Small Practice

Small Practice

Calcium Scan and Subtractive Medicine

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Being a radiologist, I rarely speak to patients, but I was asked to counsel Mrs. Patel (not her real name, so calm down HIPAA totalitarians), who was worried about the risks of radiation from cardiac calcium CT scan. Because of her risk factors for atherosclerosis, her cardiologist wanted her to take statins for primary prevention, but she was reluctant to start statins. They eventually reached a truce. If she had even a speck of calcium in her coronary arteries she would take statins. If her calcium score was zero she wouldn’t. This type of shared decision making is the most frequent reason why cardiologists order calcium scans at my institution.

The Case for Case-Based Reasoning

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flying cadeuciiCase-based reasoning has been formalized for purposes of computer reasoning as a four-step process[1]:

  • Retrieve: Given a target problem, retrieve cases from memory that are relevant to solving it. A case consists of a problem, its solution, and, typically, annotations about how the solution was derived.
  • Reuse: Map the solution from the previous case to the target problem. This may involve adapting the solution as needed to fit the new situation.
  • Revise: Having mapped the previous solution to the target situation, test the new solution in the real world (or a simulation) and, if necessary, revise.
  • Retain: After the solution has been successfully adapted to the target problem, store the resulting experience as a new case in memory.

The complexities associated with programming and implementation of a knowledge management system based on case histories is both non-obvious and difficult, but ironically this is the actual process that an expert physician uses in his day to day clinical work.

Patient-Centered Service

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flying cadeuciiAmerican healthcare has a customer service problem.  No, customer service in the US is terrible when it comes to healthcare.  No, the customer service in the US healthcare system is horrendous.  No, healthcare has the worst customer service of any industry in the US.

There.  That seems about right.

What makes me utter such a bold statement?  Experience.  I regularly hear the following from people when they come to my practice:

  • “You are the first doctor who has listened to me.”
  • “This office makes me feel comfortable.”
  • “I didn’t have to wait!”
  • “Where’s all the paperwork?”
  • “Your office staff is so helpful. They really care about my needs.”
  • “This is the first time I’ve been happy to come to the doctor.”
  • “It’s amazing to have a doctor who cares about how much things cost.”
  • “You explain things to me.”
  • “You actually return my calls.”

Why Doctors should Recommend Quantified Self Technologies for Their Patients

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The United States population suffers from staggering numbers of lifestyle related diseases. We know the situation is not improving. Recent research found that over half of the country has prediabetes or diabetes. The facts don’t lie—the vast majority of the US burden of disease are due to lifestyle.

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Photo Credit: Dr. DArriush Mozzafarian

People know they should eat less and exercise more, but they don’t. They don’t because without the right knowledge and direction, behavioral change is really hard. Doctors also know they should be advising their patients on lifestyle, but they don’t.

How to Safeguard your Career in Treacherous Healthcare Times

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Michel AccadDear medical student,

I am honored by the opportunity to offer some advice on how to safeguard your professional career in a treacherous healthcare system.

I will not elaborate on why I think the healthcare system is “treacherous.”  I will assume—and even hope—that you have at least some inkling that things are not so rosy in the world of medicine.

I am also not going to give any actual advice.  I’m a fan of Socrates, so I believe that it is more constructive to challenge you with pointed questions.  The real advice will come to you naturally as you proceed to answer these questions for yourself.  I will, however, direct you to some resources to aid you in your reflections.

I have grouped the questions into three categories of knowledge which I am sure are not covered or barely covered in your curriculum: economics, ethics, and philosophy of medicine.

I have found that reflecting on these questions has been essential to give me a sense of control over my career.  I hope that you, in turn, will find them intriguing and worth investigating.

One more thing before we proceed.  Don’t be overwhelmed by the depth of the questions posed and don’t attempt to answer them today, in a week, or in a year.  In many ways, these are questions for a lifetime of professional growth.  On the other hand, I believe that the mere task of entertaining these questions in your mind will be helpful to you.

So here we go:

A Radical Policy Proposal: Go Easy On Older Docs

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flying cadeuciiThrough Dec. 15, federal regulators will accept public comments on the next set of rules that will shape the future of medicine in the transition to a super information highway for
Electronic Health Records (EHRs).  For health providers, this is a time to speak out.

