Would allowing patients to read their mental health notes provide more benefits than risks?
In a recent article in JAMA my colleagues and I argue that it would. While transparent medical records are gaining favor in primary care settings throughout the country through the OpenNotes initiative, there has been reluctance to allow patients to see what their treaters say about their mental health issues. While this reluctance is understandable and deserves careful consideration, we suggest that several benefits could result from patients reading their mental health notes.
First of all, accuracy would be enhanced by allowing patients to cross-check what their clinicians say about their symptoms, medication doses, and so forth. Second, allowing patients to review assessments and treatment decisions privately might help to promote a richer dialogue between patient and clinician. Third, patients might learn that their clinician sees them more as a complete person, rather than as a collection of symptoms.
Many patients silently fear that their treater “will think I’m crazy/whining/lazy/boring”; seeing in print that the treater does not see them that way—and in fact recognizes and documents their strengths—can be an enormous relief and might therefore enhance the therapeutic alliance.
Clinicians have their own worries about transparent mental health notes that must be considered. Will patients feel objectified by the medical language commonly used in documentation? Will they break off treatment if they don’t like what they read? Will too much time be spent wrangling over details of what has been documented? Will vulnerable patients be psychologically harmed by reading their notes? Although our article briefly addresses these issues, only a trial of transparent mental health notes will provide the data needed to assess them.
Such a trial has just begun at the Beth Israel Deaconess Medical Center in Boston. Culminating many months of careful planning by my colleagues in the ambulatory psychiatry clinic, the Social Work department, as well as the OpenNotes team, we began a pilot project of transparent notes in our psychiatry clinic on March 1. So far almost all clinicians have chosen to participate in the project, and have identified 10% of their caseloads to be included. It’s too early to gauge results yet, but we hope to more fully evaluate the effects of making mental health notes fully transparent to our patients.
Michael W. Kahn, MD is an assistant professor of psychiatry at Harvard Medical School and Harvard Medical Faculty Physician at Beth Israel Deaconess Medical Center (BIDMC).
Filed Under: THCB
Tagged: BIDMC, Clinical Documentation, doctor/ patient relationship, FutureMed, Mental Health, Michael Kahn, Open Notes, patient engagement, personal health records, practice of medicine, Psychiatry
Apr 11, 2014
In ancient Athens, the philosopher Diogenes wandered the daylight markets holding a lantern, looking for what he termed, “an honest man.”
It seems since the dawn of the consumer economy that customers and buyers have traded most heavily on a single currency – trust.
Three millennia later, our financial system still hinges on the basic premise that the game is not rigged and any trusted intermediary is defined by a practitioner who puts his client’s interests ahead of his own.
Anyone responsible for procurement of healthcare may feel like a modern-day Diogenes as they wander an increasingly complex market in search of transparent partners and aligned interests. The art of managing medical costs will continue to be a zero-sum game where higher profit margins are achieved at the expense of uninformed purchasers.
It’s often in the shadowed areas of rules-based regulation and in between the fine print of complex financial arrangements that higher profits are made.
Are employers too disengaged and outmatched to manage their healthcare expenditures?
Are the myriad intermediaries that serve as their sentinels, administrators and care managers benefiting or getting hurt by our current system’s lack of transparency and its deficit of information?
Continue reading “ACA 101: An Employer’s Search for Objective Advice”
Filed Under: THCB, The Business of Health Care
Tagged: Benefits, brokers, consultants, Corporate America, Costs, Employers, Hospitals, Human Resources, Incentives, Insurers, Michael Turpin, purchasers, The ACA, the business of health care, Uwe Reinhardt
Apr 10, 2014
With this post, we are pleased to introduce ACAView, a joint initiative between the Robert Wood Johnson Foundation (RWJF) and athenahealth.
2014 marks the launch of the Affordable Care Act’s (ACA) most important coverage expansion provisions, designed to dramatically reduce the number of uninsured Americans. Between now and the end of 2016, millions of individuals are expected to sign up for subsidized insurance coverage through newly established health care exchanges, or marketplaces.
Other tracking initiatives are closely monitoring the number of individuals that sign up for this coverage as well as those that take advantage of expanding Medicaid coverage in some states.
With ACAView, we will take a different approach. We will focus on the provider perspective; more specifically, how the ACA affects the practice patterns and economics of physicians and other care team members around the country. This is also part of a wider effort, Reform by the Numbers, RWJF’s rich source of timely and unique data about the impact of health reform.
