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Care On the Continuum

My change from a traditional practice to direct-care has caused me to challenge some of the basic assumptions of the care I’ve given up to this point.  Certainly, the nature of my documentation will radically change with my freedom from the tyranny of E/M coding requirements.

Perhaps the biggest change in my care comes courtesy of the way I get paid.  The traditional way to be paid is for service rendered (either at an office visit or procedures done).  This means that I am financially motivated to give the bulk of my attention to people when they are in the office.  They are paying for my attention, so I try to give them their money’s worth.  The corollary of this is that I tend to not think about people who are not in the office to be seen.  The end-result is an episodic approach to care that is entirely dependent on the patient paying for an encounter.

There is a huge problem with this approach to care: people live their lives between encounters.  Life does not go on hold between office visits for my patients, and the impact of my care is not dependent on what happens in the encounter, but what happens between visits.  My ability to help my patients depends on my ability to affect the continuum.  If I do a good enough sales pitch for a person taking their medications, and if I consider the life-circumstance which may affect their ability to take the medicine, then I am successful.  I don’t learn about the success until their next visit (usually), and I also don’t learn about problems until then.  People are reluctant to call with problems they are having with medications, new symptoms, or other important details, often waiting for many months to tell me things I really want to know.  Perhaps they don’t want to be “one of those patients who calls all the time,” perhaps they don’t understand what I said, or maybe they’re worried I will “force them to come in” to pay for another office visit.  Regardless of the reason, I get very limited interaction with my patients in this episodic care model.

My new practice model allows for, and even encourages interaction between face-to-face encounters.  I intend on spending a significant part of my day systematically reviewing records to make sure they are up-to-date, and initiating contact if need be.  I will also give them resources to be able to manage their care (or their wellness) without having to pay for each encounter.  One reader (of another blog to be left unnamed) suggested that under this system he would get his “money’s worth” by using my service as much as possible.  For him that meant coming to see me often, but in the model of care on the continuum it would involve going to the web site and updating records, sending me questions, or watching videos I’ve made on a particular subject.  My hope is that all my patients would “get their money’s worth” between visits, and that perhaps this will reduce the need for actual face-to-face encounters.  In fact, that is the whole point of what I am doing.Continue reading…

It’s the Patient, Stupid

Electronic health records (EHRs) offer many valuable benefits for patient safety, but it becomes apparent that the effective application of healthcare informatics creates problems and unintended consequences. As many turn their attention to solving the seemingly intractable problems of healthcare IT, one element remains particularly challenging–integration–healthcare’s “killer app.” Painfully missing are low-cost, easy to implement, plug-and-play, nonintrusive integration solutions. But why is this?

First, we must stop confusing application integration with information integration. Our goal must be to communicate data (ie, integrate information), not to integrate application functionality via complex and expensive application program interfaces (APIs). Communicating data simply requires a loosely coupled flow of data, as occurs today via email. In contrast, integration is a CIOs nightmare. Integrating applications, when we just wanted a bit of information, is akin to killing a gnat with a brick. 

Even worse, like a bad version of Groundhog Day, the healthcare IT industry keeps repeating the same mistakes, and we keep working with these mistakes. Consultants and vendors from whom we request simple data communication solutions offer their sleight of hand, which usually recasts our problem into a profitable application integration project that simply costs us more money. This misdirection takes us down a maze of tightly coupled integrations that are costly, fragile and brittle, and not really based on loosely-coupled data exchanges, a simpler approach that allows the Internet to perform so well.

The key to unlocking the potential of EHRs lies in securely communicating (a.k.a. exchanging) data between EHR silos. If we simply begin by streaming data from EHR systems onto a common backbone, using a common currency like XML (eXtensible Markup Language), we will have solved healthcare integration in a way that works the way much of the Internet works. And this is good. When this happens, we know interoperability will work, robustly.Continue reading…

Dropping Out

After 18 years in private practice, many good, some not, I am making a very big change.  I am leaving my practice.

No, this isn’t my ironic way of saying that I am going to change the way I see my practice; I am really quitting my job.  The stresses and pressures of our current health care system become heavier, and heavier, making it increasingly difficult to practice medicine in a way that I feel my patients deserve.  The rebellious innovator (who adopted EMR 16 years ago) in me looked for “outside the box” solutions to my problem, and found one that I think is worth the risk.  I will be starting a solo practice that does not file insurance, instead taking a monthly “subscription” fee, which gives patients access to me.

I must confess that there are still a lot of details I need to work out, and plan on sharing the process of working these details with colleagues, consultants, and most importantly, my future patients.

