Month: November 2012

Denying Reality About Bad Prognoses

Nov 19, 2012• 10

By Bob Wachter, MD

The human capacity to deny reality is one of our defining characteristics. Evolutionarily, it has often served us well, inspiring us to press onward against long odds. Without denial, the American settlers might have aborted their westward trek somewhere around Pittsburgh; Steve Jobs might thrown up his hands after the demise of the Lisa; and Martin Luther King’s famous speech might have been entitled, “I Have a Strategic Plan and a Draft Budget.”

Yet when danger or failure is just around the corner, denial can be dysfunctional (see Karl Rove on Fox News), even suicidal (see climate change and Superstorm Sandy).

Healthcare is no exception. Emerging evidence suggests that patients and their surrogates frequently engage in massive denial when it comes to prognosis near the end of life. While understandable – denial is often the way that people remove the “less” from “hopeless” – it can lead to terrible decisions, with bad consequences for both the individual patient and society.

First, there is evidence that individuals charged with making decisions for their loved ones (“surrogate decision-makers”) simply don’t believe that physicians can prognosticate accurately. In a 2009 study, UCSF’s Lucas Zier found that nearly two-thirds of surrogates gave little credence to their physicians’ predictions of futility. Driven by this skepticism, one-in-three would elect continued life-sustaining treatments even after the doctor offered their loved one a less than 1% chance of survival.

In a more recent study by Zier and colleagues, 80 surrogates of critically ill patients were given hypothetical prognostic statements regarding their loved ones. The statements ranged from “he will definitely survive” to “he will definitely not survive,” with 14 statements in between (including some that offered percentages, such as “he has a [10%, or a 50%, or a 90%] chance of survival”). After hearing these statements, surrogates were asked to interpret them and offer their own survival estimates.

When the prognosis was optimistic (“definitely survive” or “90%” survival odds), surrogates’ estimates were in sync with those of the physicians. But when the prognosis was pessimistic (“definitely not survive” or “he has a 5% chance of surviving”), surrogates’ interpretations took a sharp turn toward optimism. For example, surrogates believed that when the doctor offered a 5% survival chance, the patient’s true chance of living was at least three times that; some thought it was as high as 40%. Remarkably, when asked later to explain this discordance, many surrogates struggled. Said one, “I’m not coming up with good words to explain this [trend] because I was not aware I was doing this.” The authors identified two main themes to explain their findings: surrogates’ need to be optimistic in the face of serious illness (either as a coping mechanism for themselves or to buck up their loved one), and surrogates’ beliefs that their loved one possessed attributes unknown to the physician, attributes that would result in better-than-predicted survival (the “he’s a fighter” argument).

Tough Hard Decision: What To Do About Medicare

Nov 19, 2012• 15

By ROB LAMBERTS, MD

It seems both ironic and inevitable: I won’t be getting any more “meaningful use” checks. It’s not that I didn’t qualify for the money; I saw plenty of patients on Medicare and met all of the requirements. I was paid for my first year money without much hassle. The problem I am facing is this: I am probably going to be “opting out” of Medicare, and once I do that I will cease to exist as far as HHS is concerned, and they are the ones who write the “meaningful use” checks. No existence equals no money.

This is ironic because I have gotten famous for how well I’ve used electronic medical records, have written advice for physicians trying to qualify for “meaningful use,” and am esteemed enough to be often asked for my opinion on the subject (culminating in a presentation last year for CDC public health Grand Rounds). I have spent much of the past 16 years disproving the myths that small practices couldn’t afford EMR, that EMR decreases profitability, or that they reduce quality of care. We not only could afford EMR, we flourished, using it as a tool to increase both productivity and profitability. Not to overstate the issue, but my practice (and others like it) paved the way for the existence of “meaningful use.” I don’t know if that’s a good or a bad thing.

But, as fate would have it, I am leaving the practice in which I did all of this work and am starting a new practice with a different payment system. Instead of charging for office visits or tests done in my office, I am charging a monthly “subscription” fee for access to my care and to the other resources I offer. But there isn’t a Medicare code for a monthly subscription fee, and the rules of Medicare are such that, as far as I can tell, I cannot have the practice I intend to build and be listed as a Medicare provider. This is the case even if I never charge Medicare for any of my services.

