Category: Uncategorized

How the Advent of Propofol Changed the Meaning of the term “Sedation”

Feb 4, 2015• 1

By KAREN SIBERT, MD

“Twilight! She has to have twilight,” insisted the adult daughter of my frail, 85-year-old patient. “She can’t have general anesthesia. She hasn’t been cleared for general anesthesia!”

We were in the preoperative area of my hospital, where my patient – brightly alert, with a colorful headband and bright red lipstick – was about to undergo surgery. Her skin had broken down on both legs due to poor circulation in her veins, and she needed skin grafts to cover the open wounds. She had a long list of cardiac and other health problems.

This would be a painful procedure, and there would be no way to numb the areas well enough to do the surgery under local anesthesia alone. My job was to figure out the best combination of anesthesia medications to get her safely through her surgery. Her daughter was convinced that a little sedation would be enough. I wasn’t so sure.

“Were you asleep the last time your doctor worked on your legs?” I asked the patient. “Oh, yes,” she said. “Completely asleep.”

“But she didn’t have general,” the daughter interrupted. “She just had twilight.”

Health IT: Glass Half Empty? Half Full? Shattered?

Feb 4, 2015• 5

By JACK COCHRAN, MD and CHARLES KENNEY

Technology occupies an unusual place in health care. Some people say that electronic health records are clumsy barriers between patients and their doctors. Others suggest that technology is a kind of secret sauce.

In many places physicians and other clinicians are stymied by awkward technology. In other organizations — Kaiser Permanente included — electronic health records enable some of the finest individual and population health care ever.

This humorous equation speaks volumes about technology and health care:

NT + OO = COO

New technology + old organization = Costly old organization. In other words, technology doesn’t change an organization. Change is about leadership and culture. It is about thinking in new ways and asking new questions.

For example, rather than ask how many patients can you see, let’s ask how many patients’ problems can you solve?

Instead of asking how can we convince patients to get required prevention, let’s ask how can we create systems that significantly increase the likelihood that patients get required prevention?

Instead of asking how often should a physician see a patient to optimally monitor a condition, let’s ask what is the best way to optimally monitor a condition?

When we begin asking these kinds of questions, we see technology as a tool — not a solution by itself, but as a powerful tool we can use to deliver better individual and population care. Technology, like data, is only useful when it enables clinicians and teams to work effectively to provide the highest quality care for patients.

Hospitals and physician groups throughout the country are installing and working with electronic health records at a rapid pace. Some organizations integrate the systems beautifully, others do not.

Privacy and Security and the Internet of Things

Feb 3, 2015• 7

By DAVID HARLOW

In the future, everything will be connected.

That future is almost here.

Over a year ago, the Federal Trade Commission held an Internet of Thingsworkshop and it has finally issued a report summarizing comments and recommendations that came out of that conclave.

As in the case of the HITECH Act’s attempt to increase public confidence in electronic health records by ramping up privacy and security protections for health data, the IoT report — and an accompanying publication with recommendations to industry regarding taking a risk-based approach to development, adhering to industry best practices (encryption, authentication, etc.) — seeks to increase the public’s confidence, but is doing it the FTC way: no actual rules, just guidance that can be used later by the FTC in enforcement cases. The FTC can take action against an entity that engages in unfair or deceptive business practices, but such practices are defined by case law (administrative and judicial), not regulations, thus creating the U.S. Supreme Court and pornography conundrum — I can’t define it, but I know it when I see it (see Justice Stewart’s timeless concurring opinion in Jacobellis v. Ohio).

To anyone actively involved in data privacy and security, the recommendations seem frighteningly basic:

–build security into devices at the outset, rather than as an afterthought in the design process;

– train employees about the importance of security, and ensure that security is managed at an appropriate level in the organization;

– ensure that when outside service providers are hired, that those providers are capable of maintaining reasonable security, and provide reasonable oversight of the providers;

– when a security risk is identified, consider a “defense-in-depth” strategy whereby multiple layers of security may be used to defend against a particular risk;

–consider measures to keep unauthorized users from accessing a consumer’s device, data, or personal information stored on the network;

–monitor connected devices throughout their expected life cycle, and where feasible, provide security patches to cover known risks.

–consider data minimization – that is, limiting the collection of consumer data, and retaining that information only for a set period of time, and not indefinitely;

– notify consumers and give them choices about how their information will be used, particularly when the data collection is beyond consumers’ reasonable expectations.

