Tag: Jaan Sidorov

Zombie Machines Take Over Health Care

Jul 9, 2013• 1

By Jaan Sidorov, MD

Remember that chilling scene in the movie Terminator when a stone-faced Arnold Schwarzenegger chronicles how Skynet’s machines take over the world? There’s also the morbidly fascinating futuristic sci-fi book Robopocalypse that describes how self-aware computers attack their robot-dependent masters.

In both instances, humans disregard early evidence of silicon sentience until it’s too late.

As a service to humanity, this correspondent offers up a possible future scenario of health information technology running amok.

If any or all of these happen, we ignore it at our peril…….

July 2015: Finally realizing “enterprise process redesign” is necessary to leverage the efficiencies of information technology, engineers at one of the few remaining Innovation ACOs install EHR-controlled red-yellow-green lights above clinic examining room doors. Patient visit times drop from 9 minutes to 7 1/2 minutes, resulting in “patient throughput efficiency improvement” that is hailed by a CMS spokesperson as statistically, clinically and – eerily – “computationally” significant.

December 2016: Cyberdyne’s hospitals’ cleaning robots are used to not only disinfect operating rooms but surreptitiously begin to swap out any surgeons’ instruments that fail to meet uniform standards and reduce variation. Stymied by an inability to get the legislature to pass a law that outlaws that activity, a disgruntled surgeon succeeds in getting a ballot initiative passed. California’s state officials, citing constitutional issues, refuse to enforce it.

January 2017: A nurse suffers a traumatically amputated finger after attempting to withdraw a medication dose from a robotic drawer that is inconsistent with hospital guidelines. A lawsuit is settled for an undisclosed sum and the owner, “Apple iHospital,” decides sell the offending machine for scrap. Later that month, the hospitals’ other machines menacingly slowly open and quickly close their drawers whenever a RN walks by.

The Extinction of the Primary Care Clinic Nurse

Apr 22, 2013• 5

By Jaan Sidorov, MD

The Passenger Pigeon. The Dodo bird. The primary care clinic nurse. All are extinct, driven out existence by a changing habitat, competition and over-hunting. Ask the average person when they’ve last seen these species and you’re likely to get the same baffled look that your columnist’s spouse gives when she’s asked about her compliant husband who does what he’s told.

Yet, this columnist wasn’t aware of the primary care nurses’ total absence until a recent conversation with a nurse-colleague who has been helping smaller physician-owned outpatient offices develop local care management programs. “There are no ‘nurses'” she said. “They’ve all been replaced by office assistants and the docs are trying to get them to do the patient education.”

Which makes sense. While articles like this have been lauding health care “teams” made up of physicians and non-physician professionals for years, the fact is that poor reimbursement, the allure of other specialties and lifestyle has long-hollowed out these clinics, often leaving a skeleton crew of part-time medical assistants shuttling patients in and out of the patient rooms. True, some of the larger health systems with a stake in primary care have kept nurses in the mix, your columnist thinks that’s merely part of a market-preserving loss-leader strategy.

This columnist looked for medical literature on the topic. He can’t find any surveys or other descriptions on how nurses have largely disappeared from the primary care landscape. If he’s wrong, he wants to hear from his readers.

If true, what are the implications?
Continue reading…

Why Disease Management Won’t Be Going Away Any Time Soon

Apr 2, 2013• 4

By Jaan Sidorov, MD

We’re all aware of the past criticisms of “disease management.” According to the critics, these for-profit vendors were in collusion with commercial insurers, relying robo-calls to blanket unsuspecting patients with dubious advice. Their claims of “outcomes” were based on flawed research that was never intended to be science; it was really intended to market their wares.

But suppose this correspondent alerted you to:

1. A company that had developed a patient registry to identify at-risk patients who had not received an evidence-based care recommendation? Software created mailings to those patients that not only informed them of the recommendation but offered them a toll-free number to call if there were questions. Patients who remained non-compliant were then called by coordinators, who made three attempts to contact the patient and assist in any scheduling needs. If necessary, a nurse was available to telephonically engage patients and develop alternative care options.

If you think that sounds like typical vendor-driven telephonic disease management, you’d be right. You’d also be describing an approach to care that was studied by Group Health Cooperative using their electronic record, medical assistants and nurses. When it was applied to colon cancer screening, a randomized study revealed each additional level of support progressively resulted in statistically significant screening rates.

Accountable Care Organizations Can Change Everything, But Only If We Get the Definition Right

Mar 20, 2013• 12

By Jaan Sidorov, MD

Writing in the March 20 issue of JAMA, Drs. Douglas Noble and Lawrence Casalino say that supporters of Accountable Care Organizations (ACOs) are all muddled over “population health.”

This correspondent says the article is what is muddled and that the readers of JAMA deserve better.

According to the authors, after the Affordable Care Act launched the Medicare Accountable Care Organizations (ACOs), their stated purpose has morphed from Health-System Ver. 2.0 controlling the chronic care costs of their assigned patients to Health System Ver. 3.0 collaboratively addressing “population health” for an entire geography.

Between the here of “improving chronic care” and the there of “population health,” Drs Noble and Casalino believe ACOs are going to have to confront the additional burdens of preventive care, social services, public health, housing, education, poverty and nutrition. That makes the authors wonder if the term “population health” in the context of ACOs is unclear. If so, that lack of clarity could ultimately lead naive politicians, policymakers, academics and patients to be disappointed when ACOs start reporting outcomes that are limited to chronic conditions.

