One of the many challenges I face in my clinical work is keeping track of a patient’s multiple health issues, and staying on top of the plan for each issue.
As you might imagine, if I’m having trouble with this, then the patients and families probably are as well.
After all, I don’t just mean keeping up with the multiple recommendations that we clinicians easily generate during an encounter with an older patient.
I mean ensuring that we all keep up with *everything* on the medical problem list, so that symptoms are adequately managed, chronic diseases get followed up on correctly, appropriate preventive care is provided, and we close the loop on previous concerns raised.
This, I have found, is not so easy to do. In fact, I would say that the current norm is for health issues to frequently fall between the cracks, with only a small minority of PCPs able to consistently keep up with all health issues affecting a medically complex adult.
Continue reading “Zen and the Art of Charting”
Filed Under: Tech, THCB
Tagged: Care coordination, Charting, Diagnosis, EHR, Geriatrics, HIT, Leslie Kernisan, Patients, primary care
Mar 1, 2013
At some point, this gets to be ridiculous. Online, I can buy any item from anywhere at any price, pay any bill, watch any movie, listen to any song, order dinner, schedule car repair or read about any subject on Wikipedia. I can determine the weather in Rio, sport scores of Barcelona, Parisian traffic or by GPS the location of my kids, just down the block. However, I absolutely cannot learn anything at all of the health history of the flesh and blood cancer patient sitting right in front of me.
Today, I am seeing long-term patient, Thomas R. Father of three and a really nice guy, Tom is a medical challenge.
He is immunocompromised and status post 20 years of complex chemotherapy, radiotherapy, a bone marrow transplant and several bizarre complications, we barely understand. In the last two months, since his last visit with me, he has seen an internist, a dermatologist, a podiatrist, a neurologist, a dentist and an infectious disease specialist. These doctors ordered X-rays, lab tests, blood cultures, an EMG, a skin biopsy and several new medicines.
These are confusing tests resulting in confusing diagnoses with confusing therapy in a confusing patient.
What records do I have of all this new complexity? Nada. None. Moreover, based on our files, all these other physicians have none of ours.
Continue reading “Can Facebook Save Us?”
Filed Under: THCB
Tagged: Care coordination, Facebook, James Salwitz, Medical Records, Silo Design, Stone Age, Universal Electronic Medical Record
Feb 6, 2013
Today I’m speaking at the ONC annual meeting as part of panel discussing interoperability.
For years, patients, providers and payers have complained that EHRs “do not talk to each other.”
By 2014, I expect this issue to disappear.
Do I expect that every state and territory will have a robust, sustainable healthcare information exchange by 2014? No
Do I expect that every provider will be connected to a Nationwide Health Information Network by 2014? No
Do I expect that a single vendor will create a centrally hosted method to share data by 2014 just as Sabre did for the airline industry in the 1960′s? No
What I expect is that Meaningful Use Stage 2 will provide the technology, policy, and incentives to make interoperability real.
Stage 2 requires that providers demonstrate, in production, the exchange of clinical care summaries for 10% of their patient encounters during the reporting period. The application and infrastructure investment necessary to support 10% is not much different than 100%. The 10% requirement will bring most professionals and hospitals to the tipping point where information exchange will be implemented at scale, rapidly accelerating data liquidity.
Continue reading “Are We Finally Seeing the Dawn of the Golden Age of Interoperability?”
Filed Under: Uncategorized
Tagged: Blue Button initiative, Care coordination, EHR, health information exchange, Interoperability, John Halamka, Meaningful Use Stage 2, ONC, Policy
Dec 12, 2012
This is my new office. I signed the lease for this property yesterday – another big step in the process of getting my new practice off the ground. I should feel good about this, shouldn’t I? I’ve had people comment that I’ve gotten a whole lot accomplished in the 4 weeks since I’ve been off, but the whole thing is still quite daunting. Yes, there are days I feel good about my productivity, and there are moments when I feel an evangelical zeal toward what I am doing, but there are plenty more moments where I stare this whole thing in the face and wonder what I am doing.
