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Tag: Leslie Kernisan

Doctors: We Can’t Leave It to Business to Educate Us

Recently I came across yet another media article with suggestions as to how digital health products can gain more widespread adoption. The writer notes that “we can learn a lot from the pharma and healthcare industries,” and goes on to discuss the importance of engaging the doctor.

This article, like many I read, doesn’t acknowledge the downsides of using pharma’s tactics.

I have to assume that this is because from a business perspective, there aren’t a lot of downsides to pharma’s tactics. Pharma, along with many other healthcare industry players (hospitals, insurance companies, device manufacturers) has overall been extremely successful from a business standpoint.

So if the intent is to help digital health companies succeed as businesses, then by all means one should encourage them to copy pharma’s tactics.

But as we know, what works for business has often not worked well for serving the needs of individual patients, or to society from a health services and public health perspective.

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The Tablet Transition

I purchased my first tablet a few weeks ago, and have since been thinking more about tablets for seniors and caregivers. Like many, I’ve assumed that tablet-based tools will eventually make certain aspects of healthcare easier for clinicians, for older adults, and for their caregivers. But so far I’ve found the tablet harder to use than I’d expected.

Actually, technically this is my third tablet purchase. The first was an iPad last summer, which I promptly sent back after realizing that my laptop was much better suited to supporting me in my clinical work (read my full minority report here).

The second was a Nexus 7 which I purchased as a holiday gift for my 62 year old step-father, a structural engineer. (As he’s mildly uncomfortable figuring out new-fangled technology, I set up his device and helped get him started using it.)

Now, I finally have a tablet that I’ll be keeping for myself: a Samsung Galaxy Note 10.1.

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App Prescribing: The Future of Patient-Centered Care

Dr. Leslie Kernisan recently wrote a great piece about app prescribing, asking, “Should I be prescribing apps, and if so, which ones?” Since Happtique is all about integrating apps into clinical practice, I jumped at the chance to add to this important discussion.

Dr. Kernisan is right to be concerned and somewhat skeptical about app prescribing. More than 40,000 health apps exist across multiple platforms. And unlike other aspects of the heavily-regulated healthcare marketplace, there is little to no barrier to entry into the health app market—so basically anyone with an idea and some programming skills can build a mobile health app. The easy entry into the app market offers incredible opportunity for healthcare innovation; however, the open market comes with certain serious concerns, namely, “how credible are the apps I am (or my patients are) using?”

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How Should Apps Be Prescribed?

Should I be prescribing apps, and if so, which ones?

I recently came across this video of Happtique’s CEO Ben Chodor describing his company to Health 2.0’s Matthew Holt. In it, the CEO explains that Happtique is creating a safe and organized space, to make it easy for doctors to prescribe apps and otherwise “engage with patients.”

Because, he says “we believe that the day is going to come that doctors, and care managers, are going to prescribe apps. It’s going to be part of going to the doctor. He’s going to prescribe you Lipitor, and he’s going to give you a cholesterol adherence app.”

He goes on to say that they have a special process to make sure apps are “safe” and says this could be like the good housekeeping seal of approval for apps.

Hmm. I have to admit that I really can’t imagine myself ever prescribing a “cholesterol adherence” app. (More on why below; also found myself wondering what it exactly meant for Happtique to say an app was safe. What would an unsafe cholesterol app look like?)

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What Will Tomorrow’s Doctor Look Like?

“What does the 21st Century Physician look like?”

Lisa Fields (@PracticalWisdom) cc’ed me on a tweet about this; it’s the featured question at www.tomorrowsdoctor.org, an organization founded by three young professionals who spoke at TEDMED last year.

I’ll admit that the question on the face of it struck me as a bit absurd, especially when juxtaposed with the term “tomorrow’s doctor.”

Tomorrow’s doctor needs to be doing a much better job of dealing with today’s medical challenges, because they will all be still here tomorrow. (Duh!) And the day after tomorrow.

(As for the 21st century in general, given the speed at which things are changing around us, seems hard to predict what we’ll be doing by 2050. I think it’s likely that we’ll still end up needing to take care of elderly people with physical and cognitive limitations but I sincerely hope medication management won’t still be a big problem. That I do expect technology to solve.)

After looking at the related Huffington Post piece, however, I realized that this trio really seems to be thinking about how medical education should be changed and improved. In which case, I kind of think they should change their organization’s name to “Next Decade’s Doctor,” but I can see how that perhaps might not sound catchy enough.

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Zen and the Art of Charting

One of the many challenges I face in my clinical work is keeping track of a patient’s multiple health issues, and staying on top of the plan for each issue.

As you might imagine, if I’m having trouble with this, then the patients and families probably are as well.

After all, I don’t just mean keeping up with the multiple recommendations that we clinicians easily generate during an encounter with an older patient.

I mean ensuring that we all keep up with *everything* on the medical problem list, so that symptoms are adequately managed, chronic diseases get followed up on correctly, appropriate preventive care is provided, and we close the loop on previous concerns raised.