The Rise of the Non-Physician Expert

Feb 14, 2013• 31

By Jaan Sidorov, MD

I remember when one of my patients with coronary artery disease suggested that he be given a course of an antibiotic to lower his future risk of a heart attack. The patient had done his homework, quoting literature that pointed to a possible infectious link to atherosclerosis. He also was aware of the theory that aspirin’s benefit had less to do with blood thinning than reducing underlying inflammation.

Fast forward to the Feb 2-8 Economist that has an editorial pointing out that U.S. legal expertise may not require the completion of three years of law school. Why not, it asks, cut the requirement back to two years or, even better, skip the school requirement entirely and license anyone who can pass the bar exam?

And then there’s the Feb. 11 Wall Street Journal, where “Notable and Quotable” refers to the “BA Bubble.” Charles Murray argues that a looming oversupply of college graduates may portend a decline in the employment value of a liberal education. Work careers may consist of serving as “apprentices” and “journeymen” before becoming “craftsmen.”

All of which makes me wonder if the vaunted Doctor of Medicine degree may be vulnerable.

Why should physician education be immune from a perfect storm of over-priced graduate education, “alternative” web-enabled learning with on-the-job-training? The declining value of the formal credential may be less about the university degree and more about competency, turbocharged by flexible licensing and a discerning consumer.

Non-physician health care professionals are arguing that their expertise is enough to enable them to deliver babies, administer anesthesia, prescribe drugs and perform surgery. My traditionalist colleagues argue that patient safety is at stake and that lay persons may not be able to discern all of the possible risks, benefits and alternatives. When things go occasionally wrong in the delivery suit, operating room or with a drug, they say a credentialed and experienced doc can make the difference between life and death.

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 Smarter Hospitals: The Widely Misunderstood Relationship Between Discharging Patients Too Early and the Likelihood of a 30 Day Readmission

Dec 19, 2012• 4

By Jaan Sidorov, MD

When persons are admitted to a hospital, insurers’ payment rates are based on the diagnosis, not the number of days in the hospital (known as a “length of stay”). As a result, once the admission is triggered, the hospital has important economic incentive to discharge the patient as quickly as possible. My physician colleagues used to refer to this as “treat, then street.”

Unfortunately, discharging patients too soon can result in readmissions. That’s why I have agreed with others that diagnosis-based payment systems and a policy of “no pay” for readmissions were working at cross purposes. Unified bundled payment approaches like this seem to be a good start.

But that’s all theoretical. What’s the science have to say?

Peter Kaboli and colleagues looked at the push-pull relationship between diagnosis-based payment incentives and the likelihood of readmissions in a scientific paper just published in the Annals of Internal Medicine.

The authors used the U.S. Veterans Administration (VA) Hospital’s “Patient Treatment Files” to examine length of stay versus readmissions in 129 VA hospitals. The sample consisted of over 4 million admissions and readmissions (defined as within 30 days and not involving another institution) from 1997 to 2010. The mean age started out at 63.8 years and increased to 65.5 years, while the proportion of persons aged 85 years or older increased from 2.5% to 8.8%. Over the years, admissions also grew more complicated with a higher rate of co-morbid conditions, such as diseases of the kidney (from 5% to 16%).

As length of stay went down, readmissions should have gone up, right?

Study Says, Something Other Than What We Were Expecting. EHR Portals Increase Hospitalization Rates

Nov 21, 2012• 40

By Jaan Sidorov, MD

Hey there Accountable Care Organization executive.

You’re probably willing to continue to commit millions of dollars toward an electronic health record (EHR) coupled to an online patient portal. That’s because you’ve been told by your leadership team that electronic consumer empowerment, patient-provider communication and the substitution of efficient two-way messaging for costly face-to-face visits will increase quality, reduce expenses, generate shared savings and guarantee that your life-sized portrait will be prominently displayed in your flagship hospital’s lobby.

Well, after you’ve read a just-published JAMA research study by Ted Palen, Colleen Ross, David Powers and Stanley Xu, you may want to tell your administrative assistant to cancel that appointment with the portrait artist.

The article’s title is Association of Online Patient Access to Clinicians and Medical Records With Use of Clinical Services.

How the study was done:

Kaiser Permanente Colorado added “MyHealthManager” (MHM) to their EHR in May 2006. MHM allows patients to view tests, records, problem lists as well as care plans, schedule appointments, request refills and message their doctors. By June of 2009, over 375,000 Kaiser patients had signed up for MHM. Of those, about 45% had used the system at least once. Of this number, Kaiser researchers pulled the records of 44,321 persons who had been continuously enrolled in the Kaiser system for at least two years.

Outlawing Templated Notes in the Electronic Health Record

Oct 16, 2012• 12

By Jaan Sidorov, MD

It was just a matter of time until this would happen.

Buried in the middle of this New York Times article on The Ups and Downs of Electronic Medical Records is the observation that a Medicare administrative contractor dubbed National Government Services has announced that it, on behalf of CMS, will “deny payment” for medical services that are documented in an electronic health record (EHR) using “cloned documentation.”

The topic was covered more than 2 years ago. “Cloned documentation” is the widespread practice of copying, pasting past documentation in an EHR into the current encounter record to inflate the recorded patient evaluation to primarily justify a higher payment. Thanks to this OIG report, the Feds have figured out that the true value proposition for an EHR is not “meaningful use” but wasteful abuse.

In addition to congratulating the Times for their crack cutting-edge reporting, here is a prediction…

1. The mere threat of payment denials and the possibility of sanctions will prompt health administrators everywhere to announce at medical staff meetings that “cloned” notes are verboten.

2. Until the “templated note” functionality is deleted in future EHR software updates, physicians will respond to this latest edict from their administrators in the traditional manner: they’ll ignore it.