Tag: primary care

Trauma-Informed Primary Care

Apr 24, 2019• 2

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.

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

Mar 7, 2019

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

Feb 25, 2019

By SAURABH JHA MD

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

Feb 1, 2019• 1

By HANS DUVEFELT MD

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.

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

Dec 28, 2018• 8

By HANS DUVEFELT MD

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.

Why Medical Specialists Should Want to End the Reign of the RUC

Dec 1, 2018

By PAUL M. FISCHER, MD

The old doctors know. The practice of medicine has changed in a very basic way over the last 20 years. Physician relationships have lost their civility and have been replaced by a level of tension that takes the fun out of collegial interactions. I remember my first year of family medicine as the only doctor in Weeping Water, Nebraska. My personal medical community had gone from an entire medical school campus with limitless lectures and many physicians to share in “interesting cases” to an occasional phone call with a consultant in Omaha. These contacts became my primary source for medical education and updates for Weeping Water’s health care. The phone calls were collegial, respectful, and focused on what was best for my patients.

What happened?

The RUC is the secretive committee of the AMA that has been CMS’s primary source of physician payment data over the past 20 years. It has elaborately articulated the complexity of medical procedures but ignores and confuses the cognitive work involved in patient care – collapsing it into a few evaluation and management codes. As a result, many medical specialties have found that their financial success is tied primarily to doing things TO patients, rather than caring FOR patients.

The RUC has shifted these physicians’ attention away from the hard work of knowing patients over time and fine-tuning their treatments based on subtle changes discovered by history and physical toward focusing on which procedure can be done to a patient and legitimized to an insurance company. Let the “primary” do that other stuff.

Roulette

Nov 1, 2018

By Rob Lamberts, MD

“I want you to get me a new doctor,” she told me, a bit of disgust coming out in the sharp tone in her voice.

“What happened?” I asked.

“He asked me if I was nauseated, and I told him no, I was just vomiting. Then he asked if I was feeling pain in my stomach, and again I told him no, it was just vomiting. He then told his nurse to write down nausea and abdominal pain. When I objected, he just gave me a bad expression and walked out of the room.”

I tried to come up with a plausible explanation for his action, but there was none. ”I’m sorry,” I said. ”There are a lot of people who come back from him feeling really happy and listened-to. It’s obvious that you saw none of that from him.”

“I asked his nurses if he aways acted this way,” she continued, “and they just shrugged and told me that he sometimes did.”

“I’m happy to send you to a different doctor,” I said, shaking my head.

I hate it when this happens.

I send people to specialists for two main reasons:

I am not qualified to offer the treatment or procedures the specialist can give.
The specialist has far more experience with the problem, and so can offer better care.

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

Oct 17, 2018• 18

By 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:

Data Hoarding Doesn’t Work — It Doesn’t Lock-In Patients or Build Affinity
Convenience is King in Patient Selection of Providers
Loyalty is Declining, Shopping is Increasing
Providers Have a Decreasingly Small “Share” of Patient Data
Providers Don’t Want to Become a Lightning Rod in the “Techlash” Backlash
Hoarding Works Against Public Policy and the Law
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.”

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

Oct 16, 2018• 4

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

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.

Comprehensiveness is Killing Primary Care

Aug 24, 2018• 20

By HANS DUVEFELT, MD

Dr. Hans Duvefelt

In most other human activities there are two speeds, fast and slow. Usually, one dominates. Think firefighting versus bridge design. Healthcare spans from one extreme to the other. Think Code Blue versus diabetes care.

Primary Care was once a place where you treated things like earaches and unexplained weight loss in appointments of different length with documentation of different complexity. By doing both in the same clinic over the lifespan of patients, an aggregate picture of each patient was created and curated.

A patient with an earache used to be in and out in less than five minutes. That doesn’t happen anymore. Not that doctors and clinics wouldn’t love to work that way, but we are severely penalized for providing quick access and focused care for our well-established patients.