HIT Newser: A Meaningful Sigh of Relief

Feb 3, 2015• 4

By MICHELLE RONAN NOTEBOOM

ONC Issues Draft HIT Interoperability Road Map

The ONC releases a draft of its 10-year nationwide interoperability road map, which includes a focus on helping the majority of providers across the care continuum and consumers achieve basic interoperability of health data over the next three years. The ONC also released a draft of its Interoperability Standards Advisory, which includes an assessment of the best available standards and implementation specifications for clinical health information interoperability.

Public comment for the draft Roadmap closes April 3, 2015; comment period for the Standards Advisory closes May 1, 2015.

Meaningful Use Reporting Relief

CMS proposes rule changes for the EHR incentive program, including a reduction in the 2015 reporting period from one year to 90 days. An additional change would re-align the reporting period to match the calendar year, giving hospitals more time to incorporate 2014 Edition software into their workflows and better align with other CMS quality objectives. CMS will consider additional program modifications to reduce complexity and lessen providers’ reporting burdens.

CMS noted that the proposed rule changes are separate from the upcoming Stage 3 proposed rule that should be be released in March that is expected to limit the scope of the Stage 3 requirements for MU in 2017 and beyond.

Providers, vendors, and professional organizations are breathing a collective sigh of relief over the CMS announcement. The proposed changes aren’t too surprising, given low Stage 2 attestation numbers and overwhelming provider dissatisfaction with the MU program.

New Valued-based Payment Goals to Drive HIT Adoption

HHS sets a goal for 30 percent of Medicare payments to be link to value-based performance through alternative payment models, such as ACOs, by 2016 and 50 percent by 2018. In addition, HS wants 85 percent of traditional Medicare payments tied to quality by 2016 and 90 percent 2018.

Achieving those objectives will require technology that supports quality-based payments versus the traditional fee-for-service model, so both vendors and providers will need to make aggressive moves to deploy the appropriate tracking and reporting tools. No doubt this will be one of the hotter topics at the HIMSS conference in April.

CPOE For Management

Feb 2, 2015• 9

By PETER ELIAS, MD

At a recent clinical staff meeting, a physician complained that the new requirement that clinicians enter all orders manually into the electronic record (CPOE) is slowing us down and causing errors. The IT and administrative staff were not the least sympathetic. Their message: it’s really not a big deal, it only takes an extra minute or two, and smart people like you should be able to master a simple skill like this. On the way home, I came up with a way to help them better understand: CPOE for management.

I would like to see them forced to use their own version of CPOE: Computer Process for Organizing Errands. Here’s how it would work.Every errand they do requires a computerized planning and documentation process. Whether they were going grocery shopping, out to fill up the tank on their car, buying shoes for their child, or a present for their spouse, here is what they would have to do:

Go to their computer and start the Errand Management Resource (EMR).
Go to the Schedule Errands tab and open it.
Enter each errand (picked from a list of 20,000 possible errands) and link it to a household or family category. Examples might include:
Continue reading…

KLAS Announces 2014 Best in KLAS Winners

Feb 2, 2015• 1

By MICHELLE RONAN NOTEBOOM

Epic regains its top spot in the 2014 Best in KLAS awards, winning in the Overall Physician Practice Vendor and Overall Software Suite categories. Impact Advisors was named the Overall IT Services Firm.

Last year athenahealth beat out Epic by a narrow margin. This year athena still had an excellent showing, taking the top spots for Practice Management in both the 1-10 physician and 11-75 physician categories, as well as second place (after Epic) in the over 75 physician category.

Epic won Best in KLAS or category leader honors for Acute Care EMR, Ambulatory EMR (11-75 physicians and over 75 physicians), HIE, Lab, Patient Account and Patient Management, Patient Portals, Pharmacy, Radiology, and Surgery Management.

The Therapeutic Paradox: What’s Right for the Population May Not Be Right for the Patient

Feb 2, 2015• 17

By SCOTT ABEREGG, MD

An article in this week’s New York Times called Will This Treatment Help Me? There’s a Statistic for that highlights the disconnect between the risks (and risk reductions) that epidemiologists, researchers, guideline writers, the pharmaceutical industry, and policy wonks think are significant and the risks (and risk reductions) patients intuitively think are significant enough to warrant treatment.