Regarding my status as a Medicare provider, there are three options:

Accept Medicare as a “participating” provider – This means that I see Medicare patients and accept what they say I will be paid. I bill CMS for my services, which are based on my “procedure codes.” My main procedure is the office visit, but I can also bill for things like immunizations, lab tests, and office procedures. The more procedures I bill for, the more I get paid, but I must justify this billing in my documentation or run the risk of being accused of fraud.
Become a “non-Participating” Medicare provider – In this scenario, I am paid by the patient for the encounter and then they are reimbursed for what they paid me. The choice of what I bill happens the same way, and I still must set fees based on what CMS tells me (although I can bill a little bit more than I would if I was a participating provider). Billing is, once again, based on the documentation of the visit.
“Opt out” of Medicare altogether – Opting out means that I am no longer in the Medicare database as a provider and won’t get paid by them at all. Patients are free to come to me, but they must pay what I charge, and I set my fees based on what I think is best.Continue reading…

The Good Doctor

Nov 18, 2012• 4

By Jesse Dylan

Dr. Brian Goldman is right.

We expect a level of perfection from our doctors, nurses, surgeons and care providers that we do not demand of our heroes, our friends, our families or ourselves. We demand this level of perfection because the stakes in medicine are the highest of any field — outcomes of medical decisions hold our very lives in the balance.

It is precisely this inconsistent recognition of the human condition that has created our broken health care system. The all-consuming fear of losing loved ones makes us believe that the fragile human condition does not apply to those with the knowledge to save us. A deep understanding of that same fragility forces us to trust our doctors — to believe that they can fix us when all else in the world has failed us.

I am always surprised when people say someone is a good doctor. To me, that phrase just means that they visited a doctor and were made well. It is uncomfortable and unsettling — even terrifying — to admit that our doctors are merely human — that they, like us, are fallible and prone to bias.

They too must learn empirically, learning through experience and moving forward to become better at what they do. A well-trained, experienced physician can, by instinct, identify problems that younger ones can’t catch — even with the newest methods and latest technologies. And it is this combination of instinct and expertise that holds the key to providing better care.

We must acknowledge that our health care system is composed of people — it doesn’t just take care of people. Those people — our cardiologists, nurse practitioners, X-ray technicians, and surgeons — work better when they work together.

Working together doesn’t just mean being polite in the halls and handing over scalpels. It means supporting one another, communicating honestly about difficulties, sharing breakthroughs to adopt better practices, and truly dedicating ourselves to a culture of medicine that follows the same advice it dispenses.

Winners of the Patient Safety Reporting System Challenge

Nov 16, 2012• 1

By Adam Wong

Over the past several weeks, many of us at the Office of the National Coordinator for Health Information Technology (ONC), Agency for Healthcare Research and Quality (AHRQ), and Food and Drug Administration have been evaluating the submissions for the Reporting Patient Safety Events Challenge. Team 90, consisting of KBCore (created by CRG Medical, Inc.) and iHealthExchange, was selected the winner of the challenge—and the recipient of the $50,000 prize—because the company’s patient safety reporting system best fit the criteria of the challenge to find and reduce the risks associated with patient care. Right now, finding risks through the reporting of adverse events is slow because paper-based systems may be hard to read and require transmission by fax machines. By modernizing the patient safety reporting system through the use of computer-based applications we can better shed light on medical errors and augment the discovery of new patient safety hazards more timely and efficiently.

Reporting Patient Safety Events Challenge Submissions

The Challenge submissions were evaluated on a variety of criteria to determine which would potentially improve reporting of adverse events the most. The applications were required to make it easier to file an adverse event report using AHRQ’s Common Formats while allowing for:

The inclusion of additional information during the initial submission and from a follow-up investigation;
Import of relevant electronic health record or personal health record information, including screenshots; and
Ability to submit reports to various entities including PSOs, FDA, and other health oversight organizations.

IDinc and Shands Healthcare finished in second place, while third place went to MidasPlus. They will receive $15,000 and $5,000, respectively.

