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Since the death of comedian and talk-show host Joan Rivers, more information has surfaced about the events on the morning of August 28 at Yorkville Endoscopy. But key questions remain unanswered.

News accounts agree that Ms. Rivers sought medical advice because her famous voice was becoming increasingly raspy. This could be caused by a polyp or tumor on the vocal cords, or by acid reflux irritating the throat, among other possible causes.

So Ms. Rivers underwent an endoscopy by Dr. Lawrence B. Cohen, a prominent gastroenterologist, to evaluate her esophagus and stomach for signs of acid reflux. At the same time, a specialist in diseases of the ear, nose, and throat (ENT) reportedly examined her vocal cords (also known as vocal folds).

We don’t know exactly how much or what type of sedation Ms. Rivers’ may have received, though several news sources have reported that she was given propofol, the sedative associated with the death of Michael Jackson. No physician who specializes in anesthesiology has been identified on the team taking care of Ms. Rivers, and we don’t know who was in charge of giving her propofol.

It seems clear that at some point during Ms. Rivers’ endoscopy and vocal cord examination, there was a critical lack of oxygen in her bloodstream.

Was laryngospasm the cause?

Giving sedation for upper endoscopy is tricky, as any anesthesia practitioner will tell you. A large black endoscope takes up space in the mouth and may obstruct breathing. Any sedative will tend to blunt the patient’s normal drive to breathe. But most patients breathe well enough during the procedure, and go home with no complaints other than a mild sore throat.

News reports have speculated that the root cause of Ms. Rivers’ rapid deterioration during the procedure could have been laryngospasm. This term means literally that the larynx, or voice box, goes into spasm, and the vocal cords snap completely shut. No air can enter, and of course the oxygen in the bloodstream is rapidly used up.

The most common situation that leads to laryngospasm is irritation of the vocal cords. Everyone knows that when a drop of liquid or a crumb of food goes down the wrong way, it’s highly irritating and provokes a fit of coughing. When the vocal cords are stimulated or even lightly touched, their natural protective response is to close up.

Every anesthesiologist is taught how to manage laryngospasm, because it can be a life-threatening emergency leading to brain damage or death if the patient is deprived of oxygen for too long. Sometimes the vocal cords relax and open up on their own, but often they don’t.

Continue reading “Anesthesiologist’s Review of the Facts in the Joan Rivers Case”

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I’ve always been a little skeptical of the push to get doctors to prescribe apps.

To begin with, it would be awfully easy for us to replicate the many problems of medication prescribing. Chief among these is the tendency for doctors to prescribe what’s been marketed to them, rather than what’s actually a good option for the patient, given his or her overall medical situation, preferences, and values.

Then there are the added complexities peculiar to the world of apps, and of using apps.

A medication, once a pharmaceutical company has labored to bring it to market, basically stays the same over time. But an app is an ever-morphing entity, usually updating and changing several times a year. (Unless it stops updating. That’s potentially worse.)

Meanwhile, the mobile devices with which we use apps are *also* constantly evolving, and we’re all basically forced to replace our devices with regularity.

Last but not least, how can we know the benefit of prescribing one app compared to another? Studies are few and far between. And by the time a study is published, everything – the app, people’s use of technology, the mobile devices, the sensors – will have gone through several phases of change. This means we generally won’t have much of an evidence base, when it comes to the prescribing of a given app.

All of this means that it would be a Herculean task for physicians to maintain enough current knowledge about apps, such that they could prescribe them in a thoughtful and informed matter.

Continue reading “Should Docs Prescribe Data?”

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Tom Frieden optimizedThe Ebola outbreak in West Africa is an international public health emergency. As the world responds, there is a risk that American responders working on the ground may be exposed to the virus or become ill. This summer, two American health care workers infected with Ebola while working in West Africa were successfully treated at Emory University Hospital.  Their health care team used the proper infection control practices and there was no transmission of the virus to the health care team or others in the hospital and community.

Now two more American health care workers working in West Africa have become infected with Ebola virus and are being treated in the United States.

CDC has already consulted with state and local health departments on almost 100 cases where travelers had recently returned from West Africa and showed symptoms that might have been caused by Ebola. Of those cases, only eleven of were considered to be truly at risk. Specimens from all eleven patients were tested and fortunately Ebola was ruled out in all cases.

There is understandably a lot of fear surrounding Ebola. The health care workers who might need to care for Ebola patients are right to be concerned – and they should use that concern to increase their awareness and motivation to practice the meticulous infection control measures we know will prevent transmission of the virus.

Hospitals and health care facilities must review their infection control practices, including how they’re handling environmental infection control.

