Category: Uncategorized

Mislabeling Medical Illness

Feb 12, 2013• 6

By Allen Frances, MD

Many readers of my previous blog listing the 10 worst suggestions in DSM 5 were shocked that I failed to mention an 11th dangerous mistake — that DSM-5 will harm people who are medically ill by mislabeling their medical problems as mental disorder. They are absolutely right. I apologize for my previous failure to attend to this danger and hope it is not now too late to influence the process.

Adding to the woes of the medically ill could be one of the biggest problems caused by DSM-5. It will do this in two ways: 1) by encouraging a quick jump to the erroneous conclusion that someone’s physical symptoms are ‘all in the head’; and 2) by mislabeling as mental disorders what are really just the normal emotional reactions that people understandably have in response to a medical illness.

UK health advocate, Suzy Chapman, has closely monitored every step in the development of DSM-5. Her website is the best available resource for finding just about everything you need to know about DSM-5 and ICD-11. Ms Chapman sent me a troubling email that summarizes where DSM-5 has gone wrong and the many harmful consequences that will follow. More details are available at: ‘Somatic Symptom Disorder could capture millions more under mental health diagnosis’ (http://wp.me/pKrrB-29B )

Ms Chapman writes:

…The DSM-5 Somatic Symptom Disorders Work Group is planning to eliminate several little used DSM-IV Somatoform Disorders and replace them instead with an extremely broad new category that is likely to be wildly overused (‘Somatic Symptom Disorder’ — SSD).

Continue reading…

The “Post EHR” Era

Feb 12, 2013• 6

By John Halamka, MD

Over the next few months, the majority of my time will be spent discussing topics such as care coordination, healthcare information exchange, care management, real time analytics, and population health. At BIDMC, we’ve already achieved 100% EHR adoption and 90% Meaningful Use attestation among our clinician community. Now that the foundation is laid, I believe our next body of work is to craft the technology and workflow solutions which will be hallmarks of the “post EHR” era.

What does this mean?

I’ve written previously about BIDMC’s Accountable Care Organization strategy, which can be summed up as ACO=HIE + analytics.

In a “post EHR” era we need to go beyond simple data capture and reporting, we need care management that ensures patients with specific diseases follow standardized guidelines and protocols, escalating deviations to the care team. That team will include PCPs, specialists, home care, long term care, and family members. The goal of a Care Management Medical Record (CMMR) will be to provide a dashboard that overlays hospital and professional data with a higher level of management.

How could this work?

Imagine that we define each patient’s healthcare status in terms of “properties”. Data elements might include activities of daily living, functional status, current care plans, care preferences, diagnostic test results, and therapies, populated from many sources of data including every EHR containing patient data, hospital discharge data, and consumer generated data from PHRs/home health devices.

That data will be used in conjunction with rules that generate alerts and reminders to care managers and other members of the care team (plus the patient). The result is a Care Management Medical Record system based on a foundation of EHRs that provides much more than any one EHR.

My challenge in 2013-2014 will be to build and buy components that turn multiple EHRs into a CMMR at the community level.

The RUC is a Symptom. RBRVS is the Disease

Feb 12, 2013• 6

By Robert Centor, MD

The RUC is an easy target. The RUC is flawed. But the RUC is not the problem. Several bloggers have written extensively about the RUC – How the RUC Escaped a Challenge to Our Deeply Flawed Reimbursement System and US Senate Subcommittee Asks What the RUC is About.

In no way can I defend the payment schedules that the RUC has proposed to Medicare. I can defend their recent changes. Radiology payments decreased last year; interventional cardiology payments decreased last year; and many other procedures have decreased dramatically. The relative payments are still wrong (in my opinion), but the RUC actually has been responsive to criticism. They have increased primary care payments (admittedly not enough).

But if one studies the problem carefully enough, one must decide that the idea of paying per episode almost must lead to gaming the system. Forget the RUC, the entire idea of time independent episode based payment must lead to worse medical care and higher costs. If physicians can make more money by doing more, then some will.

Practice administrators push primary care physicians to see more patients each day. If we can decrease the time spent per patient from 20 min to 15 min then we could see up to 8 more patients in an 8 hour day. Our overhead has not changed – hence the marginal financial benefits are huge.