End of the Line in the ICU

Nov 16, 2012• 103

By Kristen McConnell

Last year I graduated from nursing school and began working in a specialized intensive care unit in a large academic hospital. During an orientation class a nurse who has worked on the unit for six years gave a presentation on the various kinds of strokes. Noting the difference between supratentorial and infratentorial strokes—the former being more survivable and the latter having a more severe effect on the body’s basic functions such as breathing—she said that if she were going to have a stroke, she knew which type she would prefer: “I would want to have an infratentorial stroke. Because I don’t even want to make it to the hospital.”

She wasn’t kidding, and after a couple months of work, I understood why. I also understood the nurses who voice their advocacy of natural death—and their fear of ending up like some of our patients—in regular discussions of plans for DNRtattoos. For example: “I am going to tattoo DO NOT RESUSCITATE across my chest. No, across my face, because they won’t take my gown off. I am going to tattoo DO NOT INTUBATE above my lip.”

Another nurse says that instead of DNR, she’s going to be DNA, Do Not Admit.

We know that such plainly stated wishes would never be honored. Medical personnel are bound by legal documents and orders, and the DNR tattoo is mostly a very dark joke. But the oldest nurse on my unit has instructed her children never to call 911 for her, and readily discusses her suicide pact with her husband.

You will not find a group less in favor of automatically aggressive, invasive medical care than intensive care nurses, because we see the pointless suffering it often causes in patients and families. Intensive care is at best a temporary detour during which a patient’s instability is monitored, analyzed, and corrected, but it is at worst a high tech torture chamber, a taste of hell during a person’s last days on earth.

Health 2.0 Europe Showcased the Latest Innovations as Health Care Goes Digital

Nov 15, 2012

Health care is transforming quickly due to mobile and web technologies. The driving forces behind this development are not the traditional players, rather they are start-ups and software experts. To keep track of innovation, Health 2.0 held its annual European session in Berlin last week.

Neil Bacon, founder of the rate and review platform iwantgreatcare.org, set the tone for the panels that followed: “Power, influence and money are still with the providers. It is crucial to unleash the power of the users.” More than 75 technology demos illustrated promising web and mobile solutions that live up to his claim:

The highly acclaimed mobile phone app mySugr helps diabetics to manage their condition. It employs a gamified approach to monitor the disease and has many rewards in store to keep patients engaged.
Nhumi.com‘s mission is to improve communication between doctors and patients by providing a 3D-model of the entire human body in which diseases can be localized and described.
To overcome language barriers, universaldoctor.com helps translating between many different languages. Its crowd sourcing approach makes it easy for doctors to submit their own bilingual suggestions to facilitate medical consultation.
Biovotion presented a sensor that monitors physiological functions non-invasively and thereby helps reducing hospital stays.

Social networks also apply more and more to professional interaction. In networks like BestDoctors.com, physicians can build communities where they can ask for second opinions from the best specialists from around the world. The Spanish Fundación Recover fosters cooperation between physicians in industrialized and third-world countries via the Internet. Khresmoi.com is a powerful search and access system for biomedical information that includes a multitude of text and image sources in combination with a semantic search engine.

Building a Better Parkland

Nov 15, 2012• 9

By Peter Pronovost, MD

In recent years, Parkland Memorial Hospital in Dallas, Texas has faced intense media scrutiny and government investigations into patient safety lapses. As the hospital searches for a new CEO, the Dallas Morning News asked me and other experts to answer the question: “What kind of leader does Parkland need to emerge as a stronger public hospital?” Below is the column, re-used with the newspaper’s permission. While it is focused on one hospital, the themes apply broadly. The type of leader that I describe is needed throughout health care.

Public hospitals such as Parkland are a public trust, serving the community’s health needs by providing safe and effective care to a population that lacks alternatives.

Major shortcomings in the quality of care provided at Parkland have eroded that trust. Now trust must be restored. The community is counting on it. It’s literally a matter of life and death.

Parkland’s board is searching for a new CEO to lead this journey. The CEO’s task will not be easy: Resources are tight, resident supervision is insufficient, staff morale is low, systems need updating, and preventable harm is far too common.

