THCB

THCB

A Physician Faces Disciplinary Action For Seeing Patients on Skype — Early Guidelines For Patient Video Visits

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The medical board of the state of Oklahoma recently sanctioned a physician for using Skype to conduct patient visits.  A number of other factors add color to the board’s action, including that the physician was prescribing controlled substances as a result of these visits and that one of his patients died.  This situation brings up several challenges of telehealth — that is, using technology to care for patients when doctor and patient are not face-to-face.

• Legal/regulatory: On the legal side, physicians are bound by medical regulations set by each state.  It appears that the use of Skype is not permitted for patient care in Oklahoma.

• Privacy/security: Skype says its technology is encrypted, which means that you should not be able to eavesdrop on a Skype call.  That would seem to protect patient privacy.  At Partners HealthCare, we ask patients to sign consent before participating in a ‘virtual video’ visit.  Because this is a new way of providing care, we feel it’s best to inform our patients of the very small risk that their video-based call could be intercepted.  I don’t know if the Oklahoma physician was using informed consent or not.

But the most interesting aspects of this case involve the question of quality of care.  Can a Skype call substitute for an in-person visit?  Under what circumstances?

Video virtual visits are a new mode of care delivery.  Whenever anything new comes up in medicine, it is subject to rigorous analysis before entering mainstream care.  That same rigor applies to video virtual visits.  Although some studies suggest virtual visits can be useful, the evidence is not yet overwhelming.  I can’t say with 100% certainty how virtual visits will best be used, but based on several pilot programs under way at Partners, I have a hunch or two.

We have believed for some time that this technology should be limited to follow up visits, where the patient and physician already have a well-established relationship.  Technologies such as Skype and Facetime allow for a robust conversation, but most doctors’ visits require much more than just conversation.  For example, any time a physical exam is required, this technology will not work well.  That’s why one of our first pilot studies was to implement video technology for mental health follow up visits (as did the doctor in Oklahoma).

Our early results are promising.  It seems that virtual video visits for mental health offer both the provider and the patient important benefits.  For many mental health patients, it can be stressful to travel to the doctor’s office.  When a patient is being evaluated for a medication adjustment, for example, they are not at their best.  The convenience of having a follow-up visit from their own home can be a big lift for these patients.  On the other hand, doctors often feel that the home environment is particularly relevant in sorting out mental health problems.  A virtual visit allows them to, in effect, conduct a virtual house call.

Three Reasons Uwe Reinhardt Blames Purchasers for Everything

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Uwe Reinhardt is one of the nation’s most respected health care economists, professor at the prestigious Woodrow Wilson School at Princeton, fellow of the Institute of Medicine, and one of the shining lights in health policymaking circles.

But alas, even the best and the brightest are wrong sometimes. Case in point: Reinhardt’s recent comments in the New York Times on the role of the American business community in fueling our nation’s health care problems. To paraphrase, Reinhardt believes that employer purchasers of health care are 1) dim bulbs and 2) responsible for the escalating costs of care.

This seemed puzzling coming from Reinhardt, whose views are widely respected by purchasers.  But I was able to diagnose the problem by drawing on insights from social psychology.

Social psychology investigates “attribution,” our mind’s process for inferring the causes of events or behaviors. It’s how we describe why things happen — to us or to someone else. It turns out, we humans aren’t very accurate in our attribution processes because all of us suffer from at least one of the following problems. In his New York Times piece, poor Professor Reinhardt appears afflicted by all three at the same time. Let’s take a closer look at each:

1. Actor-Observer Bias: This is the notion that when it comes to explaining our own behavior, we tend to blame external forces more often than our own personal characteristics.

Reinhardt is rightfully troubled by a decade of escalating health care cost growth under employment-based health insurance. But seized by Actor-Observer Bias, Reinhardt blames this problem not on the world of health care that he played such an influential role in over the past few decades, but on external forces, the employers who purchase health care.