ACAView will monitor the impact of coverage expansion on a monthly basis, mining insights from athenahealth’s cloud-based network of more than 50,000 providers and 50 million patients.
athenahealth is a technology and services provider that delivers physicians the tools and support needed to manage the business and clinical aspects of their medical practices. Our cloud-based, centrally hosted software platform provides us with near real-time visibility into practice patterns of physicians around the country.
Our goal is to inform, exchange ideas, and provide a timely, front-row view of how this landmark legislation affects a robust cross-section of providers across the nation. In subsequent reports, we will examine an evolving set of metrics that address a broad range of topics.
We will also share our analyses on the extent to which our providers represent all providers in the US. For more about our data on practices and patients, as well as our preliminary list of metrics, please read our Methodology report.
No Meaningful Change to Date in New Patient Volumes
Among the many unknown questions surrounding coverage expansion is the number of new patients physicians will accommodate. This is a critical issue because one of the goals of health care reform is to allow individuals to form stable physician relationships, rather than seek care in high-acuity settings or forgo care altogether.
If the ACA is working, we would expect physicians to see a higher percentage of new patients over the course of the year. Over the long term, this number should eventually return to historical levels as these new patients become established.
Continue reading “Measuring the Impact of Health Care Reform on Day-to-Day Physician Practice”
Filed Under: Physicians, Tech, THCB
Tagged: ACAView, athenahealth, athenaResearch, Iyue Sung, Josh Gray, RWJF
Apr 9, 2014
The Affordable Care Act might not bend the cost curve or improve the quality of health care, but it will save thousands of lives, as millions of uninsured persons receive the health care they need.
At least that’s the conventional wisdom.
But while observers assume that ACA will improve the health of the uninsured, the link between health insurance and health is not as clear as one may think. Partly because other factors have a bigger impact on health than does health care and partly because the uninsured can rely on the health care safety net, ACA’s impact on the health of the previously uninsured may be less than expected.
To be sure, the insured are healthier than the uninsured. According to one study, the uninsured have a mortality rate 40% higher than that of the insured. However, there are other differences between the insured and the uninsured besides their insurance status, including education, wealth, and other measures of socioeconomic status.
How much does health insurance improve the health of the uninsured? The empirical literature sends a mixed message. On one hand is an important Medicaid study. Researchers compared three states that had expanded their Medicaid programs to include childless adults with neighboring states that were similar demographically but had not undertaken similar expansions of their Medicaid programs.
In the aggregate, the states with the expansions saw significant reductions in mortality rates compared to the neighboring states.
On the other hand is another important Medicaid study. After Oregon added a limited number of slots to its Medicaid program and assigned the new slots by lottery, it effectively created a randomized controlled study of the benefits of Medicaid coverage. When researchers analyzed data from the first two years of the expansion, they found that the coverage resulted in greater utilization of the health care system.
However, coverage did not lead to a reduction in levels of hypertension, high cholesterol or diabetes.
Continue reading “Will the Uninsured Become Healthier Once They Receive Health Care Coverage?”
Filed Under: THCB
Tagged: chronic care, Costs, David Orentlicher, Diabetes, Health insurance, High cholesterol, Hypertension, Oregon Medicaid Experiment, The ACA, the uninsured, Wellness
Apr 9, 2014
A recent ProPublica expose co-published with the Boston Globe typifies a growing gotcha genre of health journalism that portrays doctors as the enemy in a struggle for honesty and openness in medicine.
These reports make unfounded leaps in their efforts to subject doctors to levels of skepticism once reserved for politicians and lawyers. They’re going to end up doing patients a disservice.
For this particular hunting expedition ProPublica set its sights on Dr. Yoav Golan, an infectious diseases specialist caring for patients at Tufts Medical Center in Boston who also works with pharmaceutical companies developing antibiotics.
But in its zeal to argue how physicians like Golan are corrupting medicine through their industry partnerships, ProPublica went to press without an iota of evidence Golan is corrupt.
A close look at Golan’s impressive career suggests quite the contrary and raises questions about ProPublica’s claim to objectivity.
Yoav Golan is a remarkably bad choice for anyone who hopes to use him as a poster boy of pharma-physician malfeasance.
As Tufts said in a statement in response to the ProPublica story, Golan enjoys international respect in the infectious diseases community and has assisted the development of “two important antibiotics, including the first antibiotic developed in the past 25 years to treat the growing threat of deadly C. difficile.”
(Disclosure: I held an academic appointment at Tufts for one year when I was practicing in Boston, but in another department and I never met Golan before this story.)
That antibiotic, fidaxomicin, is pricey, and you’d think an industry shill would liberally advise its use. Yet Golan and his team advised a Tufts committee setting internal standards for its use that the hospital should heavily restrict the drug. “We were very active in making sure it’s not used in pathways where it’s not cost effective,” Golan told me.
