a better network, lower deductibles, and at a rate 66% less than the best Obamacare compliant policy I could get––presuming my insurance company and state allow it.
But for the sake of Obamacare’s long-term sustainability, this is not a good decision.
The fundamental problem here is that the administration is just not signing up enough people to make anyone confident this program is sustainable.
Continue reading “What Extending the Obamacare Cancelled Policy Moratorium Really Means”
Filed Under: THCB, The Business of Health Care
Tagged: enrollment numbers, Health Plans, Obamacare Fix, Robert Laszewski, The ACA
Mar 6, 2014
I was reading a medical home advocacy group’s upbeat approach to a recent JAMA study that had found scant benefit in the concept when, suddenly, we tumbled into Alice in Wonderland territory.
The press release from the leadership of the Patient-Centered Primary Care Collaborative (PCPCC) started out reasonably enough. The three-year study of medical practices had concluded that the patient-centered medical home (PCMH) contributed little to better quality of care, lower cost and reduced utilization. This was an “important contribution,” said the PCPCC, because it showed “refinement” of the concept that was still necessary.
That was just the set up, though, to this challenge from Marci Nielsen, chief executive officer of the group. “It is fair,” said Nielsen, “to question whether these pilot practices (studied) had yet transformed to be true medical homes.”
Where might one find these true medical homes? The answer turns out to be as elusive as a white rabbit. Formal recognition as a medical home via accreditation “can help serve as an important roadmap for practices to transform.” However, accreditation as a PCMH “is not necessarily synonymous with being one.” Conversely, you can be a “true PCMH” without having received any recognition at all!
But maybe the true medical home does not yet exist, since, “the evidence base” for the model “is still being developed.”
In Through the Looking Glass, Humpty Dumpty scornfully informs Alice: “When I use a word, it means just what I choose it to mean – neither more nor less.” And so we learn that a true medical home means just what the PCPCC says it does.
It’s confusing. If the truly transformational medical home lies in the future, why does the PCPCC chide the JAMA researchers in this “otherwise well-conducted study” for failing to “reference the recent PCPCC annual report which analyzed 13 peer-reviewed and 7 industry studies and found cost savings and utilization reductions in over 60 percent of the evaluations”?
Continue reading “The Medical Home’s Humpty Dumpty Defense”
Filed Under: OP-ED, THCB
Tagged: health care delivery, Michael Millenson, patient centered medical homes (PCMH), patient centered primary care collaborative (PCPCC), Population Health, primary care
Mar 6, 2014