Cloud Only is Dead for Health

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A lot of people are intrigued with using “cloud” applications and storage for personal health data. This week we’re seeing what I think is the final nail in the coffin of “cloud only” for anything important. You gotta have offline backups: two huge cloud vendors – Amazon and now Google – have demonstrated that even they can go down, leaving their users absolutely powerless.

Cloud applications diagram from Wikipedia

Cloud computing (Wikipedia) is hugely attractive to software developers and businesses. As shown in this diagram from Wikipedia, the idea is that you do your computing using storage or tools that are on some computer somewhere out there “in the cloud.” You don’t know or care where, because somebody out there takes care of things. As your business or database grows, “they” take care of it.

And it’s real – it works.

But when “they” screw up, you could be screwed.

Last month Amazon Web Services went down for a couple of days. PC Magazine posted a good summary, and many of us learned that well known companies like Hootsuite and Foursquare don’t actually own the computers that deliver their product: they rent services from Amazon Web Services (AWS).

So when AWS went down, there was nothing they could do to help their customers.

What I Need

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So, the question has been raised: why am I doing this?  Why re-invent the EMR wheel?  What is so different about what I am doing that makes it necessary to go through such a painful venture?  I ask myself this same question, actually.

Here’s my answer to that question:

What medical records offer:
High focus on capturing billing codes so physicians can be paid maximum for the minimum amount of work.

What I need:
No focus on billing codes, instead a focus on work-flow.

What medical records offer:
Complex documentation to satisfy the E/M coding rules put forth by CMS.This assures physicians are not at risk of fraud allegation should there be an audit.  It results in massive over-documentation and obfuscation of pertinent information.

What I need:
Documentation should only be for the sake of patient care. I need to know what went on and what the patient’s story is at any given time.

What medical records offer:
Focus on acute care and reminders centered around the patient in the office (which is the place where the majority of the care happens, since that is the only place it is reimbursed)

What I need:
Focus on chronic care, communication tools, and patient reminders for all patients, regardless of whether they are in the office or not. My goal is to keep them out of the office because they are healthy.

What medical records offer:
Patient access to information is fully at the physician’s discretion through the use of a “portal,” where patients are given access to limited to what the doctor actively sends them.

Denying Reality About Bad Prognoses

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The human capacity to deny reality is one of our defining characteristics. Evolutionarily, it has often served us well, inspiring us to press onward against long odds. Without denial, the American settlers might have aborted their westward trek somewhere around Pittsburgh; Steve Jobs might thrown up his hands after the demise of the Lisa; and Martin Luther King’s famous speech might have been entitled, “I Have a Strategic Plan and a Draft Budget.”

Yet when danger or failure is just around the corner, denial can be dysfunctional (see Karl Rove on Fox News), even suicidal (see climate change and Superstorm Sandy).

Healthcare is no exception. Emerging evidence suggests that patients and their surrogates frequently engage in massive denial when it comes to prognosis near the end of life. While understandable – denial is often the way that people remove the “less” from “hopeless” – it can lead to terrible decisions, with bad consequences for both the individual patient and society.

First, there is evidence that individuals charged with making decisions for their loved ones (“surrogate decision-makers”) simply don’t believe that physicians can prognosticate accurately. In a 2009 study, UCSF’s Lucas Zier found that nearly two-thirds of surrogates gave little credence to their physicians’ predictions of futility. Driven by this skepticism, one-in-three would elect continued life-sustaining treatments even after the doctor offered their loved one a less than 1% chance of survival.

In a more recent study by Zier and colleagues, 80 surrogates of critically ill patients were given hypothetical prognostic statements regarding their loved ones. The statements ranged from “he will definitely survive” to “he will definitely not survive,” with 14 statements in between (including some that offered percentages, such as “he has a [10%, or a 50%, or a 90%] chance of survival”). After hearing these statements, surrogates were asked to interpret them and offer their own survival estimates.