The authors, bloggers at The Incidental Economist, begin the article with a sobering look at the number needed to treat (NNT). For the primary prevention of myocardial infarction (MI), if 2000 people with a 10% or higher risk of MI in the next 10 years take aspirin for 2 years, one MI will be prevented. 1999 people will have gotten no benefit from aspirin, and four will have an MI in spite of taking aspirin. Aspirin, a very good drug on all accounts, is far from a panacea, and this from a man (me) who takes it in spite of falling far below the risk threshold at which it is recommended.

One problem with NNT is that for patients it is a gratuitous numerical transformation of a simple number that anybody could understand (the absolute risk reduction – “your risk of stroke is reduced 3% by taking coumadin“), into a more abstract one (the NNT – “if we treat 33 people with coumadin, we prevent one stroke among them”) that requires retransformation into examples that people can understand, as shown in pictograms in the NYT article. A person trying to understand stroke prevention with coumadin could care less about the other 32 people his doctor is treating with coumadin, he is interested in himself. And his risk is reduced 3%. So why do we even use the NNT, why not just use ARR?

Tele Taking Off

Jan 31, 2015• 12

By CECI CONNOLLY

In Washington, sometimes the most significant developments quietly creep up on you. No epic debate or triumphant bill-signing ceremony, but rather a collection of seemingly small events begin to tip the scales.

That’s what is happening today with telehealth. Almost under the radar, federal and state officials have been giving a much-needed push in support of virtual care. Though the technology has long existed, until recently the money had not followed. And sadly in our current fee-for-service healthcare system, little gets done without a payment code, even if it makes eminent medical and economic sense.

Consider some of the recent action. In November, the Department of Agriculture released more than $8.5 million in health-related grants to 31 recipients in rural communities. Many are using the money to purchase telehealth equipment such as high-quality cameras and broadband Internet.

The previous month the federal government issued rules expanding Medicare payment for a range of telehealth services. Caregivers can earn about $42 per month for chronic care management under the new regulations. Seven new procedure codes were also added, covering such services as annual wellness visits and psychotherapy.

And the end-of-year spending bill approved by Congress designates more than $26 million for telemedicine programs largely in rural communities and through the Veteran’s Administration.Continue reading…

You Owe Me a BMW

Jan 29, 2015• 7

By ROBERT McNUTT, MD

During a move necessitated 20+ years ago by my change from a “private practice of medicine” life to a “back to school” life, I decided to undertake the move on my own using a rented van. I also had to affix a small trailer packed with furniture to the van. As I lifted the not so heavy trailer to the hitch, one of my children ran toward the trailer. I stopped my child’s progress with a holler and an out-stretched hand. As I did that, a disc in my back popped and dropped me to the ground. I have had back pain every day since. I have managed my back pain on my own. But, I now think it is time to start using my medical insurance to pay for the care of my back pain. So, fellow insured, you owe me a BMW.

Yes, a BMW. I know that my back pain is a subjective complaint and you can’t prove or disprove that I have it. I also know that there is no measure of my back pain; I can grade it on a scale from 0-10, as some do, but that is such a difficult task that I can’t internally come up with a number. I am sure, though, that the number changes daily. Even if I could assign a number to my pain, there is no guarantee that you would assign the same number should you suffer the exact pain as me, or that you could assign a number to my complaint better than I could. The pain is there, though. I feel it and alter my activities to not exacerbate.

Recently, a friend gave me a ride in his BMW. The seats fit my back to a t and as I sat there, my pain abated. I asked him to turn on the heated seats. Even more remarkable pain relief followed. In fact, after the ride in his car, I had no back pain for over 3 weeks, the first 3-week, pain-free stretch of time in over 20 years. So, since insurance plans often pay for some types of interventions such as heaters, buzzers, or needles, as examples, to help people with their back pain, so, then, shouldn’t insurance pay for a BMW for me? I think so.

Medical Necessity and Unnecessary Care

Jan 29, 2015• 9

By PAUL KECKLEY

Unnecessary care that’s not evidence-based—usually associated with excess testing, surgical procedures or over-prescribing—accounts for up to 30% of what is spent in healthcare. In recent months, enforcement actions against physicians and hospitals have gained increased attention. But unnecessary care and over-utilization is not a new story or one that’s easy to understand.

Background

Medical necessity means something slightly different in every part of the healthcare industry. Varied definitions and interpretations are used by providers, physicians, courts, pharmacy benefits managers, government insurers, private insurers, and consumers. Perhaps the two most important are from the largest and most influential payer, Medicare, and the industry’s most important clinical authority, the American Medical Association (AMA).