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A Tale of Two Sore Throats: On Retail Clinics and Urgent Care

Leslie Kernisan new headshotSix years ago, just after arriving in Baltimore for a winter conference, I fell sick with fever and a bad sore throat.

After a night of feeling awful, I went looking for help. I found it at a Minute Clinic in a CVS near the hotel. I was seen right away by a friendly NP who did a rapid strep test, and prescribed me medication. I picked up my medication at the pharmacy there. The visit cost something like $85, and took maybe 30 minutes. They gave me forms to submit to my California insurance. And I was well enough to present my research as planned by day 3 of the conference.

Fast forward to this year. After feeling a bit blah on a Monday evening, I developed a sore throat, headache, and fever overnight.

I figured it was a winter viral pharyngitis, rearranged my schedule, and planned to make it an “easy day.” Usually a low-key day plus a good night’s sleep does the trick for me.

But not with this bug.

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The Trouble with Home Health Care & Care Coordination

Leslie Kernisan new headshotHome health care is in many ways a fantastic service, especially for those Medicare beneficiaries who are essentially home bound due to frailty or illness.

But it often feels surprisingly hard to synergize with home health care.

The main problem, as I see it, is that home health care agencies have set themselves up to provide only administratively required communication with the ordering doc. (There are rules governing home health care, you know!)

Now, what I need is clinically relevant communication. As in, how is the patient clinically doing, so that you and I can coordinate our efforts together. This has apparently not been built into the home health care workflow.

And things get even more complicated when it’s a patient in assisted living, because then you have the facility nurse who should be kept in the loop as well.

Right now, I am trying to follow up on an elderly woman who lives in assisted living and has paid in-home aides (which are provided by a separate company).

I referred her to home health care a few weeks ago for help managing her skin. On one hand, she was starting to develop a pressure sore from sitting too much in the same position. And on the other hand, she had a fungal rash in her groin, under her incontinence brief.

I prescribed an antifungal cream to be used twice a day for two weeks.

Now it’s been three weeks, and the pharmacy is requesting a refill.

Well…what’s going on with that rash?

What I want to do is send an email to everyone who is involved and might know something.

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Health Care for Dummies (and Innovators): In search of a practical definition of health

flying cadeuciiFor a while now, I’ve been working on an ebook about making digital health more useful and usable for older adults.

(Don’t hold your breath, I really have no idea when it will be done. I can only work on it for about an hour every weekday.)

In reflecting on the health innovation conferences and conversations in which I’ve participated these past few years, I found myself musing over the following two questions:

1. What is health?
2. What does it mean to help someone with their health?

Three Components

After all, whether you are a clinician, a health care expert, or a digital health entrepreneur, helping people with their health is the core mission. So one would think we’d be clear on what we’re talking about, when we use terms like health and health care.

But in fact, it’s not at all obvious. In practical parlance, we bandy around the terms health and health care as we refer to a wide array of things.

Actually defining health has, of course, been addressed by experts and committees. The World Health Organization’s definition is succinct, but hasn’t been updated since 1948:

“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”

A more recent attempt to define health, described in this 2011 BMJ editorial, proposed health as “’the ability to adapt and self manage’ in the face of social, physical, and emotional challenges.”

This left me scratching my head a bit, since it sounded more like a definition of one’s resilience, or self-efficacy. Which intuitively seem much related to health (however we define it), but not quite the same thing.

I found myself itching for a definition of health that would help me frame what I perceive as the health – and life – challenges of my older patients.

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It Cost What? Crowdsourcing Costs In An Evolving Healthcare System

flying cadeuciiCrowdsourcing is engaging a lot of news organizations today. While some journalists are nervous about crowdsourcing — “Yikes, we’d rather talk than listen, and what if they tell us something we don’t want to hear? Or something that we know isn’t true?” — we here at clearhealthcosts.com love crowdsourcing. We find, as journalists, that our communities are smart, energized, truthful and engaged, and happy to join hands in thinking, reporting and helping us make something that’s bigger than the sum of its parts. We learn great things by listening, so … now we’re going to to an experiment crowdsourcing coverage for our blog.

Our current project crowdsourcing health care prices in California, with KQED public radio in San Francisco and KPCC/Southern California public radio in Los Angeles, has been a great success, as was our previous project with WNYC public radio, and we’re looking forward to launching similar projects with other partners.Continue reading…

Let’s Make Sure “Health” Encompasses “Care”

Risa preferred headshotFor the past several months the Robert Wood Johnson Foundation has been promoting a particular vision– of a Culture of Health in America, where everyone  has the opportunity to live the healthiest life possible, no matter their income, or where they live, or work, or play.

With  that vision in mind, geriatrician Dr. Leslie Kernisan asks an important question in her Oct 7 Health Care Blog post, “Why #CultureofHealth Doesn’t Work For Me.”  She writes: “Is promoting a Culture of Health the same as promoting a Culture of Care? As a front-line clinician, they feel very different to me.”