Here are my main frustrations with the health care system that drove me to this big change:

  1. I don’t feel like I can offer the level of care I want for my patients. I am far too busy during the day to slow down and give people the time they deserve.  I have over 3000 patients in my practice, and most of them only come to me when there are problems, which bothers me because I’d rather work with them to prevent the problems in the first place.
  2. There’s a disconnect between my business and my mission.  I want to be a good doctor, but I also want to pay for my kids’ college tuition (and maybe get the windshield on the car fixed).  But the only way to make enough money is to see more patients in my office, making it hard to spend time with people in the office, or to handle problems on the phone.  I have done my best to walk the line between good care and good business, but I’ve grown weary under the burden of having to make this choice patient after patient.  Why is it that I would make more money if I was a bad doctor?  Why am I penalized for caring?
  3. The increased burden of non-patient issues added to the already difficult situation.  I have to comply with E/M coding for all of my notes.  I have to comply with “Meaningful Use” criteria for my EMR.  I have to practice defensive medicine to avoid lawsuits.  I have more and more paperwork, more drug formulary problems, more patients frustrated with consultants, and less time to do it all.  My previous post about burn-out was a prelude to this one; it was time to do something about my burn out: to drop out.Continue reading…

Getting the Right Benchmarks For Stroke Care

Late last week, thanks to Liz Kowalczyk (@globeLizK) of the Boston Globe, I discovered the statewide report on quality of stroke care in Massachusetts.  It’s a plain document, mostly in black and white, much of what you might expect from a state government report.  Yet, this 4-page document is a reminder of how we have come to accept mediocrity as the standard in our healthcare delivery system.

The report is about 1,082 men and women in Massachusetts unfortunate enough to have a stroke but lucky (or vigilant) enough to get to one of the 69 Massachusetts hospitals designated as Primary Stroke Service (PSS) in a timely fashion. Indeed, all these patients arrived within 2 hours of onset of symptoms and none had a contradiction to IV-tPA, a powerful “clot busting” drug that has been known to dramatically improve outcomes in patients with ischemic stroke, a condition in which a blood clot is cutting off blood supply to the brain.  For many patient-ts, t-PA is the difference between living a highly functional life versus being debilitated and spending the rest of their lives in a nursing home.  There are very few things we do in medicine where minutes count – and tPA for stroke is one of them.

So what does this report tell us?  That during 2009-2010, patients who showed up to the ER in time to get this life-altering drug received in 83.3% of the time.  Most of us who study “quality of care” look at that number and think – well, that’s pretty good.  It surely could have been worse.

Pretty good?  Could have been worse?  Take a step back for a moment:  if your parent or spouse was having a stroke (horrible clot lodged in brain, killing brain cells by the minute) – you recognized it right away, called 911, and got your loved one to a Primary Stroke Service hospital in a fabulously short period of time, are you happy with a 1 in 5 chance that they won’t get the one life-altering drug we know works?  Only 1 in 5 chance that they might spend their life in a nursing home instead of coming home?  Is “pretty good” good enough for your loved one?

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Burnout

It happened again.  I was talking to a particularly sick patient recently who related another bad experience with a specialist.

“He came in and started spouting that he was busy saving someone’s life in the ER, and then he didn’t listen to what I had to say,” she told me.  ”I know that he’s a good doctor and all, but he was a real jerk!”

This was a specialist that I hold in particular high esteem for his medical skill, so I was a little surprised and told her so.

“I think he holds himself in pretty high esteem, if you ask me,” she replied, still angry.

“Yes,” I agreed, “he probably does.  It’s kind of hard to find a doctor who doesn’t.”

She laughed and we went on to figure out her plan.

This encounter made me wonder: was this behavior typical of this physician (something I’ve never heard about from him), or was there something else going on?  I thought about the recent study which showed doctors are significantly more likely than people of other professions to suffer from burn-out.

Compared with a probability-based sample of 3442 working US adults, physicians were more likely to have symptoms of burnout (37.9% vs 27.8%) and to be dissatisfied with work-life balance (40.2% vs 23.2%) (P < .001 for both).

This is consistent with other data I’ve seen indicating higher rates of depression, alcoholism, and suicide for physicians compared to the general public.  On first glance it would seem that physicians would have lower rates of problems associated with self-esteem, as the medical profession is still held in high esteem by the public, is full of opportunities to “do good” for others, and (in my experience) is one in which people are quick to express their appreciation for simply doing the job as it should be done.  Yet this study not only showed burn-out, but a feeling of self-doubt few would associate with my profession.

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What Next After Implementation? Challenges For the Informatics Community

I had the opportunity recently to attend this year’s Healthcare Forum, put on by Xerox’s the Breakaway Group,  an organization whose mission is to improve healthcare through optimization of the electronic health record (EHR). The forum brought together about 100 leaders from healthcare delivery organizations, academia, and industry. We had the great opportunity to take a break from our daily grind to step back and take a look at the big picture. Clearly much progress has been made, but there is still so much more to do to improve healthcare and its use of information technology.

In my reflection of the event, I had the opportunity to gather some thoughts on what the biomedical and health informatics (BMHI) field must do to contribute to the larger picture going forward. The last few years have been very good for those who work professionally and academically in BMHI, which I have defined as the field that is concerned with the optimal use of information, often aided by the use of technology, to improve individual health, health care, public health, and biomedical research [1]. The Health Information Technology for Economic and Clinical Health Act (HITECH) Act has provided tremendous opportunity to expand the use of informatics systems to improve health.