When the prognosis was optimistic (“definitely survive” or “90%” survival odds), surrogates’ estimates were in sync with those of the physicians. But when the prognosis was pessimistic (“definitely not survive” or “he has a 5% chance of surviving”), surrogates’ interpretations took a sharp turn toward optimism. For example, surrogates believed that when the doctor offered a 5% survival chance, the patient’s true chance of living was at least three times that; some thought it was as high as 40%. Remarkably, when asked later to explain this discordance, many surrogates struggled. Said one, “I’m not coming up with good words to explain this [trend] because I was not aware I was doing this.” The authors identified two main themes to explain their findings: surrogates’ need to be optimistic in the face of serious illness (either as a coping mechanism for themselves or to buck up their loved one), and surrogates’ beliefs that their loved one possessed attributes unknown to the physician, attributes that would result in better-than-predicted survival (the “he’s a fighter” argument).

Consult: Bleomycin Lung Injury

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I have a close friend who is looking for treatment for a “bleomycin lung injury” to a close family member. Bleomycin is one of the chemicals included in chemotherapy treatment for Hodgkins Lymphoma. The patient had 9 of 12 chemotherapy treatments for Hodgkins Lymphoma and the cancer was responding very well. It became evident about two months ago that the patient was suffering from lung damage, so his oncologist took him off the bleomycin component of his chemotherapy regimen in September.

Then a couple of weeks ago his lungs suddenly gave out and he was gasping for breath and had to be rushed to the hospital. He was placed on supplemental oxygen and has been taking steroids to counteract the effects of the bleomycin. His lungs seemed initially to be improving, but his body was under such extreme strain that they chose to intubate and put him on a ventilator to avoid a collapse of the heart or lungs from the sheer exhaustion of breathing. He’s been on the ventilator since then, but improvement of the lungs appears to have plateaued. There have been various other complications but they appear surmountable if the lungs improve. The core problem is bleomycin injury or bleomycin toxicity.

The patient is receiving care south of Boston. The primary MD on the case is a critical care doctor and pulmonary specialist. Moving to another facility is not an option (he’s too fragile) but current doctor is open to input from other providers.

Regina Holliday is a Washington, D.C., art teacher, artist, muralist, patient rights arts advocate, founder of the Walking Gallery and the Medical Advocacy Mural Project. She is a blogger at her Medical Advocacy Blog.

Should Medical Schools Teach to the Boards?

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flying cadeuciiIn the 2012 National Residency Match Program Survey, which is sent out to residency program directors around the country by the NRMP, the factor that was ranked highest with regards to criteria considered for receiving an interview—higher than honors in clinical clerkships, higher than extracurricular experiences or AOA election, and even higher than evidence of professionalism, interpersonal skills, and humanistic qualities—was the USMLE Step 1 score.

When considering where to rank an interviewed applicant, the Step 1 score took a backseat to some of the aforementioned criteria that are perhaps more telling of what kind of person the interviewee is, although it was still one of the highest considered criteria for ranking applicants as well.

When a single exam is given this level of importance in determining a future physician’s most critical period in career development—their residency—we have to look carefully at our system.

Two points of consideration come to mind. First, is it wise to weigh a test score so heavily? Many students and faculty could easily point out that student performance on exams by no means always reflects their clinical acumen and social skills when seeing patients.

Medicine is, after all, an art far more than a science.

Nonetheless, it would be foolish to assume that scores have no worth—a high score on an exam, particularly a behemoth such as the USMLE Step 1, points out many qualities in an individual: hard work, persistence, discipline, and frankly, an understanding of textbook medicine.

And thus, we are left somewhere in the middle—perhaps we should weigh scores less than we do, but when you have to sort through thousands of applications, the only standardized metric to quickly compare is, in the end, a number somewhere between 192 and 300.

ACOs and Antitrust: A Few Words of Caution

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I am coauthoring (with Cory Capps) a chapter on healthcare antitrust for the forthcoming International Handbook of Antitrust Economics. As we finish our first draft, we were searching for a good way to tie everything together. We both thought of concluding by discussing antitrust and ACOs. Cory and I believe that the underappreciated (and often excruciatingly boring) topic of antitrust is fully interwoven with the story of ACOs. And even if the Supreme Court strikes down the ACA (note to readers of my prior blog – I was just kidding), ACOs may endure. So this is as good a time as any to explain the connections between antitrust and ACOs.

