There’s a war being waged on one of America’s most revered institutions, the Emergency Room. The ER, or Emergency Department (ED for the sake of this post) has been the subject of at least a dozen primetime TV shows.
What’s not to love about a place where both Doogie Houser and George Clooney worked?
Every new parent in the world knows three different ways to get to the closest ED. It’s the place we all know we can go, no matter what, when we are feeling our worst. And yet, we’re not supposed to go there. Unless we are. But you know, don’t really go.
Somehow, we’ve turned the ED into this sacrosanct place where arriving by ambulance is ok, and all others are deemed worthy based on their insurance rather than acuity. If you think I’m wrong, ask any ED director if they want to lose 25% of their Blue Cross Blue Shield volume.
But its true. I hear ED physicians openly express disappointment in people who came into the ED and shouldn’t have.
It’s just a stomach bug, you shouldn’t be here for this… Or, it’s not my job to fill your prescriptions…
The Emergency Department is a fairly modern invention. The first EDs were born of two separate, though similar, aims. At Johns Hopkins, the ED began as the accident room, place where physicians could assess and treat —wait for it —minor accidents.
Elsewhere, in Pontiac Michigan and Northern Virginia early EDs were modeled after army M.A.S.H. field hospitals. They were serving more acute needs.
Today, billing for emergency department visits is done on the E&M Levels where level 1 is the least acute (think removing a splinter) and level 6 is traumatic life saving measures requiring hospitalization (think very bad car wreck). Most EDs, and CMS auditors, look for a bell curve distribution, which means there are more level 3 and 4 incidents than most others. While coding is unfortunately subjective, solid examples of level 3 visits include stomach bugs requiring IV fluids, a cut requiring stitches, and treatment of a migraine headache.
Continue reading “Stop the War on the Emergency Room!!! (Fix the System Failure)”
Filed Under: Economics, THCB
Tagged: E&M coding, ED visits, Emergency Medicine, EMR, ER, Nick Dawson, Oregon Medicaid Experiment, prevention, primary care, Wellness
Apr 21, 2014
Sorry to get all Katie Couric on you, but I’m going to have a colonoscopy on Friday. I turned 40 last October and I have some family history that leads my doctor to get one done now rather than at 50.
Unlike Katie, I won’t be broadcasting mine live, but I’ll share some articles and reflections on the process and, being process focused, what could go wrong. It’s a very necessary procedure, but there are, sadly, some very unnecessary and preventable risks.
According to Dr. Wikipedia (backed by journals):
This procedure has a low (0.35%) risk of serious complications
That’s about 1 in 300 patients, put another way.
For those of you who speak Six Sigma, that’s a 99.65% first time yield and a 4.2 sigma level.
That’s not going to scare me away.
Maybe I should have asked what my physician’s complication rates are. What are the complication rates at the surgical center where this will be done? Is this safer than being at a full-blown hospital or doesn’t it matter? Should I be more of an “engaged patient?”
Should I have asked more questions of my primary care provider? Why did she refer me to this GI specialist? Is he a “Best” doctor? Does that matter?
If I treat them as a supplier (respectfully), should I be able to walk the process and see what they do to prevent, say, instrument or scope disinfection errors?
Should I have asked:
- Show me how you disinfect the equipment
- Show me your training records for the people doing this work
- Show me your equipment maintenance records
- How do you verify that the work is being done properly?
- Have you had any complaints or incidents in the past?
I had my pre-procedure phone call on Monday. Maybe I should follow up and ask a few of these questions, even if I can’t go “walk the gemba” to check things out myself. What would you do?
Of course, I didn’t have data or information available to me to know:
- Which specialist is best at this?
- Who has the highest or lowest complication rates?
- What are the prices for different doctors or locations?
I don’t know how a busy person makes an informed decision.
Continue reading “Things That Make Me Worry About My Colonoscopy”
Filed Under: THCB
Tagged: Colonoscopy, Hospitals, LEAN, Mark Graban, medical error, Patient Safety, Quality, Wellness
Apr 17, 2014
I know it seems like the obvious choice, but I would not run a randomized clinical trial.
I have recently lamented the pernicious influence, within my domain of public health practice, of hyperbolic headlines proclaiming “this,” followed unfailingly by equally and oppositely hyperbolic headlines reactively proclaiming “that.”
But we are obligated to acknowledge that there are, generally, research studies underlying the headlines, however extreme the pop culture distortions of the actual findings. So to some extent, the problem originates before ever the headlines are a gleam in an editor’s eye, with our expectant anticipation of the next clinical trial, and the next, and the next.
By all means, bring on the clinical trials! They serve us well. They advance the human condition. I run a clinical research lab — my career is devoted to just such trials.
But still, I wouldn’t conduct one if my foot caught fire.
Of course, there is a very good case for running such a study, as many vitally important questions about the right response to a foot on fire are at present unanswered. What, for instance, would be the ideal volume of water? Should it be hard water, or soft? Fluoridated, or not? A controlled trial is very tempting to address each of these.