When we issued our infection prevention and control recommendations for hospitalized patients with known or suspected Ebola virus disease , we began hearing from those concerned that standard environmental infection control procedures might not be sufficient.

Part of the concern is that no EPA-registered disinfectant has a labeling claim specifying that it is effective against the Ebola virus. You cannot go to the shelf and find a product that says it will be effective in killing Ebola. However, because Ebola is readily killed by soap and water, bleach, or hospital disinfectants that are labeled as being effective against non-enveloped viruses, standard infection control procedures are indeed sufficient.

Continue reading “Ebola Update from CDC Director Thomas Frieden”

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Matthew Holt interviewed Jacob Reider, Deputy National Coordinator for Health Information Technology and Chief Medical Officer at the ONC, ahead of his appearance at the 8th Annual Health 2.0 Fall Conference. Jacob will be participating in several panels at Health 2.0, beginning with the Monday main stage panel ”Smarter Care Delivery: Amplifying the Patient Voice”.

In this interview, Jacob gives an overview of the HITECH program, the question of interoperability, and the broad adoption of technology in health care as an industry.  

Matthew Holt: So, let’s touch base on a couple of things. You’ve been in ONC some time now. Let’s talk about how the general HITECH program has gone and is going. If you were to get to rate it, the spread of EMRs and the usefulness of them, their usability, how would you say we’re doing so far?

Jacob Reider: I think we’re doing very well. Some of your readers know I went to college at a place that had no grades. So I’ll give you the narrative score.

The narrative score is that the program has been very successful achieving the goals that were defined at the outset. So the first iteration of the program, stage one, was all about getting organizations to adopt Health Information Technology, and I think all of the metrics that we’ve seen have validated that the program has been quite successful in accelerating the adoption of Health Information Technology, in both hospitals and practices. That doesn’t mean that we’re finished, but the vast majority of these organizations have now adopted Health Information Technology. Are there additional goals that we’d like to be able to meet? Absolutely, we’d like to see interoperability working better. As you mentioned, we would like the products to be more usable, and therefore, safer.

We’d like to see patients even more engaged than they currently are, so they have more access to the information in their records. We’d like to solve a problem that we’re starting to see in the industry, which I started to call hyperportalosis, which is that in any given community, there may be many portals that patients are expected to log in to. So we’re trying to think about how those problems can be solved in the next iteration of the HITECH program.

Continue reading “Countdown to Health 2.0 2014: Exclusive Interview with ONC Chief Medical Officer Jacob Reider”

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Screen Shot 2014-09-14 at 1.49.42 PMWith the fast adoption of smart phones, tablets and wearable devices, the way people communicate, travel, eat and entertain have all been simplified. Why not streamline the way we experience healthcare as well? A study released in May 2014 from MDLive discovered that 82% of young adults 18-34 would prefer consulting with their doctor via a mobile device than show up for an appointment. Twenty seven percent of patients confirmed they’d be willing to give up shopping for a month, skip their next vacation, even refrain from showers for a week—if it meant they would be able to access their doctor via a smart phone! These results, along with the multiple surveys and studies conducted in the past year, confirm that a new way to conduct healthcare services is in high demand.

The solution to changing up the healthcare system sits at the center of three key advancements: patient engagement, population health and electronic health records (EHRs). At eClinicalWorks, we consider these components of healthcare to be like a three-legged stool where two cannot stand without the other. We recognized this need as an opportunity within the healthcare IT space and created healow in order to provide our customers and their patients with a platform to schedule doctors’ appointments and get immediate access to medical records via an online interface or mobile app. healow empowers doctors and patients by packaging personal health records (PHRs), healthcare tools and appointment scheduling together, making the data readily accessible to patients and their doctors from the palm of their hand.

Continue reading “What Would You Give Up For a Virtual Doctor Visit?”

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The Future Looks Like a Girl With a Gun Resized

I am a public health professional, educated at the vaunted Johns Hopkins University Bloomberg School of Hygiene and Public Health. I like guns, and I believe the Second Amendment clearly secures the rights of individuals to own firearms.

You read that correctly. I am a public health professional.

And I like guns.

This make me a heretic in American public health, where embracing firearms and the rights of gun owners is a gross violation of orthodoxy.

As a society, our focus on guns and not gun users derives from the shock of mass killings, such as those in Newtown, CT, Aurora, CO, Virginia Tech, and Norway, which has some of the strictest gun control laws on the planet. Mass killings, however tragic, get distorted by saturation media hysterics and 24-hour political grandstanding. What gun opponents refuse to discuss is the precipitous fall in violent crime and deaths by firearms over the past 20 years, and how it coincides with an equally dramatic increase of guns in circulation in the US.