Continue reading “Going after the Wrong Doctors”
Filed Under: OP-ED, THCB
Tagged: Dollars for Docs, Ford Vox, Physicians, ProPublica, Yoav Golan
Apr 8, 2014
Using a survey fielded by the RAND American Life Panel, we estimate a net gain of 9.3 million in the number of American adults with health insurance coverage from September 2013 to mid-March 2014.
The survey, drawn from a small but nationally representative sample, indicates that this significant uptick in insurance coverage has come not only from enrollment in the new marketplaces established under the Affordable Care Act (ACA), but also from new enrollment in employer coverage and Medicaid.
Put another way, the survey estimates that the share of uninsured American adults has dropped over the measured period from 20.5 percent to 15.8 percent. Among those gaining coverage, most enrolled through employer-sponsored coverage or Medicaid.
Although a total of 3.9 million people enrolled in marketplace plans, only 1.4 million of these individuals were previously uninsured. Our marketplace enrollment numbers are lower than those reported by the federal government at least in part because our data do not fully capture the surge in enrollment that occurred in late March 2014.
Using the RAND American Life Panel, a nationally representative panel of individuals who regularly participate in surveys, we have conducted monthly surveys since November 2013 about insurance choices and public opinion. This particular survey work—which is ongoing—is known as the RAND Health Reform Opinion Study(RHROS).
We match these data with data collected in September 2013 about insurance choices. The results presented here are based on 2,425 adults between the ages of 18 and 64 who responded in both March 2014 and September 2013.
People shift from one type of health insurance to another for a number of reasons, such as job changes or marital status changes. Our survey work can’t say for certain which of these shifts are due to the ACA and which are due to other factors, but we can draw some limited conclusions.
Continue reading “RAND: Net Gain of 9.3 Million American Adults with Health Insurance”
Filed Under: Economics, THCB
Tagged: Christine Eibner, Enrollment Data, Katherine Grace Carman, RAND Corporation, RAND Health Reform Opinion Study (RHROS), The ACA
Apr 8, 2014
The janitor approached my office manager with a very worried expression. ”Uh, Brenda…” he said, hesitantly.
“Yes?” she replied, wondering what janitorial emergency was looming in her near future.
“Uh…well…I was cleaning Dr. Lamberts’ office yesterday and I noticed on his computer….” He cleared his throat nervously, “Uh…his computer had something on it.”
“Something on his computer? You mean on top of the computer, or on the screen?” she asked, growing more curious.
“On the screen. It said something about an ‘illegal operation.’ I was worried that he had done something illegal and thought you should know,” he finished rapidly, seeming grateful that this huge weight lifted.
Relieved, Brenda laughed out loud, reassuring him that this “illegal operation” was not the kind of thing that would warrant police intervention.
Unfortunately for me, these “illegal operation” errors weren’t without consequence. It turned out that our system had something wrong at its core, eventually causing our entire computer network to crash, giving us no access to patient records for several days.
The reality of computer errors is that the deeper the error is — the closer it is to the core of the operating system — the wider the consequences when it causes trouble. That’s when the “blue screen of death” or (on a mac) the “beach ball of death” show up on our screens. That’s when the “illegal operation” progresses to a “fatal error.”
The Fatal Error in Health Care
Yeah, this makes me nervous too.
We have such an error in our health care system. It’s absolutely central to nearly all care that is given, at the very heart of the operating system. It’s a problem that increased access to care won’t fix, that repealing the SGR, or forestalling ICD-10 won’t help.
It’s a problem with something that is starts at the very beginning of health care itself.
The health care system is not about health.
Continue reading “Fatal Error”
Filed Under: Physicians, THCB
Tagged: Coding, Coding Errors, Costs, culture of health, ICD-10, payors, practice management, Providers, Rob Lamberts, sick care system
Apr 7, 2014
It’s a strange business we are in.
I can freeze a couple of warts in less than a minute and send a bill to a patient’s commercial insurance for much more money than for a fifteen minute visit to change their blood pressure medication.
I can see a Medicaid or Medicare patient for five minutes or forty-five, and up until now, because I work for a Federally Qualified Health Center, the payment we actually receive is the same.
I can chat briefly with a patient who comes in for a dressing change done by my nurse, quickly make sure the wound and the dressing look okay and charge for an office visit. But I cannot bill anything for spending a half hour on the phone with a distraught patient who just developed terrible side effects from his new medication and whose X-ray results suggest he needs more testing.