I walked through the office today with a builder to discuss what I want done with the inside; it quickly became obvious that there was a problem: I don’t know what I want done, and nobody can tell me what I should do. Yes, I need a waiting area, at least one exam room, an office for me, a lab area, bathrooms, and place for my nurse, but since I don’t really know which of my ideas about the practice will work, I don’t know what my needs will truly be. How much of my day will be spent with patients, how much will be doing online communication, and how much will be spent with my nurse? I want a space for group education, but how many resources should I put toward that? I also want a place to record patient education videos, but some of my “good ideas” just end up being wasted time, and I don’t know if this is one of them.
I come across the same problem when I am trying to choose computer systems. I know that I want to do that differently: I want the central record to be the patient record, not what I record in the EMR. I want patients to communicate with me via secure messaging and video chat, and I want to be able to put any information I think would be useful into their PHR. So do I build a “lite” EMR product centered around the PHR, or do I use a standard EMR to feed the PHR product? Do I use an EMR company’s “patient portal” product, or do I have a stand-alone PHR which is fed by the EMR? I have lots of thoughts and ideas on this, but I don’t really know what will work until I start using it.
Continue reading “The Good Doctor Learns to Fly”
Filed Under: Physicians, THCB
Tagged: Care coordination, EHR, PHR, primary care, private practice, Rob Lamberts
Oct 26, 2012
What comes to mind when you hear the term “medical home?” Perhaps you favor the definition put forth by our government (AHRQ):
The medical home model holds promise as a way to improve health care in America by transforming how primary care is organized and delivered. Building on the work of a large and growing community, the Agency for Healthcare Research and Quality (AHRQ) defines a medical home not simply as a place but as a model of the organization of primary care that delivers the core functions of primary health care.
1. Comprehensive care
3. Coordinated care
4. Accessible services
5. Quality and Safety.
The presence of these five attributes to care should then constitute a medical home, right? It depends on who you get your definition from.
Continue reading “The Organic Medical Home”
Filed Under: THCB, The Business of Health Care
Tagged: AHRQ, Care coordination, National Committee for Quality Assurance, Patient-Centered Medical Home, primary care, Quality, Rob Lamberts
Oct 23, 2012
Health information technology has, in many ways, been a calling for me. I passionately believe in the ability of technology and information to reduce costs, improve quality and transform healthcare. For the last seven years (I won’t say the “better part” as my wife and kids would probably not appreciate that characterization…on the other hand, they would quickly confirm that it has consumed most of my waking hours), I have collaborated with hundreds organizations in healthcare and technology across the public sector and the private sector to try and positively influence the adoption and use of health information technology. By many measures, this work has been successful.
Awareness levels and perceived value of health IT among doctors, hospitals, policymakers and many other audiences has improved dramatically. A wide majority of physicians in the U.S. have by now adopted technologies such as electronic health records and e-prescribing. Playing a small part in this progress to date has been the most gratifying work of my career.
But then came Dad and his own personal experience with health IT. My father’s experience as a patient has left me questioning the level of progress that has been achieved.
Continue reading “Health IT and Dad”
Filed Under: THCB
Tagged: ACOs, Care coordination, EHR, Health 2.0, HIT, Meaningful Use, Patient Care, Rob Cronin
Oct 12, 2012
Once again, the Supreme Court was unsurprisingly surprising. The conventional wisdom was that at least part of the health reform law would be overturned, but in practice the court blessed the status quo we have known for two years: The reform law will continue to be implemented.
It’s the devil we’ve known. Washington will issue more regulations. Insurers will be buried in requirements on coverage and benefits, driving up costs. Physicians will have more oversight and report to the government. Hospitals will see Medicare cuts. Millions of individuals will either get a new federal subsidy for insurance or be enrolled in Medicaid.
States will have more interference from Washington. While the Supreme Court gave them some flexibility on whether to expand their Medicaid programs, states will still be forced to either build a new insurance exchange, like Expedia for health insurance, or have the federal government build it for them.
By upholding the law, the court also left untouched two huge problems looming on the horizon. First, as the law expands coverage there will be a tremendous increase in demand for medical services, but there will not be an increase in the number of doctors, nurses and other providers to deliver care.
