[This post is Part 2 of a commentary on “Medicine in Denial,”(2011) by Dr. Lawrence Weed and Lincoln Weed. You can read Part 1 here.]
An excellent chapter in “Medicine in Denial” discusses the problem-oriented medical record (POMR), a comprehensive charting approach that Dr. Larry Weed began developing in the late 1950s.
The Weeds begin by detailing what a good health care record should allow clinicians, and the healthcare system to do. In other words, they start by clearly defining the needs of patients, the purpose of the medical record, and the kind of health care it should support.
Specifically, the Weeds make the following points:
- Managing chronic illness often involves multiple interventions that require adjustment over time, rather than a single treatment that results in cure/resolution. This requires tracking of physiologic variables and medical interventions over time.
- Chronic care of medically complex patients, especially those with multimorbidity, requires coordination of care among multiple clinicians at multiple sites over time.
- For the many people suffering from multi-morbidity, chronic medical problems and their associated interventions often interact. This makes it particularly important that care be individualized, and carefully tracked over time.
- Enabling patient awareness, participation, and commitment is essential, with the Weeds noting that “unavoidable complexity must somehow be made manageable by patients who need to cope with what is happening to their own bodies and minds.”
- Patient care – and hence the charting of medical data — must be oriented towards a single purpose: individualized medical problem solving for unique patients.
In other words, the Weeds consider the longitudinal, comprehensive, person-centered, individualized, collaborative care of the medically complex patient to be a fundamental base scenario around which we should design healthcare, and healthcare information systems.
Continue reading “The Problem-Oriented Medical Record”
Filed Under: THCB
Tagged: Charting, Leslie Kernisan, Medicine in Denial, primary care
May 10, 2013
“Any system of care that depends on the personal knowledge and analytic capabilities of physicians cannot be trusted.”
Finally, I’ve come across a really spot-on analysis of what ails healthcare, and some proposals that have serious potential to improve healthcare for people like my patients. Come to think of it, implementing these proposals would surely improve care for all patients.
The analysis, and the proposed fixes, are detailed by Dr. Lawrence Weed and his son Lincoln Weed, in their book “Medicine in Denial.” (The quote above is from this book.)
The book is a little long, but for those who are interested in leveraging technology to make healthcare more consistent and more patient-centered, I’d say it’s a must-read and must-discuss. (I’m a bit surprised that this book doesn’t seem to have many reviews, and that Dr. Weed’s ideas are not more often cited by those advocating for digital health and patient empowerment.) In particular, the Weeds’ book provides:
- An excellent description and analysis of two huge fundamental problems in healthcare. One is the way we persist in relying on fallible physician minds to manage the process of evaluating, diagnosing, and managing medical problems. The other is our lack of standards for consistently documenting and organizing information related to our evaluation and management of patients. Both lead to idiosyncratic, disorganized healthcare that generally serves patients poorly, especially those who are medically complex or have multiple chronic conditions.
- A proposed method of using computers and technology to consistently connect patient data to medical knowledge, leading to better diagnosis and medical management.
Continue reading “Medicine in Denial”
Filed Under: OP-ED, Tech, THCB
Tagged: Book Review, digital health, Lawrence Weed, Leslie Kernisan, Lincoln Weed, Medicine in Denial, patient empowerment, Physicians
May 4, 2013
A few weeks ago, The Health Care Blog published a truly outstanding commentary by Jeff Goldsmith, on why practice redesign isn’t going to solve the primary care shortage. In the post, Goldsmith explains why a proposed model of high-volume primary care practice — having docs see even more patients per day, and grouping them in pods — is unlikely to be accepted by either tomorrow’s doctors or tomorrow’s boomer patients. He points out that we are replacing a generation of workaholic boomer PCPs with ”Gen Y physicians with a revealed preference for 35-hour work weeks.” (Guilty as charged.) Goldsmith ends by predicting a “horrendous shortfall” of front-line clinicians in the next decade.
Now, not everyone believes that a shortfall of PCPs is a serious problem.
However, if you believe, as I do, that the most pressing health services problems to solve pertain to Medicare, then a shortfall of PCPs is a very serious problem indeed.
So serious that maybe it’s time to consider the unthinkable: encouraging clinicians to become Medicare PCPs by aligning the job with a 35 hour work week.
I can already hear all clinicians and readers older than myself harrumphing, but bear with me and let’s see if I can make a persuasive case for this.
Continue reading “An Indecent Proposal That Just Might Solve the Primary Care Crisis: Meet the 35 Hour Work Week”
Filed Under: OP-ED, THCB, The Business of Health Care
Tagged: Burnout, Hospitals, Jeff Goldsmith, Leslie Kernisan, Long Term Care, Medicare, Physicians, practice management, primary care, primary care shortage
Apr 16, 2013
Recently I came across yet another media article with suggestions as to how digital health products can gain more widespread adoption. The writer notes that “we can learn a lot from the pharma and healthcare industries,” and goes on to discuss the importance of engaging the doctor.
This article, like many I read, doesn’t acknowledge the downsides of using pharma’s tactics.
I have to assume that this is because from a business perspective, there aren’t a lot of downsides to pharma’s tactics. Pharma, along with many other healthcare industry players (hospitals, insurance companies, device manufacturers) has overall been extremely successful from a business standpoint.
So if the intent is to help digital health companies succeed as businesses, then by all means one should encourage them to copy pharma’s tactics.
But as we know, what works for business has often not worked well for serving the needs of individual patients, or to society from a health services and public health perspective.