One idea:  Why not suggest options to give leniency to older doctors struggling with the shift to technology late in their careers?

By the government’s own estimate,in a report on A 10-Year Vision to Achieve an Interoperable Health IT Infrastructure, a fully functioning EHR system, for the cross-sharing of health records among providers, will take until 2024 to materialize.The technology is simply a long way off.

Meanwhile, doctors are reporting data while the infrastructure for sharing it doesn’t exist.  Now, for the first time, physicians will be reporting to the federal government on progress toward uniform objectives for the meaningful use of electronic health records.  Those who meet requirements will be eligible for incentive payments from Medicare and Medicaid, while those who don’t may face penalties. In addition, audits are expected to begin in 2016.

When it Comes to Healthcare IT Success Stories, Don’t Count out the Little Guy

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Tom GuillaniToday’s healthcare information technology headlines are littered with how large delivery networks are scaling up and successfully building and using IT infrastructure. But the real success story is hiding in the shadows of these large enterprise deployments, in the small and independent practices across the US. The recent ICD-10 transition, that had been foretold to drive small enterprise into financial despair due to their lack of IT savvy and infrastructure, has shown just the opposite. A report from a leading provider of billing software that was based on government and private payer claims analysis for the past 30 days shows a different story.

Being Graded

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Munia Mitra MD“Lawyers aren’t graded.”

“CEOs aren’t graded”

“How would you feel if I tracked every e-mail you sent and tracked how many people responded to them? You wouldn’t like that very much would you?”   

“The people who make EMRs. Why aren’t they graded?”

If there’s one negative I hear time and time again from doctors when the subject of quality measurement comes up, it’s this one near-universal complaint. The world is unfair, the cards are stacked against us.

As a specialist at a busy urban medical center I hear the complaints almost every day from colleagues and peers at other hospitals. We’re being singled out for unfair treatment:  They’re out to get us. It’s the world against the doctors.

Many of the so-called experts I’ve talked to at meetings around the country express disdain when the topic of physician resistance to quality improvement programs comes up.

But it shouldn’t be terribly surprising that the idea that one’s performance is being tracked can be seen as intrusive and threatening. The reaction is in many ways completely predictable.

The Doctor- Patient Relationship and the Outcomes Movement

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Screen Shot 2015-10-01 at 9.46.12 AMIn a recent Harvard Business Review article, authors Erin Sullivan and Andy Ellner take a stand against the “outcomes theory of value,” advanced by such economists as Michael Porter and Robert Kaplan who believe that in order to “properly manage value, both outcomes and cost must be measured at the patient level.”

In contrast, Sullivan and Ellner point out that medical care is first of all a matter of relationships:

With over 50% of primary care providers believing that efforts to measure quality-related outcomes actually make quality worse, it seems there may be something missing from the equation. Relationships may be the key…Kurt Stange, an expert in family medicine and health systems, calls relationships “the antidote to an increasingly fragmented and depersonalized health care system.”

In their article, Sullivan and Ellner describe three success stories of practice models where an emphasis on relationships led to better care.

But in describing these successes, do the authors undermine their own argument?  For in order to identify the quality of the care provided, they point to improvements in patient satisfaction surveys in one case, decreased rates of readmission in another, and fewer ER visits and hospitalizations in the third.  In other words…outcomes

ONC’s Interoperability Plan: a Day Late and $19bn Short

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Screen Shot 2015-10-21 at 8.40.34 AMEarlier this month, the Office of the National Coordinator for Health Information Technology released an update to Connecting Health and Care for the Nation: A Shared Nationwide Interoperability Roadmap. The roadmap was first announced back in January, and the changes shared this month aren’t significant.

Ultimately, it calls for all healthcare providers nationwide to be able to send and receive electronic clinical information by the end of 2017.

This is a good plan on the surface, although it comes six years and millions of dollars late, and like other programs it may be more cumbersome that it first seems. Essentially, there are three facets:

1) Data standards to format and request/receive data

2) Incentives (again!)

3) Governance

Despite the intention to move data across the Union, each state will have the right to create its own unique rules on how to manage the exchange of information. This is a problem as we have seen before in the simple Case of e-prescription routing. A few states make it almost impossible to send e-scripts and layer on their own special form of bureaucracy. This inhibits the ultimate goal of reducing costs and errors and increasing Efficiency at the expense of both providers and patients.