But any honest physician will tell you that the result is rushed medical care. Do we want our surgeon trying to do 5 surgeries today rather than 4? Do you want to be the 5th patient? Continue reading…

How to Win Friends and Influence Millennials: Health Exchanges Edition

Feb 11, 2013• 26

By MIKE MIESEN

America is only a few months away from Exchange Day—October 1, 2013—when the state and federal health exchanges open up for business. And when they do… well, I’d surprised if a whole lot happens at first; most people assume they open on January 1, 2014. But eventually there will be a flood of people streaming into the exchanges (virtually) to search for health insurance plans, including the Millennials.

Why? A variety of reasons. One is that people like being insured and prefer it to the uncertainty of being uninsured; those previously unable to purchase a policy they could afford now have subsidies to help them do so. Another is that people largely don’t have a choice—forego purchasing health insurance and get fined.

But the bottom line is this: whether compelled to do so by the safe feeling of being insured or the specter of a fine, Millennials are expected to be an enormous group of entrants into the exchanges: while we make up only 22% of the population, we account for 38% of the uninsured in America.

To compound our already-stratospheric opinion of ourselves, we know that the Millennials are a coveted market for health exchange insurers. Face it: you want us. Bad. That’s because we’re relatively healthy, loyal to brands we like that we see as having a positive impact (70% identify as being brand loyal), and we could actually be the first generation to recommend our health insurance plan to others.

So, culling from Millennial research, surveys, and conversations with fellow Millennials, here are a few morsels of unsolicited advice on how to win us over.

Fundamentals of Electronic Medical Record Design Part I

Feb 11, 2013• 12

By MARGALIT GUR-ARIE

Our ancestors began using tools millions of years ago and humanity assumed control of the planet it lives on through a succession of tools ranging from sticks and stones all the way to iPhones and drones. The basic process for discovering or inventing tools hasn’t changed much over the millennia, and it follows two basic patterns. Either an existing artifact is examined for fitness to various purposes until one such purpose is discovered accidentally or through organized efforts, or a problem is identified and a tool is then invented, or located, to solve the problem.

The problem itself could be something that was thought impossible before, such as flying, or a more mundane desire to reduce the effort and expand the capabilities associated with an existing activity, such as moving goods from one place to another. Tools can have limited effects, revolutionize an entire economic sector or can change history, and some tools can have harmful effects that must be balanced with the benefits they offer for the intended task. Tools usually undergo long processes of change, improvement and expansion, and sometimes the evolving tool looks nothing like the original invention. Why are we talking about tools here? Because programmable computers are tools. The computer hardware is like the hammer head and the programming software is like the hammer’s handle (more or less). And EMRs are one such handle.

Let’s imagine that we are software builders and we have a desire to help doctors deliver patient care. And let’s further assume that we, and our prospective customers, examined all the existing tools out there and found them not quite fit for purpose. Let’s also assume that we are not suffering from delusions of grandeur, have the humility to admit that we don’t know how to cure disease and have no interest in global social engineering initiatives. Let’s imagine that we are the misguided founders of a small social business interested in doing well by helping others do good things.

Engaged Patients Translate to Better Outcomes and Costs

Feb 10, 2013• 10

By JUDITH HIBBARD and JESSICA GREENE

The expansion of health insurance coverage may be the most visible aspect of health reform, but other elements will ultimately have a significant impact on how we all experience health care. One pivotal change is how health care organizations are paid. New payment approaches will reward providers based on whether services actually improve patients’ health and keep costs down versus simply incentivizing them to provide more care.

One of the more consequential changes will be a greater focus on helping patients to be more involved in their care. There is ample evidence that the behaviors people engage in and the health care choices they make have a very clear effect on both health and costs, positively and negatively. The most innovative health care delivery systems recognize this and see their patients as assets who can help them achieve the goals of better health at lower costs. From this point of view, “investing” in patients and helping them to be more effective partners in care makes good sense.

Our study, reported in the February issue of Health Affairs, highlights this role that patients play in determining health-related outcomes. We found that patients who were more knowledgeable, skilled and confident about managing their day-to-day health and health care (also known as “patient activation,” measured by the Patient Activation Measure) had health care costs that were 8 percent lower in the base year and 21 percent lower in the next year compared to patients who lacked this type of confidence and skill. These savings held true even after adjusting for patient differences, such as demographic factors and the severity of illnesses.