History may provide some guidance. Historian Rufus Fears notes that great leaders – leaders who changed the world – have four attributes: a bedrock of values, a clear moral compass, a compelling vision and the ability to inspire others to make the vision happen. Parkland needs one of these great leaders.

Roundup of State Ballot Initiatives on Health Issues

Nov 15, 2012• 2

By Katie Booth

This November, voters weighed in on an array of state ballot initiatives on health issues from medical marijuana to health care reform. Ballot outcomes by state are listed below (more after the jump).

Voters in Alabama, Montana, and Wyoming passed initiatives expressing disapproval of the Affordable Care Act, while a similar initiative in Florida garnered a majority of the vote but failed to pass under the state’s supermajority voting requirement. Missouri voters passed a ballot initiative prohibiting the state executive branch from establishing a health insurance exchange, leaving this task to the federal government or state legislature.

Florida voters defeated a measure that would have prohibited the use of state funds for abortions, while Montana voters passed a parental notification requirement for minors seeking abortions (with a judicial waiver provision).

Perhaps surprisingly, California voters failed to pass a law requiring mandatory labeling of genetically engineered food. Several states legalized medical marijuana, while Arkansas voters struck down a medical marijuana initiative and Montana voters made existing medical marijuana laws more restrictive.

Colorado and Washington legalized all marijuana use, while a similar measure failed in Oregon.

Physician-assisted suicide was barely defeated in Massachusetts (51% to 49%), while North Dakotans banned smoking in indoor workplaces. Michigan voters failed to pass an initiative increasing the regulation of home health workers, while Louisiana voters prohibited the appropriation of state Medicaid trust funds for other purposes.

The Next Generation of Entrepreneurs

Nov 14, 2012• 3

By JOHN HALAMKA, MD

When I was 13 years old, the Altair 8800 appeared on the cover of Popular Electronics. By 16, I was building enough hardware and software that I achieved the Malcolm Gladwell 10,000 hours of competency by age 18. By 19, I founded a company that produced tax calculation software for the Kaypro, Osborne, and new IBM PC. Every week in the Silicon Valley of the early 1980’s brought a new startup into the nascent desktop computer industry.

To me, we’re in a similar era – a perfect storm for innovation fueled by several factors. Young entrepreneurs are identifying problems to be rapidly solved by evolving technologies in an economy where existing “old school” businesses are offering few opportunities.

This morning, I lectured to an entire classroom of MIT Sloan school entrepreneurs . Today the Boston Globe published articles about the Harvard Innovation Lab and the Mayor’s efforts to connect entrepreneurial students with mentors.

Tonight I’ll introduce a Harvard Medical School entrepreneurial team at the Boston TechStars event.

This pace of innovation reminds of that time 30 years ago when Sand Hill Road was just beginning its evolution to the hotbed of venture investing it is today.

Who are these new entrepreneurs and what kind of work are they doing? Tonight I’ll be introducing Lissy Hu and Gretchen Fuller.

Beacons: Beaming EKG Results to Emergency Departments

Nov 14, 2012• 3

By Ted Chan, MD

I grew up watching the Star Trek television series and was always intrigued by the amazing technology that included phasers, warp speed, cloaking devices and the transporter – the fastest (and coolest) way of getting from point A to point B! “Beam me up Scotty” still comes to my mind as the iconic phrase that promises fast and immediate action in the most dire of circumstances.

Today, the San Diego Beacon Community is implementing our own “beaming” technology with dramatic results. We are using health information technology to electronically transmit electrocardiograms (EKGs) from ambulances to hospital emergency departments to ensure faster and better coordinated care for emergency cardiac patients. When a patient demonstrates symptoms of a heart attack, getting the right information quickly to a cardiac specialist is critical.

“Beaming” the EKGs and other relevant health information to the hospital while the patient is still miles away allows for the patient’s condition to be appropriately assessed by specialists before he or she arrives. Then, immediate treatment can be provided as soon as the patient arrives at the hospital. The sooner blood flow is restored to the heart muscle, the better the outcomes for surviving a heart attack.