As a primary care physician I get dozens of reports every day, from specialists, emergency rooms, the local Veterans’ clinic and so on, and everybody expects me to go over all these reports with a fine-toothed comb.
A specialist will write “I recommend an angiogram”, and we have to call his office to make sure if that means he ordered it, or that he wants us to order it.
An emergency room doctor orders a CT scan to rule out a blood clot in someone’s lung and gets a verbal reading by the radiologist that there is no clot. But the final CT report, dictated after the emergency room doctor’s shift has ended, suggests a possible small lung cancer.
Did anyone at the ER deal with this, or is it up to me to contact the patient and arrange for followup testing? All of this takes time, but we cannot bill for it.
Most people are aware these days that procedures are reimbursed at a higher rate than “cognitive work”, but many patients are shocked to hear that doctors essentially cannot bill for any work that isn’t done face to face with a patient. This fact, not technophobia, is probably the biggest reason why doctors and patients aren’t emailing, for example.
Continue reading “How Should Doctors Get Paid?”
Filed Under: Physicians, THCB
Tagged: E-mail visit, Hans Duvefelt, PCMH, physician compensation, Physicians, primary care
Apr 6, 2014
Fred Shaw went to St. Martin and all he got was a painful virus called chikungunya.
On an island stop during his Caribbean cruise vacation, Mr. Shaw was infected with the mosquito-borne virus that causes a severe fever and an arthritis-like condition in people, similar to dengue fever. After infection, the virus still may cause long periods of fatigue and incapacitating joint pain.
Writing on Facebook, Mr. Shaw said, “The fever, leg rash and swelling were bad enough, but then followed by months of headache, joint pain and malaise, I finally have gotten over it (I think).”
Chikungunya virus was first described during an outbreak in Tanzania in 1952 and was subsequently discovered in other parts of Africa and Asia. The name ‘chikungunya’ is derived from a local phrase that means ‘that which bends up’ and describes the stooped appearance of sufferers with joint pain.
In late 2013, chikungunya was found for the first time in modern history on islands in the Caribbean. Based on our research and the evidence we have observed, it is likely that the virus is on its way to the U.S.
Vector-borne viruses—which are transmitted to people by an animal or insect—threaten half the world’s population and are responsible for millions of human infections annually. Various mosquitoes and ticks transmit a subgroup of these viruses that are called arboviruses.
There are over 100 known arboviruses that infect humans and can cause neuroinvasive diseases like encephalitis, febrile illnesses and hemorrhagic fevers. Except for yellow fever, tick-born encephalitis and Japanese encephalitis, there are no commercially available vaccines for most arboviral disease.
As the world becomes flatter and the globe opens to new opportunities for international trade and travel, viruses that used to be confined to “over there” are increasingly coming “over here,” and they are arriving sooner rather than later.
Continue reading “Are We Prepared For The Next Viral Disease Threat?”
Filed Under: THCB
Tagged: chikingunya, FutureMed, Global Virus Network, public health, Robert Gallo, Scott Weaver, Sharon Hrynkow, vector-borne diseases
Apr 6, 2014
Being against Obamacare has been the keystone, the capstone, the mighty sledgehammer, the massive metaphor of your choice for the right for five years now. They couldn’t stop it from being passed. They couldn’t stop it at the Supreme Court.
They weren’t able to choke it off by “defunding” it. They rejoiced at the rubber-meets-the-sky rollout of Healthcare.gov, but then the kinks got worked out of that.They railed at the administration using discretionary powers built into the law to help it work better. Every horror story of Obamacare ruining people’s lives they came up with turned out to be false.
Almost all of the people cynically cancelled by the insurance companies as a way to sell them more expensive insurance got insured again fairly quickly. Then 7 million people signed up on the exchanges, and altogether some 10 million formerly uninsured people now have medical coverage.
But the right still needs to call it a “train wreck.” The magic mantra has to work for them. Just this morning, here’s a Republican Congressman saying that we have to cut Food Stamps because: Obamacare. Say that again slowly?
It’s getting harder and harder on the right to come up with new ways to say it isn’t working when it actually seems to be working. I have to hand it to them, though: Those spin factories are filled with hard-working creative people. Get to work early, stay late, trash Obamacare. Hey, it’s a living.
So what’s the latest? This fall, Obamacare premiums are going to “skyrocket”!
Continue reading “Obamacare Premiums Are Going To “Skyrocket”? Forget About It.”
Filed Under: THCB, The Business of Health Care
Tagged: Death Spirals, MLRs, Obamacare, Premiums, Reinsurance, Risk adjustment
Apr 5, 2014