This, I have found, is not so easy to do. In fact, I would say that the current norm is for health issues to frequently fall between the cracks, with only a small minority of PCPs able to consistently keep up with all health issues affecting a medically complex adult.

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The Four Things You Should Absolutely, Positively Do For Somebody at Risk of Developing Alzheimer’s

Do they need a PET scan to confirm the presence or absence of amyloid plaque?

More importantly, would doing such PET scans make meaningful impacts on patients’ health?

Those are the questions that a Medicare expert panel recently considered, and their impression, after carefully reviewing lots of high-quality research, is that we don’t yet have evidence supporting the benefit of using the PET scans. Unsurprisingly, some experts disagree, including a working group convened by the Alzheimer’s Association. This group of experts reviewed the evidence and common clinical scenarios, and concluded that in certain select situations, use of the PET scan would be appropriate. (See their guidelines here.)

As someone who evaluates many memory complaints, I’m certainly interested in Medicare’s inquiry, and in whether they’ll decide to cover the scan. (The NYT’s New Old Age Blog has a nice summary of the debate; a good read if you haven’t seen it yet, esp the comments.)

Also, I blogged last fall about how I thought the new scan could and wouldn’t help clinicians like myself evaluating cognitive complaints, especially in those who likely have early dementia. In particular, I commented on the difficult period of uncertainty that we often go through, as we wait to see if subtle problems progress or not.

Would the PET scan meaningfully help with that period of uncertainty? Hard to say, and it hasn’t yet been tested. I myself think that this period of uncertainty can be pretty hard on families, but measuring this burden is tricky. (Much easier to measure hospitalizations and utilization!)

I also suspect that it’ll be hard to prove benefit from “knowing earlier,” in large part because our healthcare system is currently so poorly equipped to meaningfully help people with a new dementia diagnosis.

Which brings me to the part of this story that has me annoyed.

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One Woman Brand: How one Doctor Started Over Again With a New Practice, a New Specialty and a Great New Outlook on Life

A little over a year ago, I found myself burning out and realized that my worklife was unsustainable.

I’d been working at an FQHC clinic, and had become the site’s medical director a few months before. I was practicing as a primary care doc, trying to improve our clinical workflows, problem-solving around the new e-prescribing system, helping plan the agency’s transition from paper charts to electronic charts, and working on our housecalls and geriatrics programs.

All of this was supposed to be a 50% position — plus 5% paid time for follow-up — because I had two young children that I wanted to have some time for, and was also working one day/week for a caregiving website (Caring.com).

Needless to say, this job was taking far more than 55% of my time, and seemed to be consuming 110% of my psyche. I very much liked my boss and colleagues, was learning a lot, and felt I was improving care for older adults.

But I was also irritable, stressed out, and had developed chronic insomnia. And clinic sessions were leaving me drained and feeling miserable: try as I might, I couldn’t find a way to provide care to my (and my patients’) satisfaction with the time and resources I had available.

One evening my 3 year old daughter looked at me and asked “Why are you always getting mad and saying no?”

Good question, kiddo.

A few weeks later, I told my boss that I’d be resigning my position in 5 months. And I started trying to reimagine how I might practice geriatrics.

My current clinical practice, which I launched last October, is the result of that reimagining.

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Six Awkward Concerns in My OpenNotes

I found out this past weekend that the VA will be making clinician progress notes available for patients to view on the MyHealtheVet portal. In other words, the VA is going OpenNotes. (Note: I was a primary care provider in geriatrics clinic at the San Francisco VA from 2006-2010.)

My first reaction was to be impressed by this bold progressive move.

My next reaction was to feel mildly relieved that I’m no longer a PCP there.

Now, it’s not because I’m against transparency in healthcare, or am suspicious of patient engagement, or feel that patients shouldn’t see their health information without the assistance/gatekeeping/interference of a clinician. Far from it.

It’s because in my own VA practice caring for WWII vets, I used to frequently document certain concerns that would’ve been a bit, shall we say, awkward for the patient to see. Reading about these concerns would’ve quite possibly infuriated the patient, or the caregivers, or both.

So whew, I find myself relieved that I don’t have to figure out how to document (or not document?) these concerns.

Instead, I’ll get to see how my friends at the VA handle these issues.

Wondering what they are? Ok, I will tell you but shh … don’t tell my elderly patients that I may be considering these topics as I care for them.

Six awkward concerns in geriatric primary care practice

· Possible dementia. As a geriatrician, I focus on an age group that has a high incidence of dementia. Which means that when someone starts to tell me odd stories (concerns related to poison are a popular theme, as well as reports that someone is stealing things repeatedly), I start wondering about possible dementia. Ditto if he or she starts floundering with the medications, or starts having other difficulties with IADLs.

Why it’s awkward: Patients and families really hate it when I bring up the possibility that there might be dementia. Many find the possibility of a disease such as Alzheimer’s truly terrifying, both because it’s perceived as a terrible disease, and because they worry about having to leave their homes or otherwise losing their independence. Note that if I’m considering the possibility of dementia, I usually let the patient know during the visit.

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