Even among patients with the same chronic illness, those who were more “activated” had lower overall health care costs than patients who were less so. Among asthma patients, the least activated patients had costs that were 21 percent higher than the most activated patients. With high blood pressure, the cost differential was 14 percent.

Behavioral Economics and Influenza Immunization

Feb 10, 2013• 1

By JAAN SIDOROV

On occasion, your correspondent fights the northeast’s dreary weekend winter evenings with a dram of spirituous liquor like Macallan 12. Unlocked with a small splash of water and a single ice cube, a generous ounce of that pungent cinnamon leathery elixir turns the cold into cozy.

So naturally, your correspondent relies on spouse to help keep a therapeutic stock available. Both yours truly and spouse run errands and it shouldn’t be too hard for either to be proactive by periodically checking supplies, buying some Macallan when necessary and avoiding the unhappiness of a dispirited and cold author.

Unfortunately, spouse doesn’t always see it that way.

Welcome to the complicated world of behavioral economics. It tells us that it’s difficult for persons to expend effort today to reduce the tomorrow’s risk of an unlikely event. It’s why many persons chose to not take or pay for medications today to reduce the distant likelihood of disability or early death. There’s more on the topic here.

This also explains why persons don’t do a good job getting a flu shot for themselves or their loved ones. Check out this interesting information from athenahealth. According to their pooled electronic health record (EHR) data, 2.5% of children without a flu shot came down with the flu, versus only 0.9% of those who got the shot. While getting a shot reduced the relative risk of coming down with the disease by approximately two thirds, the vast majority of kids who went without immunization (97.5%) did OK. Data from the CDC in adults reflects the same kind of numbers: 80% of persons in the U.S. do not come down with the flu in the course of the year.

How can the population health and care management community leverage behavioral economics to increase immunization rates?

Building a Better Health Care System: Why the Next Blockbuster Drug Probably Won’t Be a Drug at All

Feb 10, 2013• 4

By David Katz, MD

A recent meta-analysis published in the American Journal of Clinical Nutrition suggests that coenzyme Q10 is of benefit in congestive heart failure. For those who like the idea that food and nutrients can be excellent medicine, this paper is interesting at the very least. But there is a case to be made that it is far more than that. There is a case to be made that it is, in a word, miraculous.

For resurrection, after all, is a miracle. And according to a paper published in the Annals of Internal Medicine in April of 2000, coenzyme Q10 for heart failure was a dead concept. The authors reported 13 years ago that “coenzyme Q10 has been studied in randomized, blinded, and controlled studies and … these studies have found no detectable benefit” and that “coenzyme Q10 should not be recommended for treatment of heart failure.”

The final nail had been driven into the CoQ10-for-heart-failure hypothesis 13 years ago — and yet now, it’s back. If that’s not a miracle — then what is going on?

First, a bit of relevant orientation. The condition in question here, congestive heart failure, occurs in particular in the aftermath of one or more heart attacks (myocardial infarctions) which cause portions of the heart muscle to die for want of oxygen. Those areas stop pumping, of course, and the whole heart does its job less well.

The pumping efficiency of the heart is routinely measured using ultrasound as the “left ventricular ejection fraction” (LVEF), which, as the name suggests, is the proportion of blood the left ventricle is able to pump out of itself when it contracts. Roughly 55 to 70 percent is considered normal. High values can occur when the heart is stiff and muscle-bound, and tend to mean the heart empties well, but fills poorly. Congestive heart failure is associated with low values.

Redesigning the Personal Health Record

Feb 9, 2013• 1

By Kel Smith

Health_design_1

In November 2012, the digital team at HealthEd embarked on a challenge to redesign the face of personal health records. That effort has been rewarded with a first-place win in the category of Best Lab Summaries. And another HealthEd entry was cited as a finalist that “inspired the judges and challenged the status quo.”

About the Health Design Challenge

The Office of the National Coordinator of Health Information Technology and the Department of Veterans Affairs issued a challenge to designers throughout the United States: imagine how personal health records could be improved for clarity, readability, and visual appeal. Given HealthEd’s mission to create better outcomes in personal wellness, the team embraced the Health Design Challenge with typical enthusiasm.

The Health Design Challenge was more than an exercise in graphic design, however. Entrants were required to demonstrate expert knowledge of clinical systems and to render information of relevance for both millennials and senior citizens. The judges wanted more than pretty pictures—participants had to know their stuff.Continue reading…