Millions of people may have very generous coverage, but they will struggle to find providers to deliver it.
Second, as businesses face requirements in 2014 to offer federally approved health insurance or pay a fine, many companies will do the math and see that paying the penalty is far less expensive than continuing to provide coverage.
Continue reading “The Devil We Know”
Filed Under: THCB
Tagged: Care coordination, David Merritt, Future of Healthcare, Health insurance, health trends, The ACA, The Supreme Court Challenge
Jul 3, 2012
Don’t assume anything.
Assumptions can kill.
Assuming something regarding your own health care can cost you money, cause you pain, and yes, even kill you. Here’s my list of potentially harmful assumptions:
1. No news is good news
If you have a test done and don’t hear anything about the result, do not assume it is fine. This assumption kills people. I have too many patients with too much information flying at me every day for me to catch every important detail. Sometimes things are missed, but sometimes the results don’t come to our office. We have trained our patients to expect an email or letter with their results within a certain amount of time, so they sometimes call when the test results don’t come in. I tell them to do so in the clinical summary sheet I hand out at the end of each visit, but the assumption remains.
Continue reading “Zen and the Art of Not Thinking Magically”
Filed Under: Uncategorized
Tagged: Assumptions, Care coordination, Checklists, Choosing Wisely Campaign, doctor/ patient relationship, OP-ED, patient-doctor communication, personal health records, primary care, recommendations, Smart Medicine, standard care, The Insider's Guide To Health Care
Jun 25, 2012
This house believes that society benefits when we share information online! This was the topic of debate before the Economist magazine’s Ideas Economy: Information 2012 conference here in San Francisco on Tuesday afternoon. Tom Standage, digital editor for the Economist, moderated this lively battle of wits.
Defending the motion was John Perry Barlow, former Grateful Dead lyricist and co-founder of the Electronic Frontier Foundation. “This is a little like defending sex!” he started off by saying.
I am paraphrasing here but he went on to say, ‘The Internet is an environment where what is great about human beings can manifest itself…collectively we are much smarter than any individual. Just as my mitochondria are unaware of my thoughts, we are largely unaware of our collective genius.’
I could not agree more.
Opposing the motion was Andrew Keen, Internet entrepreneur and author of “Cult of the Amateur.”
Again, paraphrasing, ‘Repressive governments and private companies who make the 1% look poor, are also benefitting. Most of the information is being stolen,’ Keen said. ‘Today everything has to be social.’
Keen rails against our intimate selves being taken from us and traded on by bazzilionaires, with not much coming back to we, the sharers. ‘Barlow would not be who he is, if he not had his years of very aloneness,’ said Keen, paraphrased.
Continue reading “The Importance of Data and Care Coordination”
Filed Under: THCB
Tagged: athenahealth, Big Data, Care coordination, Cloud Computing, Data, information privacy and security, John Perry Barlow, the Economist, Transparency
Jun 8, 2012
I’ve seen a number of responses to the news that the Medicare demonstration projects were not successful. Some have claimed that they were only demonstration projects, and the fact that some succeeded means we should look into those further. Others asserted that this once again proves that the government is incapable of making the health care system better.
As to the first point, it’s hard to get excited about this. By chance alone, a couple of programs were likely to save money. Four out of 34 reducing hospitalizations (when the best of them might have had inadequate data)? Hardly something to get excited about. Remember that two out of the 34 actually saw increased hospitalizations, too. I think it’s totally reasonable to think hard before just assuming there was something special about those four programs, and throwing more money at them.
But I think the latter point, made by Peter Suderman, is a bit of an over-reach as well. It’s important to remember that these were attempts by private hospitals and private physicians to change the way they care for patients. Granted, government was paying the insurance bills through Medicare, but this would have looked awfully similar if a private company had footed the bill. And, yes, private insurance companies have tried to use care coordination and disease management to reduce costs as well.
Continue reading “What Does Failure Mean?”
Filed Under: THCB
Tagged: Aaron Carroll, Care coordination, Disease Management, Health policy, Medicare, Pay for Performance
Jan 23, 2012