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Do Computers Really Come Between Doctors and Patients?

Sep 1, 2018

Davis Liu, MD

One of my favorite movies is Back to the Future starring Michael J. Fox. I must admit after reading this New York Times piece, titled “When Computers Come Between Doctors and Patients” I have to wonder.

Am I fortunate to be coming from the future? Because I completely disagree with Dr. Danielle Ofri, again.

I’ve had the privilege and opportunity to work in a medical group which has deployed the world’s largest civilian electronic medical record and have been using it since the spring of 2006. I don’t see the issue quite as much as Dr. Ofri did. It is possible that she examined patients in her office with a desk rather than an examination room.

If placed and mounted correctly in the exam room, the computer actually is an asset and can improve the doctor patient relationship. It is part of the office visit. The flat screen monitor can be rotated to begin a meaningful dialogue between the patient and I. We review the lab work together as well as the trends. Look at xrays. Who needs anatomy flip charts when I can Google any image instantly? Patient friendly information to reinforce our discussion is a click away.

Pay-for-Performance Attacks Hospitals

Sep 1, 2018

By Michael Kirsch, MD

This blog has tried to support the virtue of personal responsibility. If you smoke, don’t blame Joe Camel. If you surrender to Big Mac attacks, don’t go after Ronald McDonald. If you love donuts, and your girth is steadily expanding, is it really Krispy Kreme’s fault? And, if you suffer an adverse medical outcome, then…

Medicare aims to zoom in on hospitals, suffocating them with a variation of the absurd pay-for-performance charade that will soon torture practicing physicians. Of course, a little torture is okay, as our government contends, but pay-for-performance won’t increase medical quality, at least as it currently exists. It can be defended as a job creator as several new layers in the medical bureaucracy will be needed to collect and track medical data of questionable value.

Medical quality simply cannot be easily and reliably measured as one can do with a diamond, an athlete or a wine. Most professions resist being graded or claim that the grading scheme is a scheme. Teachers, for example, refute that testing kids is a fair means to measure their teaching performance. Conversely, any individual or profession who scores well on any quality review program will applaud the system’s worth and fairness. Shocking.

Leaders Of Science-Driven Businesses Should Understand … Science

Sep 1, 2018

By David Shaywitz, MD

Even as a med student, I was struck by the discrepancy between how much the junior doctors (particularly the interns and second-year residents) seemed to know, and how much the more experienced doctors knew: with few exceptions, the junior doctors seemed to know a lot more. Or at least, they would always have a definitive answer at their fingertips. Such was their apparent understanding of human pathophysiology that they were usually able to offer plausible, immediate explanations of anything, make a rapid assessment, and move on.

In contrast, the expert physicians – the doctors who had spent decades of their lives treating particular types of patients, and studying a specific disease – tended to be far less definitive, and much more likely to say, “to tell you the truth, we really don’t know.” If a patient responded in a certain way to a new treatment, the experienced doctor is more likely to say “well, that happens sometimes,” while the second-year resident would more likely say, “of course we expect that, it’s because …”

I did most of my clinical training after completing my PhD, which focused on the relationship between several proteins involved in intracellular transport, and I was struck by how difficult it was to define with precision how a handful of proteins interacted, even when I was able to study these proteins essentially in isolation in a test-tube – an extremely reduced system. It was a struggle to say with certainty exactly what was going on (though the results – here, for instance – seem durable, at least to this point).

How Much Does it Cost to Have a Baby?

Sep 1, 2018

By Kenny Lin, MD

When my wife delivered our second child in 2008, the hospital sent our health insurance company a bill for $8569. The insurance company then wrote off $4117 of that bill, paid $4352, asked us for a copayment of $100. When we found out last year that we were expecting again, we noted that my wife’s new insurance plan requires us to pay 20% coinsurance for all non-preventive care. That would have amounted to several hundred dollars of our 2008 bill, and knowing the rapid rate of health care inflation, we thought it would be good to find out how much it would cost this time around. So we went back to the same hospital, where we expect our third child to be born in a few weeks, and asked if they could give us an estimate of the charges. It seemed like a reasonable enough request, especially since the pre-admission consent form we signed specifically said that patients had a right to know what the hospital charged for its services.

We’re just looking for a ballpark number for our flexible savings account, we said. The charge for an uneventful labor, vaginal delivery and single overnight stay. We understand that unexpected things can happen in childbirth, and we won’t hold you to it.

Cost Awareness in Health Care: An Idea Whose Time Has Come

Sep 1, 2018

By Christopher Moriates, MD

It didn’t take that long during intern year to realize that something was wrong. As I signed so many orders that my signature, once proudly readable, began its gradual but clear progression towards more abstraction, I eventually started to wonder just how much all of these tests were actually costing my patients. After all, once you start checking boxes on an order sheet, the “calcium/phos/mag” just seems to roll off of the tongue. However, not just how much was this “costing” patients financially, but also in potential risks, harms and adverse effects.

I particularly remember being bothered when told by an Emergency Room attending physician that I had to get the Head CT on my 28-year-old male patient presenting with a benign-sounding headache and a normal physical examination, “unless you could go in there and tell him that you personally can guarantee him with 100% certainty that he does not have something bad like a brain tumor.” This did not seem like a fair bar to hop, particularly having put the M.D. after my name a mere few months prior. So I scribbled my name on another form and with the whisk of my pen subjected this patient to a normal CT head examination, saddling this young man with a significant amount of radiation and a hospital bill that now included an approximately $2,500 imaging charge. Nobody seemed to flinch, but it got me thinking.

