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The ABCs of Beginning a Clinical Encounter

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By HANS DUVEFELT, MD

You’re running late and many things didn’t go right today. You knock on the door and enter the exam room with an apology. If you’re like me, you have a few papers and an iPad or a laptop in your hand. You sit down and open the patient’s chart in your device or perhaps on the big desktop, eyes not exactly locked on the patient.

Only after getting to where you need to be in the computer do you really look the patient in the eyes. Your body language has been one of hurry and distraction. Now you try to repair the damage of that, so you try to show you’re settling down now, at least for a few moments. You might sigh, move your arms in a gesture of relaxation and say something to get the history taking underway.

So far, you’re failing. I do that often, too.

Here’s what we all know we need to do, but often don’t; we should follow these ABCs:

A – Attention:

Clear your mind. It doesn’t matter what happened in the other room with the other patient, or on the phone with the insurance company or the smug specialist or ER doc who pointed out the diagnosis you missed. Open the door (I always knock first) and immediately look at the patient. Make eye contact and observe them. Pay attention to how they look, what they are signaling. The computer can wait; a few moments of focused attention will usually save you time in the end. After all, red or teary eyes, a leg cast, a big bruise or change in grooming can make the visit go in a direction you wouldn’t have expected from he listed chief complaint. How many times have we heard a patient comment about another doctor: He didn’t pay attention to me. Do we always do that ourselves if we’re rushed or preoccupied?

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Brief is Good

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By HANS DUVEFELT, MD

How long does it take to diagnose guttate psoriasis versus pityriasis rosea? Swimmers ear versus a ruptured eardrum? A kidney stone? A urinary tract infection? An ankle sprain?

So why is the typical “cycle time”, the time it takes for a patient to get through a clinic such as mine for these kinds of problems, close to an hour?

Answer: Mandated screening activities that could actually be done in different ways and not even necessarily in person or in real time!

Guess how many emergency room or urgent care center visits could be avoided and handled in the primary care office if we were able to provide only the services patients thought they needed? Well over 50% and probably more like 75%.

Primary Care clinics like mine are penalized if a patient with an ankle sprain comes in late in the year and has a high blood pressure because they are in pain and that becomes the final blood pressure recording for the year. (One more uncontrolled hypertensive patient.)

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The Folly of Self Referral

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By HANS DUVEFELT, MD

A lot of Americans think they should be able to make an appointment with a specialist on their own, and view the referral from a primary care provider as an unnecessary roadblock.

This “system” often doesn’t work, because of the way medical specialties are divided up.

If belly pain is due to gallbladder problems you need a general surgeon. If it’s due to pancreas cancer, you need an oncologic surgeon. If the cause is Crohn’s disease, any gastroenterologist will do, but with Sphincter of Oddi problems, you’ll need a gastroenterologist who does ERCPs, and not all of them do. Now, of course, if you’re a woman, that abdominal pain may actually be referred pain from an ovarian cancer, best treated by a GYN-oncology surgeon, which anywhere in Maine means a drive down to Portland.

The other day I saw an older man for a second opinion. He had been through one hand surgery for a small tumor many years ago in Boston, and another unrelated operation for a fracture in Bangor a few years ago. Then, after a non surgical injury, he developed stabbing pains in the same hand. Someone referred him to a neurologist for EMG testing, which was normal, and the man told me that was all the neurologist did, not a full consultation.

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Trauma-Informed Primary Care

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Samyukta Mullangi

By SAMYUKTA MULLANGI MD, MBA, DANIEL W. BERLAND MD, and SUSAN DORR GOOLD MD, MHSA, MA

Jenny, a woman in her twenties with morbid obesity (not her real name), had already been through multiple visits with specialists, primary care physicians (PCPs), and the emergency department (ED) for unexplained abdominal pain. A plethora of tests could not explain her suffering. Monthly visits with a consistent primary care physician also had little impact on her ED visits or her pain. Some clinicians had broached the diagnosis of functional abdominal pain related to her central adiposity, and recommended weight loss. This suggestion inevitably led her to become defensive and angry.

Though our standard screen for safety at home had been completed long ago, I wanted to probe further, knowing that many patients with obesity, chronic pain and other chronic conditions have suffered an adverse childhood – or adulthood – experience (ACE). Yet, I hesitated. Would a busy primary care setting offer enough latitude for me to ask about a history of trauma when it can occur in so many forms, in so many ways and at different times of life? Furthermore, suppose she did report a history of trauma or adverse experience. What then? Would I be able to help her?

Nonetheless, I began: “Jenny, many patients with symptoms like yours have been abused, either emotionally, physically, or sexually, or neglected in their past. Sometimes they have suffered loss of a loved one, or experienced or witnessed violence. Has anything like this ever happened to you?”

This yielded our first breakthrough. Yes, she had experienced neglect, with parents who were separated for much of her childhood, and then later divorced. She had seen her father physically abuse her mother. With little parental oversight, she had engaged in drug and alcohol use throughout her teenage years. But, she wanted to be sure we understood that this was all behind her. She had gotten an education, was in a committed relationship, and had a stable job as a teacher. That part of her life was thankfully now closed.