While that isn’t cause and effect, the association is certainly curious.

In 2013, the Institute of Medicine, at the behest of the Centers for Disease Control, produced a report on firearms violence that has been ignored by the mainstream media. The upshot: defensive use of firearms occurs much more frequently than is recognized, “can be an important crime deterrent,” and unauthorized  possession (read: by someone other than the lawful owner) of a firearm is a crucial driver of firearms violence.

That report went away for political reasons. Translation. Nobody wanted to talk about it because it raised more questions than it answered.

Continue reading “Why Public Health Needs a New Gun Doctrine”

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Today’s healthcare industry bears a startling resemblance to a Charles Dickens novel. It is the best of times, and the worst of times. In an age where advancements in technology have extended patient lifespans, many healthcare systems are struggling to pay their bills. Deloitte pegs healthcare spending at over $3.8 Trillion in 2014, and providers are desperately searching for any cost-cutting solutions. Many found a means to treat their own symptoms, with a prescription of mobile apps.

It seems to not make sense. How would hospitals save money by spending thousands to build an app? Today, almost 60% of the U.S. population owns smartphones. Patients, especially seniors, are adopting tablets at a rapid rate.  Successful hospitals are leveraging branded mobile apps not only to engage their patients and boost HCHAPS scores, but to achieve cost reduction by launching efficient mobile apps.

Continue reading “Can Self-Made Hospital Apps Reduce Healthcare Costs?”

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Jack CochranThe Health Care Blog recently featured our Open Letter to Primary Care Physicians,generating quite a bit of reaction. A commenter made the point that “we cannot expect” primary care physicians “to act differently until and unless they get paid differently.” [Emphasis added]

The comment refers to a doctor in solo practice and notes that “the first step is changing how you are paid, in one way or another. And there are many ways that work better than the current code-driven fee-for-service model.”

Does waiting for payment reform make sense? Or should primary care practices act now to change the way they practice in anticipation of payment shifts?

Moving Toward Value-based Care

Some physicians groups seem somewhat frozen – unsure exactly where health care payment is headed and thus waiting until there is a clearer signal.

But it seems to us that the payment reform signal grows louder and clearer and support for that contention comes in a recent research report* from McKesson, the international consultancy:

We can now say with certainty that healthcare delivery is moving in one direction: towards value-based care.

This is care that is paid for based on results – on measurable quality – as opposed to the traditional fee-for-service approach that pays for volume. McKesson notes that

The affordability crisis is causing unprecedented changes in the healthcare landscape, the most significant of which is the transition from the current volume-based model [fee-for-service] to myriad models based on measures of value.

To remain relevant and competitive, payers, hospitals, health systems, and clinicians must respond now to integrate value-based models into their existing systems.

Continue reading “Waiting For Payment Reform?”

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Screen Shot 2014-09-10 at 6.22.08 AMBritain’s most prolific serial killer was a General Practitioner (GP), Dr. Harold Shipman. He wasn’t England’s most famous murderer. That accolade goes to Jack the Ripper. The Ripper killed five women in the streets of Whitechapel. Shipman might have been responsible for over 200 deaths.

Shipman’s legacy to the medical profession was not just a permanent simmering of mistrust. He triggered the introduction of revalidation, Britain’s version of maintenance of certification (MOC).

During Shipman’s prosecution the media scrutiny on physicians was intense. It’s both a beauty of and curse on our profession that we’re assumed to have such high code of ethics yet not spared the foibles of human nature.

“Homo homini lupus” doesn’t spare physicians. Bashar al-Assad was an ophthalmologist. Ayman al-Zawahiri once had taken the Hippocratic Oath.

This means that outliers, inevitable products of a Gaussian distribution, also get past the gates of medical school.

The government set up an inquiry headed by Dame Janet Smith. How could Shipman have gotten away with murder for so long? What were the systemic failures?

The Shipman Inquiry is 5000 pages long, compiled after interviewing 2500 witnesses. It cost the tax payer nearly 21 million pounds. Its conclusion was stunningly bland even if of military precision: doctors need more policing. This is like concluding that the First World War happened because people aren’t always nice to one another; a truism so uniformly true that it ceases to inform policy.

The report called for the General Medical Council (GMC), the prime regulatory agency for physicians, to work for patients, not physicians.

The solution: Revalidation.

Continue reading “On the origins of Maintenance of Certification in the National Health Service: A Serial Killer”

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FROM THE VAULT

The Power of Small Why Doctors Shouldn't Be Healers Big Data in Healthcare. Good or Evil? Depends on the Dollars. California's Proposition 46 Narrow Networking

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