The vessel is even more vexing. What would be the best kind of bucket? What size should it be? What color should the bucket be, what composition, and what’s the ideal kind of handle? I think the variations here are the basis for an entire research career.
Perhaps the notion of running randomized, double-blind, controlled intervention trials to determine the right response to a foot on fire seems silly to you. But if so, you must be suggesting that science does not preclude sense.
That’s rather radical thinking in some quarters.
Continue reading “What I Would Do If My Foot Caught Fire”
Filed Under: THCB
Tagged: academic research, Clinical Trials, David Katz, Evidence Based Medicine, public health, Wellness
Apr 16, 2014
Here’s a design approach that I really, really dislike: the scrolling wheel that is often used for number entry in iOS apps:
I find that the scrolling wheel makes it very tiresome to enter numbers, and much prefer apps that offer a number pad, or another way to touch the number you need. (Or at least decrease the number at hand in sensible increments.)
You may think I’m being too picky, but I really think our ability to leverage technology will hinge in part on these apps and devices being very usable.
And that usability has to be considered for everyone involved: patients, caregivers, and clinicians.
Why am I looking at an app to enter blood pressure?
Let me start by saying that ideally nobody should be entering vitals data manually. (Not me, not the patient, not the caregivers, not the assisted-living facility staff.)
Instead, we should all be surrounded by BP machines that easily send their data to some computerized system, and said system should then be able to display and share the data without too much hassle.
But, we don’t yet live in this world, to my frequent mild sorrow. This means that it’s still a major hassle to have regular people track what is probably the number one most useful data for us in internal medicine and geriatrics: blood pressure (BP) & pulse.
Why is BP and pulse data so useful, so often?
To begin with, we need this data when people are feeling unwell, as it helps us assess how serious things might be.
And of course, even when people aren’t acutely ill, we often need this data. That’s because most of our patients are either:
- Taking medication that affects BP and pulse (like cardiovascular meds, but many others affect as well)
- Living with a chronic condition that can affect BP and pulse (such as a-fib)
- All the above
As we know, the occasional office-based measurement is a lousy way to ascertain usual BP (which is relevant for chronic meds), and may not capture episodic disturbances.
Continue reading “An Example of Bad Design: This App’s Interface for Entering Blood Pressure”
Filed Under: THCB
Tagged: Apps, Blood Pressure, Caregiving, Geriatrics, Leslie Kernisan, Tech, Telemonitoring, Wellness
Apr 14, 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
T was never a star service tech at the auto dealership where he worked for more than a decade. If you lined up all the techs, he wouldn’t stand out: medium height, late-middle age, pudgy, he was as middle-of-the-pack as a guy could get.
He was exactly the type of employee that his employer’s wellness vendor said was their ideal customer. They could fix him.
A genial sort, T thought nothing of sitting with a “health coach” to have his blood pressure and blood taken, get weighed, and then use the coach’s notebook computer to answer, for the first time in his life, a health risk appraisal.
He found many of the questions oddly personal: how much did he drink, how often did he have (unprotected) sex, did he use sleeping pills or pain relievers, was he depressed, did he have many friends, did he drive faster than the speed limit? But, not wanting to rock the boat, and anxious to the $100/month bonus that came with being in the wellness program, he coughed up this personal information.
The feedback T got, in the form of a letter sent to both his home and his company mailbox, was that he should lose weight, lower his cholesterol and blood pressure, and keep an eye on his blood sugar. Then, came the perfect storm that T never saw developing.
His dealership started cutting employees a month later. In the blink of an eye, a decade of service ended with a “thanks, it’s been nice to know you” letter and a few months of severance.
T found the timing of dismissal to be strangely coincidental with the incentivized disclosure of his health information.
Continue reading “What If Your Employer Gets Access to Your Medical Records?”
Filed Under: THCB, The Vault
Tagged: Al Lewis, data breaches, Employers, personal health records, Privacy, Vik Khanna, Wellness, workplace wellness programs
Mar 25, 2014
Amid the rancorous debates over the Affordable Care Act, one provision deserves to be getting serious discussion.
It’s a provision that allows employers to increase the amount that they may fine their employees for “lifestyle” conditions, such as being overweight or having high blood pressure or high cholesterol.
Almost 37% of Americans are overweight or obese. The supposed goal is to use financial penalties to reduce obesity, the health costs of which exceed $200 billion per year. But this idea, while well intended, will not help Americans suffering from obesity, a medically defined disease and disability. In fact, it will likely make their situation worse.
For years, the country’s “wellness” industry has offered health-enhancement and obesity-reduction programs to corporations, from gym memberships to dietary counseling. For obesity, this approach has not worked. Research on these programs shows that they have not significantly reduced weight or cholesterol levels, or improved any other health outcomes.
Even the most successful programs, such as Weight Watchers, achieve an average two-year weight loss of only about 3% for their members— and even that tiny weight loss often returns later.
Continue reading “An Obamacare Fine on Overweight Americans: Discriminatory and Ineffective”
Filed Under: THCB
Tagged: High blood pressure, High cholesterol, Incentives, Obesity, Pre-Existing Condition, Stephen Soumerai, Wellness
Mar 25, 2014
It’s 8.30 am, just before clinic opens. It is 2010. Dr Byte* checks an online forum, and something catches his eye.