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Health in 2 Point 00, Episode 72 | Haven, Scott Gottlieb, & Crossover Health

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On Episode 72 of Health in 2 Point 00, Jess and I give you a run down of the latest in health tech. At long last, the joint health care venture between Amazon, Berkshire Hathaway and J.P. Morgan has a name: Haven. In other news, Scott Gottlieb has decided to leave the FDA; we’ll just have to see what happens with the next FDA Commissioner. On the behavioral health front, AbleTo has acquired Joyable, a mental health coaching app. Finally, Crossover Health, which provides medical services to large employers like Facebook, acquired Sherpaa, a text messaging-based service—we’re seeing virtual services combining with a physical space more and more. And as mentioned, you can catch my talk from the 2017 HIC conference in Australia on how SMACK Health and Karl Marx will change health care here. —Matthew Holt

Advance Practice vs Primary Care

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By SAURABH JHA MD SAURABH JHA

In this episode of Radiology Firing Line Podcast, Danny Huges and I discuss a JAMA paper: A comparison of diagnostic imaging ordering patterns between advanced practice clinicians and primary care physicians following office-based evaluation and management visits.

Listen to our conversation on Radiology Firing Line here.

Saurabh Jha is a contributing editor to THCB and host of Radiology Firing Line Podcast of the Journal of American College of Radiology, sponsored by Healthcare Administrative Partner

Checking Boxes

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By HANS DUVEFELT MD Dr. Hans Duvefelt, A Country Doctor Writes, physician burnout

I pay $500 per year for UpToDate, the online reference that helps me stay current on diagnostic criteria and best treatment options for most diseases I might run into in my practice. They also have a rich library of patient information, which I often print out during office visits.

I don’t get any “credit” for doing that, but I do if I print the, often paltry, patient handouts built into my EMR. That was how the rules governing meaningful use of subsidized computer technology for medical offices were written.

If I describe in great detail in my office note how I motivated a patient to quit smoking but forgot to also check the box that smoking cessation education was provided, I look like a negligent doctor. My expensive EMR can’t extract that information from the text. Google, from my mobile device, can translate between languages and manages to send me ads based on words in my web searches.

When I do a diabetic foot exam, it doesn’t count for my quality metrics if I freetext it; I must use the right boxes. If I do it diligently on my iPad in eClinicalWorks, one of my EMRs, even if I use the clickboxes, it doesn’t carry over to the flowsheet or my report card.

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Where is Relationship, Authority, and Trust in Health Care Today?

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By HANS DUVEFELT MD Dr. Hans Duvefelt, A Country Doctor Writes, AI

Healthcare is on a different trajectory from most other businesses today. It’s a little hard to understand why.

In business, mass market products and services have always competed on price or perceived quality. Think Walmart or Mercedes-Benz, even the Model T Ford. But the real money and the real excitement in business is moving away from price and measurable cookie cutter quality to the intangibles of authority, influence and trust. This, in a way, is a move back in time to preindustrial values.

In primary care, unbeknownst to many pundits and administrators and unthinkable for most of the health tech industry, price and quality are not really even realistic considerations. In fact, they are largely unknown and unknowable.

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Hoarding Patient Data is a Lousy Business Strategy: 7 Reasons Why

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By VINCE KURAITIS & LESLIE KELLY HALL

Vince Kuraitis

Leslie Kelly Hall

Among many healthcare providers, it’s been long-standing conventional wisdom (CW) that hoarding patient data is an effective business strategy to lock-in patients — “He who holds the data, wins”. However…we’ve never seen any evidence that this actually works…have you?

We’re here to challenge CW. In this article we’ll explore the rationale of “hoarding as business strategy”, review evidence suggesting it’s still prevalent, and suggest 7 reasons why we believe it’s a lousy business strategy:

  1. Data Hoarding Doesn’t Work — It Doesn’t Lock-In Patients or Build Affinity
  2. Convenience is King in Patient Selection of Providers
  3. Loyalty is Declining, Shopping is Increasing
  4. Providers Have a Decreasingly Small “Share” of Patient Data
  5. Providers Don’t Want to Become a Lightning Rod in the “Techlash” Backlash
  6. Hoarding Works Against Public Policy and the Law
  7. Providers, Don’t Fly Blind with Value-Based Care

Background

In the video below, Dr. Harlan Krumholz of Yale University School of Medicine capsulizes the rationale of hoarding as business strategy.

We encourage you to take a minute to listen to Dr. Krumholz, but if you’re in a hurry we’ve abstracted the most relevant portions of his comments:

“The leader of a very major healthcare system said this to me confidentially on the phone… ‘why would we want to make it easy for people to get their health data…we want to keep the patients with us so why wouldn’t we want to make it just a little more difficult for them to leave.’ …I couldn’t believe it a physician health care provider professional explaining to me the philosophy of that health system.”

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Ensuring that the 21st Century Cures Act Health IT Provisions Promotes Interoperability and Data Exchange

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By KENNETH D. MANDL, MD; DAN GOTTLIEB;
JOSH C. MANDEL, MD

Josh Mandel

Kenneth Mandl

Dan Gottlieb

The opportunity has never been greater to, at long last, develop a flourishing health information economy based on apps which have full access to health system data–for both patients and populations–and liquid data that travels to where it is needed for care, management and population and public health. A provision in the 21st Century Cures Act could transform how patients and providers use health information technology. The 2016 law requires that certified health information technology products have an application programming interface (API) that allows health information to be accessed, exchanged, and used “without special effort” and that provides “access to all data elements of a patient’s electronic health record to the extent permissible under applicable privacy laws.”

After nearly two years of regulatory work, an important rule on this issue is now pending at the Office of Management and Budget (OMB), typically a late stop before a proposed rule is issued for public comment. It is our hope that this rule will contain provisions to create capabilities for patients to obtain complete copies of their EHR data and for providers and patients to easily integrate apps (web, iOS and Android) with EHRs and other clinical systems.

Modern software systems use APIs to interact with each other and exchange data. APIs are fundamental to software made familiar to all consumers by Google, Apple, Microsoft, Facebook, and Amazon. APIs could also offer turnkey access to population health data in a standard format, and interoperable approaches to exchange and aggregate data across sites of care.

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