Much of the focus of the early (2009-present) HITECH era has focused on implementation of electronic health record (EHR) systems. Many healthcare organizations, especially larger ones, have made the transition to electronic systems and collected their meaningful use dollars.Continue reading…

The Drug Formulary Death Cage Match of Awesomeness

I got an unusual request last week.  I had written a prescription of a generic medication (which has been generic for a couple of years) and the prescription was denied by the insurance carrier.  The reason for denial: I had to try a brand-name medication first.

Stop.  Read that again.  They wouldn’t allow me to give a prescription for the (cheaper) generic drug because I had to try the brand-name medication first. This is opposite of the usual reason for denial, the availability of a cheaper alternative than the prescribed drug, and, to my knowledge, is the first time I have ever seen it upside-down like this, and I have been in the ring for the duration of the drug formulary death cage match of awesomeness.  I’ve seen it all unfold.

Here is what happened.

I am not, like many physicians and patients, against the idea of cost-control through the use of drug formularies.  Medications are very expensive (unnecessarily expensive, as I have discussed previously), and the previously strong influence of drug reps made many doctors quick to jump for the latest and greatest medication.  I did this myself, during the first few years of practice – before the advent of drug formularies.

We were constantly detailed on new NSAID’s, antibiotics, cholesterol, and blood pressure pills.   There was always a reason the latest drug was worth using over the old one (sounds a lot like fancy smart phones, doesn’t it?), and since insurance paid the same for brand drugs, I was often influenced by the drug reps.

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Why the Electronic Medical Record Needs to be Viewed as a Medical Device

In our rush to establish a national electronic medical record (EMR) system as part of the American Recovery and Reinvestment Act of 2009, powerful silos of independent EMR systems have sprung up nationwide.

While most systems are being developed responsibly, like the Wild, Wild West, many have been developed without an objective eye toward quality and the potential  harm they may be causing our patients.

As most readers of this blog are aware, since 2005 the medical device industry in which I work has had widely publicized instances of patient deaths splashed all over the New York Times and other mainstream media outlets from defibrillator malfunctions that resulted in a just a few patient deaths.

The backlash in response to these deaths was significant: device registries were developed, software improvements to devices created, and billions of dollars in legal fees and damages paid to patients and their families on the path to improvement.  In addition, we also learned about the limits of corporate responsibility for these deaths thanks to legal precedent established by the Reigel vs. Medtronic case.

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Hospital Quality Under Scrutiny

Last week’s New York Times article on cardiac care at some HCA-owned hospitals yielded a chorus of comments from readers who argued that for-profit hospital care is inherently low-quality care. As it happened, in working on a history of the investor-owned hospital sector, I had just been crunching data that might either support or refute that assertion. The results are surprising, if far from decisive.

Last September, the Joint Commission released the first of what it said would be annual lists recognizing “Top Performers on Key Quality Measures™” among the nation’s accredited hospitals. The all-star roster is based on “core measure performance data” that hospitals report to the Commission. The data cover adherence to “accountability measures ” established as best practice in the eyes of the Commission – making sure to prescribe beta-blockers for heart attack patients at discharge, for example, or to discontinue prophylactic antibiotics within 24 hours after surgery.

Unlike hospital quality measures that look at results – death rates and other outcomes – this one looks at processes. In theory, then, it ought to be more fair to hospitals that tend to serve sicker or more compromised patients, such as government-run hospitals in inner cities.

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Et tu Dr. Gupta?

As well intentioned and thoughtful as he is, Sanjay Gupta nonetheless misses the point in his recent New York Times op-ed “More treatment, more mistakes.”  The theme of the chief medical correspondent for the Health, Medical & Wellness unit at CNN is:

Certainly many procedures, tests and prescriptions are based on legitimate need. But many are not…. This kind of treatment is a form of defensive medicine, meant less to protect the patient than to protect the doctor or hospital against potential lawsuits.

Herein lies a stunning irony. Defensive medicine is rooted in the goal of avoiding mistakes. But each additional procedure or test, no matter how cautiously performed, injects a fresh possibility of error.

With a quick aside in admiration of Peter Pronovost’s approach to harm reduction and some other process improvements, he then says:

What may be even more important is remembering the limits of our power. More — more procedures, more testing, more treatment — is not always better.

And then, remarkably, he presents M&M conferences as a remedy:

One place where I have seen these issues addressed is in Morbidity and Mortality, or M and M — a weekly gathering of doctors, off limits to the public, which serves in most hospitals as a forum for the discussion of mistakes, complications, deaths and unusual cases. It is a sort of quality-assurance conference where doctors hold one another accountable and learn from one another’s mistakes. They are some of the most candid and indelible meetings I have ever attended.

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