A female patient is complaining about a doctor. Her posting has led to strident reactions from other doctors. Patients are taking her side. It looks ugly.
It turns out that the patient had asked her family doctor whether she could use her smartphone to record the encounter. Her doctor was apparently taken aback and had paused to gather his thoughts. He asked the patient to put her smartphone away, saying that it was not the policy of the clinic to allow patients to take recordings.
The patient described how the mood of the meeting shifted. Initially jovial, the doctor had become defensive. She complied and turned off her smartphone.
The patient wrote that as soon as the smartphone was turned off the doctor raised his voice and berated her for making the request, saying that the use of a recording device would betray the fundamental trust that is the basis of a good patient-doctor relationship.
The patient wrote that she tried to reason, explaining that the recording would be useful to her and her family. But the doctor shouted at her, asking her to leave immediately and find another doctor.
Some participants on the online forum expressed disbelief. But the patient then went on to state that she could prove that this had actually happened, because she actually had a recording of the encounter. Although she had turned off her smartphone, she had a second recording device in her pocket, turned on, that had captured every word.
Continue reading “Patientgate: Why Patient Recordings Will Change Everything”
Filed Under: Tech, THCB
Tagged: doctor/patient communication, Glyn Elwyn, Privacy, shared decision making, Transparency, UK Data Protection Act, Wellness
Mar 13, 2014
One thing that is known about electronic cigarettes: they’ve become a serious business in the United States.
Although e-cigarettes represent only a tiny percentage of the U.S. tobacco market, the industry is growing.
The number of people currently “vaping” has increased substantially over the last few years, with sales of nearly $2 billion in 2013.
Some analysts predict that this could grow to $10 billion by 2017 and eventually overtake sales of conventional cigarettes. It’s worth noting that the industry is maturing without much in the way of oversight or regulation.
We also know how e-cigarettes work—mechanically speaking. Using a battery-powered heating element, they convert liquid nicotine (sometimes flavored with food additives) into a vapor that users then inhale or “vape.”
This unique system delivers nicotine without the cancer-causing and other harmful elements associated with burning tobacco.
Unfortunately, that’s where a lot of the certainty ends. Currently, evidence for the safety, harmfulness, utility, and addictiveness of e-cigarettes is lacking.
The questions that research needs to answer, however, are clear as day—particularly since business is booming.
Are E-Cigarettes Bad for You?
Some of the food additives that flavor e-cigarette vapor may be dangerous when inhaled; the long-term health effects of inhaling the vapor are unknown. And of course, e-cigarettes still deliver nicotine, the main addictive ingredient in cigarettes and other tobacco products.
Nicotine from e-cigarettes could have detrimental effects on cardiovascular health and may impair breathing among those with already compromised lung functioning.
Continue reading “Where There’s Vapor, Is There Fire? We Need Evidence on E-Cigarettes”
Filed Under: OP-ED, THCB
Tagged: E-cigarettes, Joan S. Tucker, RAND Corporation, smoking cessation, Steven Martino, Wellness, William G. Shadel
Mar 4, 2014
I wish I had a better story to tell you about why I am typing this with one hand (and some help from Dragon Dictate).
A shark attack would be interesting. An assassination attempt would be intriguing. Skydiving mishaps always make for good copy. An out-of-control quad copter that turns on its master would be entertaining (and would come complete with a grim, potentially viral, video).
No, the reason I am now one-handed is a little more prosaic than those scenarios.
I had finished my last shoot after a long reporting trip to Japan and the Philippines and was stacking the Pelican cases brimming with TV gear onto my cart. As I tried to bungee cord them into some semblance of security for movement, one of the cases toppled onto my left forearm. Ouch! It hurt, but I wasn’t all “911” about it. It was painful and swollen but I figured it would be okay without any medical intervention. Maybe a little bit of denial?
The next day, February 13, things seemed status quo. It was sore and swollen but seemingly no worse. Then, that night, things got worse. Both the pain and swelling increased.
So on the morning of February 14, I asked the hotel for a referral to a doctor and went to see him right away. While my concern was already growing, the look on his face when he saw my forearm got me a little more nervous.
The doctor told me he suspected that I might be having an Acute Compartment Syndrome. I had to Wiki it, but in essence it is an increase in pressure inside an enclosed space in the body. This can block blood flow causing a whole host of serious, life-threatening consequences.
He had me admitted to the hospital. Over the next few hours, I endured probably the longest, most painful experience I could ever imagine. My forearm developed some dusky discoloration, but more alarming was the numbness. I could not feel my forearm!
The doctor recommended an emergency fasciotomy to relieve the pressure. This is a gruesome enough procedure on its own, but the he was clear that the problem was progressing rapidly and there was a clear and present threat to my limb.
Continue reading “Just a Flesh Wound”
Filed Under: THCB
Tagged: Acute Compartment Syndrome, Emergency amputation, Fasciotomy, Miles O'Brien, Wellness
Mar 3, 2014