I first recognized this connection twenty years ago, when my colleague Steve Shortell was touting the growth of integrated delivery systems. Steve even offered a universal health insurance proposal (which several states explored) built around competing IDSs. In Steve’s world, an IDS would consist of several hospitals and hundreds of physicians. I argued with Steve that economic theory provided little support for massive vertical integration (and theory is still not all that kind to the idea.) I granted Steve that if integration made theoretical sense, integration would be all well and good for Chicago, where there might be four or five competing IDS. But what about Milwaukee, Cleveland, or any number of other midsize metropolitan areas? They would do well to have two or three IDS. Indeed, even with a legislative mandate to form IDS, consolidation has left these and other midsize markets with just two or three health systems. Smaller metro areas might have only had one IDS.

Telehealth is Working in Texas. Here’s Why

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Over the past two years, policy makers across the nation have been actively adopting policies in support of the rapid adoption of telehealth. From states affirming that health insurance plans should appropriately cover care provided through innovative technologies, to Congress contemplating multiple proposals for telehealth expansion within Medicare – telehealth is fast becoming a permanent part of our healthcare ecosystem.

This movement has been most clearly demonstrated by state medical boards. It has been their job to answer the questions: can physicians use technology to extend the reach of their care? Can telehealth be used to create a treatment relationship, and if so, are their limitations to this relationship?

Overwhelmingly, the resounding answer to these questions has been a consistent one – yes, you can use robust telehealth technologies to provide care and the main limitation is simple – uphold the same standard of care. The Federation of State Medical Boards has upheld this concept.

But if you’ve been following this movement, you know there’s a rather large blip on the national map: Texasa state with more than 27 million residents and a clear need for increased access to care – was recently ranked “worst in telehealth” by the National Center for Policy Analysis. The good news: despite restrictive rules and a lawsuit that’s hindering progress, telehealth is working in Texas and changes, they are a coming.

The Data Diet: How I Lost 60 Pounds Using A Google Docs Spreadsheet

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The author in early 2010 and mid 2011

I’ve been thinking about how to write this story for a long time. Should it be a book? A blog? A self-help guide? Ever since I realized I’d lost 60 pounds over the course of a year and a half, I knew I wanted to find a way to talk about it, and maybe help others. This is my first public attempt.

A note about the rounding of my roundness: My peak weight, shortly after I began weighing myself in 2010, was 242 lbs. My lowest weight since I started weighing myself has been 183.2 lbs — right in line with where I should be, at 6’3″ tall. I’m sure that I weighed more than 242 lbs. at peak, but frankly, I don’t care that I don’t have the data to account for those last 1.2 lbs.

Adam Davidson’s New York Times Magazine story, “How Economics Can Help You Lose Weight,” helped organize my thinking about how to finally write this. In his story, Adam explains that the rigid protocol his doctor puts him through acts as a kind of economic incentive for him to stay on the diet. I’m highly skeptical that the special liquid meals he can only buy directly through his dietician will help him keep off the weight. I tried all sorts of diets in the many years that I was overweight and though I never tried the Adam’s solution, it doesn’t sound like a recipe for long term success. At least twice, I lost weight and then gained it all, and more, back. (Meta note: I feel terrible writing that. Adam, I wish you the best. Maybe something you read here will help you keep off the weight you have already lost, and congratulations on that difficult achievement.)

Now that I’ve managed to make weight loss sound simple, and sound smug about my success (I’ve stayed within the 183-192-pound range for more than two years now), what’s my big secret? It’s data. Just like I said in the headline, I keep a Google Doc spreadsheet in which I’ve religiously logged my weight every morning for the last three-plus years, starting on January 1, 2010, when I knew I had to do something about my borderline obesity.