For physicians treating the chronically ill and patients facing the end of life, good health might seem like a pipe dream. Kernisan and some of her commenters even wonder if the phrase “Culture of Health” could be misconstrued as “blaming the victim.”

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Why #CultureofHealth Doesn’t Work For Me

Leslie Kernisan new headshotEarlier this month, I attended the Fall Annual Health 2.0 conference. There was, as usual, much talk of health, total health, and of extending healthy years.

And this year, there was a special emphasis on promoting a “Culture of Health,” a meme that has become a centerpiece of the Robert Wood Johnson Foundation’s work.

So much so, that when I approached a conference speaker, to briefly comment on my interest in helping beleaguered family caregivers with their carees’ health and healthcare issues, I was advised to work on promoting a culture of health.

Hm. Funny, but as a generalist and geriatrician who focuses on the primary care of older adults with multiple medical problems, I’d been thinking more along the lines of:

  1.  Promoting the wellbeing of older adults and their caregivers.
  2. Optimizing the health – and healthcare — of my aging patients.

In other words, I’d been thinking of a “Culture of Care.”

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Should Docs Prescribe Data?

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I’ve always been a little skeptical of the push to get doctors to prescribe apps.

To begin with, it would be awfully easy for us to replicate the many problems of medication prescribing. Chief among these is the tendency for doctors to prescribe what’s been marketed to them, rather than what’s actually a good option for the patient, given his or her overall medical situation, preferences, and values.

Then there are the added complexities peculiar to the world of apps, and of using apps.

A medication, once a pharmaceutical company has labored to bring it to market, basically stays the same over time. But an app is an ever-morphing entity, usually updating and changing several times a year. (Unless it stops updating. That’s potentially worse.)

Meanwhile, the mobile devices with which we use apps are *also* constantly evolving, and we’re all basically forced to replace our devices with regularity.

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What PHR Should I Use? It’s Complicated.

Leslie Kernisan new headshotA friend called me the other day: he is moving his 93 year old father from New England to the Bay Area.

This is, of course, a relatively common scenario: aging adult moves — or is moved by family — to a new place to live.

Seamless transition to new medical providers ensues. As does optimal management of chronic health issues. Not.

Naturally, my friend is anxious to ensure that his father gets properly set up with medical care here. His dad doesn’t have dementia, but does have significant heart problems.

My friend also knows that the older a person gets, the more likely that he or she will benefit from the geriatrics approach and knowledge base. So he’s asked me to do a consultation on his father. For instance, he wants to make sure the medications are all ok for a man of his father’s age and condition.

Last but not least, my friend knows that healthcare is often flawed and imperfect. So he sees this transition as an opportunity to have his father’s health — and medical management plan — reviewed and refreshed.

This last request is not strictly speaking a geriatrics issue. This is just a smart proactive patient technique: to periodically reassess an overall medical care plan, and consider getting the input of new doctors while you do this. (Your usual doctors may or may not be able to rethink what they’ve been doing.) But of course, if you are a 93 year old patient — or the proxy for an older adult — it’s sensible to see if a geriatrician can offer you this review.

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An Example of Bad Design: This App’s Interface for Entering Blood Pressure

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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.

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Clinic: A Cautionary Note About the Risks of Blood Pressure Treatment in the Elderly

When it comes to high blood pressure treatment in the elderly, the plot continues to thicken.

Last December, a minor controversy erupted when the JNC hypertension guidelines proposed a higher blood pressure (BP) treatment target (150/90) for adults aged 60+.

And now this month, a study in JAMA Internal Medicine reports that over 3 years, among a cohort of 4961 community-dwelling Medicare patients aged 70+ and diagnosed with hypertension, those on blood pressure medication had more serious falls.

Serious falls as in: emergency room visits or hospitalizations for fall-related fracture, brain injury, or dislocation of the hip, knee, shoulder, or jaw. In other words, we talking about real injuries and real patient suffering. (As well as real healthcare utilization, for those who care about such things.)

How many more serious falls are we talking? The study cohort was divided into three groups: no antihypertensive medication (14.1%), moderate intensity treatment (54.6%), and high-intensity treatment (31.3%).

Over the three year follow-up period, a serious fall injury happened to 7.5% of those in the no-antihypertensive group, 9.8% of the moderate-intensity group, and 8.2% of the high-intensity group. In a propensity-matched subcohort, serious falls happened to 7.1% of the no-treatment group, 8.6% of the moderate-intensity group, and 8.5% of the high-intensity group. (Propensity-matching is a technique meant to adjust for confounders – such as overall illness burden — between the three groups.)

The methodologists in the audience should certainly read the paper in detail and go find things to pick apart. For the rest of us, what are the practical take-aways?

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