Continue reading “Doctors: We Can’t Leave It to Business to Educate Us”
Filed Under: Physicians, THCB
Tagged: Big pharma, clinicians, digital health, entrepreneurship, Innovation, Journal Watch, Leslie Kernisan, Physicians, the business of healthcare
Apr 5, 2013
I purchased my first tablet a few weeks ago, and have since been thinking more about tablets for seniors and caregivers. Like many, I’ve assumed that tablet-based tools will eventually make certain aspects of healthcare easier for clinicians, for older adults, and for their caregivers. But so far I’ve found the tablet harder to use than I’d expected.
Actually, technically this is my third tablet purchase. The first was an iPad last summer, which I promptly sent back after realizing that my laptop was much better suited to supporting me in my clinical work (read my full minority report here).
The second was a Nexus 7 which I purchased as a holiday gift for my 62 year old step-father, a structural engineer. (As he’s mildly uncomfortable figuring out new-fangled technology, I set up his device and helped get him started using it.)
Now, I finally have a tablet that I’ll be keeping for myself: a Samsung Galaxy Note 10.1.
Continue reading “The Tablet Transition”
Filed Under: Tech, THCB
Tagged: Leslie Kernisan
Mar 29, 2013
Dr. Leslie Kernisan recently wrote a great piece about app prescribing, asking, “Should I be prescribing apps, and if so, which ones?” Since Happtique is all about integrating apps into clinical practice, I jumped at the chance to add to this important discussion.
Dr. Kernisan is right to be concerned and somewhat skeptical about app prescribing. More than 40,000 health apps exist across multiple platforms. And unlike other aspects of the heavily-regulated healthcare marketplace, there is little to no barrier to entry into the health app market—so basically anyone with an idea and some programming skills can build a mobile health app. The easy entry into the app market offers incredible opportunity for healthcare innovation; however, the open market comes with certain serious concerns, namely, “how credible are the apps I am (or my patients are) using?”
Continue reading “App Prescribing: The Future of Patient-Centered Care”
Filed Under: Tech, THCB
Tagged: Ben Chodor, Happtique, Health Apps, HIT, Innovation, Leslie Kernisan, Mobile health, Patients, Physicians
Mar 28, 2013
How to effectively keep tabs on a patient’s multiple medical problems? And how to do so without losing sight of the whole person?
The first question is the one I wrote about in a recent blog post. The second was the theme of many of the responses posted on THCB and also LinkedIn.
I love this second question; it’s an issue that’s always been of interest to me. Plus it’s especially relevant in geriatrics, where we are constantly re-orienting our approach to problems based on what seems to be happening with the whole person. (Good PCPs do this too.)
And it’s an issue that good hospitalists think about too: several people brought up Dr. Bob Wachter’s post from last fall, in which he noted how using EPIC’s problem-based charting at UCSF’s hospital was having the unintended effect of making it harder for all clinicians to understand what the heck was going on overall with the patient.
Based on reading my post and Wachter’s post, an EMR designer asked me the following specific questions:
• Should the entire EHR be functionally and logically structured around problems, or would it be sufficient for a chart user interface to be presented in a problem oriented manner?
• What are your thoughts about the possibility of such a solution becoming overly reductionist, losing the patient between the problems?
Continue reading “Zen and the Art of Problem-Based EMR Design”
Filed Under: Tech, THCB
Tagged: Charting, clinical decision making, EHR, Hospitalists, Leslie Kernisan
Mar 18, 2013
Should I be prescribing apps, and if so, which ones?
I recently came across this video of Happtique’s CEO Ben Chodor describing his company to Health 2.0’s Matthew Holt. In it, the CEO explains that Happtique is creating a safe and organized space, to make it easy for doctors to prescribe apps and otherwise “engage with patients.”
Because, he says “we believe that the day is going to come that doctors, and care managers, are going to prescribe apps. It’s going to be part of going to the doctor. He’s going to prescribe you Lipitor, and he’s going to give you a cholesterol adherence app.”
He goes on to say that they have a special process to make sure apps are “safe” and says this could be like the good housekeeping seal of approval for apps.
Hmm. I have to admit that I really can’t imagine myself ever prescribing a “cholesterol adherence” app. (More on why below; also found myself wondering what it exactly meant for Happtique to say an app was safe. What would an unsafe cholesterol app look like?)
Continue reading “How Should Apps Be Prescribed?”
Filed Under: Tech, THCB
Tagged: Apps, FutureMed, Happtique, Leslie Kernisan
Mar 13, 2013
“What does the 21st Century Physician look like?”
Lisa Fields (@PracticalWisdom) cc’ed me on a tweet about this; it’s the featured question at www.tomorrowsdoctor.org, an organization founded by three young professionals who spoke at TEDMED last year.
I’ll admit that the question on the face of it struck me as a bit absurd, especially when juxtaposed with the term “tomorrow’s doctor.”
Tomorrow’s doctor needs to be doing a much better job of dealing with today’s medical challenges, because they will all be still here tomorrow. (Duh!) And the day after tomorrow.
(As for the 21st century in general, given the speed at which things are changing around us, seems hard to predict what we’ll be doing by 2050. I think it’s likely that we’ll still end up needing to take care of elderly people with physical and cognitive limitations but I sincerely hope medication management won’t still be a big problem. That I do expect technology to solve.)
After looking at the related Huffington Post piece, however, I realized that this trio really seems to be thinking about how medical education should be changed and improved. In which case, I kind of think they should change their organization’s name to “Next Decade’s Doctor,” but I can see how that perhaps might not sound catchy enough.
Continue reading “What Will Tomorrow’s Doctor Look Like?”
Filed Under: Physicians, THCB
Tagged: CQI, e-patients, FutureMed, Leslie Kernisan, Medical Education, OpenNotes, PDSA, practice of medicine, Quality, shared decision making, TEDMED
Mar 8, 2013
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