Spring Training for Health Care Teams

Sep 1, 2018

By Thomas H. Lee, MD

Two years ago, I wrote a piece in HBR called “Turning Doctors into Leaders,” which began with the sentence “The problem with health care is people like me” — that is, physicians who had been trained in an era when excellence in medicine was defined by what you did as an individual. In the short period since, the concept that medicine is actually a team sport has become increasingly accepted. Because of medical progress, there is too much to know, too much to do, and too many people involved to give patients excellent care, unless we get better at working in teams. A lot better.

Sounds good — but it’s a lot easier to write or talk about than to do. In fact, organization and collaboration are unnatural acts in much of medicine, where payment is still fee-for-service and the culture of individualism still dominates. Progress is being made — more in some regions and at some delivery systems than others. In this post, I will assess that progress by giving grades in various key functional areas akin to those that sportswriters are currently giving baseball teams as they get ready to break spring training. Like those sportswriters, I will try to blend optimism and realism.

Ability to put a team on the field — C. The payment system actually is changing, and ambitious pilots like Medicare’s Accountable Care Organization contracts are underway. In these new contracts, providers share heavily in savings and losses. And, as a provider, I can tell you that we really hate to lose (i.e., bear financial losses for care we have given).

E-Prescribing: Experiences from Physician Practices and Pharmacies

Sep 1, 2018

By Teresa Zayas-Cabán

The May 2012 edition of the Journal of the American Medical Informatics Association (JAMIA) offers the opportunity for a second look at an important recent study on e-prescribing. The study, “Transmitting and processing electronic prescriptions: experiences of physician practices and pharmacies,” examines practitioners’ experiences with this potentially game-changing technology.

The study, first available on the AMIA web site in November 2011, is now one of 12 articles included in the JAMIA issue on the “Focus on health information technology, electronic health records and their financial impact.” (It is available at no cost at http://jamia.bmj.com/content/current.) In the article, Joy M. Grossman, PhD, and colleagues from the Center for Studying Health System Change (HSC) conducted a qualitative analysis of 114 telephone interviews with representatives from 97 organizations including 24 physician practices, 48 community pharmacies, and three mail-order pharmacies actively transmitting or receiving e-prescriptions. This study is part of a larger qualitative project on e-prescribing. An earlier publication, released in May 2011, explored physician practice use of e-prescribing to access external information on patient medication histories, formularies and generic alternatives. It can be found at http://www.hschange.org/CONTENT/1202/.

How Much Are We Paying For a Choice of Insurers?

Aug 1, 2018

By Patricia Salber, MD

A number of years ago, a family doc friend of mine took me on a tour of his small group practice. He proudly showed me the exam rooms, his medical equipment, and other parts of the facility that related to patient care. Then we came to a large room with a bunch of desks piled high with paper. He explained, bitterly, that this part of his office was for the people he had to keep on the payroll to do nothing but deal with insurers. This administrative expense was cutting his margins to the bone and did not help him take better care of his patients. He eventually left practice, to pursue a second career as a physician executive – a job that was, for him, more remunerative and more satisfying.

Part of the problem is that physicians in the US have to deal with multiple health plans – each with its own set of managed care rules, formularies (or list of approved drugs), requirements for prior authorization, rules for billing, submission of claims, and adjudication. Until recently, almost all of this administrative work was done by phone or fax. Picture this: rooms full of practice-based nurses talking to insurance company nurses about the details of a case that may or may not lead to payment for medical care.

Physician, Feed Thyself …

Aug 1, 2018

By Margaret Polaneczky, MD

This post first appeared on The Blog That Ate Manhattan.

All this medical food blogging has gotten me to thinking about the similarities between chefs and doctors.

What is the same

1. They’ve got the whites and the chef’s hat, we’ve got the greens and the caps and masks.

2. Both require intensive training with a clear hierarchy of ascent.

3. The chef and the surgeon are captains of their respective ships – the kitchen and the OR.

4. Skill with sharp instruments is necessary for both professions.

5. We both work long hours, including nights and weekends.

6. If we both do our jobs right, our clients walk out feeling better than when they walk in.

7. We have JCAHO, they have Frank Bruni.

8. A knowledge of organic and biochemistry is essential in both cooking and medicine.

Decentralization and home health kits: Thoughts from Health 2.0

Aug 1, 2018

By Joe Flower

Take a look at this video from the Worrell design firm, who took part in the recent Health 2.0 confab in San Francisco. They took some insights from following ER folks around and charting their workflow into designing a better way for people to interact with the health system from their homes. At about the 4-minute mark, they start discussing what kind of home health kit/device would work, and then there is a demo of a mother consulting about her child’s flu, and getting actual testing, care, and monitoring from a live nurse remotely, all from this kit. According to the member of the design team whom I spoke with, the kit shown is a real prototype, and all the technology used is currently available.

What this says to me in the frame of my discussion of change in healthcare: If the technology is all there, why don’t we do this already? Because in a fee-for-service system there is no billing code for remote care. But: We are going to see many more healthcare organizations move into ACO-like risk contracting relationships with customers. If the healthcare organization is at risk for the costs of the care for the family in the demo, treating them in the home through such a device (one device per family) could be far cheaper, faster, and more effective than getting them to come into an urgent care clinic — cheap enough that the healthcare organization would simply buy the devices and give them to the covered families.

So as major provider organizations move into risk-contracted relationships, actual medical care that would now be taking place in the built clinical environment would be taking place in the home, supported by a live nurse monitor in a dedicated environment at the clinic. The home becomes an extension of the clinic, not only for the chronically ill and frail elderly whom we now might tend with home care, but for the well family in primary care.