4. If you need to learn about a disease, procedure, or drug that you know nothing about, your best starting point is probably Wikipedia. Google will lead you to some incorrect answers, and diagnose-yourself websites will give you answers that are much too broad to use practically in legal practice. Once you have familiarized yourself with the general topic on Wikipedia, you can then go back to your search engine of choice for more specific terms and weed out the wrong information. Starting on PubMed or GoogleScholar probably isn’t the best idea either because most of what you’re reading will be highly technical and the articles you find will likely be about novel uses or instances of whatever you’re searching. Another fantastic source is UpToDate, an evidence-based Wikipedia-like source for healthcare providers, but many people may not have access to all the information on this site.

5. Physicians don’t know as much as you’d expect them to about the health insurance system. (Note: I have only the utmost respect for healthcare providers and understand that the quantity of information they are expected to retain is nothing short of ridiculous. See Atul Gawande’s Complications for an interesting perspective on society’s unrealistic and unattainable expectations of modern medicine.) They receive almost no formal training on health insurance and, realistically, don’t need to know much about it on a day-to-day basis. Little to none of their day is spent looking through the details of coverage or payments. I write this only to emphasize that talking to a physician about your client’s insurance is likely not the best use of anyone’s time. Unless your client has particular conditions that would make the provider aware of his insurance, such as an inability to pay for necessary medications, the client’s health insurance probably has never crossed the provider’s mind. This is most applicable to providers in academic and public institutions. Providers in private practice may handle more of their billing and insurance work.

6. This is an extremely broad generalization, but, as a whole, lawyers make physicians nervous. I’ve started to notice that lawyers and physicians may not understand the type of relationship that they have with one another. When providing an example of an authority figure in her life, my HLS professor who formerly worked at the White House named her physician. Not the President of the United States, but her personal physician.

What lawyers need to understand is that physicians have a similar (but not same!) attitude toward lawyers. When I was volunteering in a large hospital in an affluent area of Southern California known for its zip code, the surgeon I was working with gave me a memorable talk on what is flawed with our healthcare system. He explained that costs are high not because people are sick, but because there is too much waste and inefficiency, particularly in wealthy neighborhoods. Immediately after this, we went out to see his next patient. She simply said, “My neck hurts. I think I need an MRI.” The surgeon then agreed and pointed her to the front desk where she could schedule her MRI. After she left the room, he turned to me and whispered, “She doesn’t need an MRI, but she’s a lawyer so we’re not going to disagree with her.”

I heard more about being sued when I was in medical school than I have during my time in law school. Unfortunately, the training I received regarding malpractice amounted to (1) Don’t mess up, and (2) Be nice to patients and say sorry, but, actually, don’t say sorry too much.
To give a more concrete example of medical education on medical malpractice, an exam question on the topic would look something like this:

Question
A scenario of possible medical malpractice is described. What is the patient’s burden of proof?
Answer Choices
(A) Preponderance of the evidence
(B) Beyond reasonable doubt
(C) XYZ
(D) None of the above

What medical student has any idea what the above actually means in practice? (What law student does?) The student will memorize the phrase preponderance of the evidence and possibly understand, incorrectly, that patients have a very low burden to bear based on the explanation “more likely than not,” and then move on. What all this does is leave physicians with the idea that suing doctors is an easy, get-rich-quick pastime of lawyers. In fact, when I told my physician husband that I was writing a blog post on lawyers and medicine, his response was, “Are you writing about how you’re all out to get us?”

My take-home message on the point is this: As a lawyer, when speaking with physicians, be upfront about what information you need and why you need it. After introducing yourself as a law student, lawyer, or as part of a law firm, be quick to note why you are calling. If you need information about your client, make sure to send your HIPAA release form first and note that you are representing the client. The physician may worry you are trying to sneak one past her and get information about an opposing party. If you forget to send your release form and the physician accidentally gives you information, send the release immediately afterward and be by your phone for when she calls to confirm that you have clearance. If you think you and the physician are on the same advocate-wavelength and that a release form is not necessary, you are mistaken. The physician will spend the rest of her afternoon imagining you smugly sitting in your office, pleased with yourself that you tricked a doctor into divulging confidential information and surrounded by the briefs that will eventually be used in suing her. I have seen this happen.

Last week, I wrote the first of a two-part series on tips that may be helpful for law students and lawyers interested in or working in health/medical law.  I continue with Tip #4 here.

4. If you need to learn about a disease, procedure, or drug that you know nothing about, your best starting point is probably Wikipedia.  Google will lead you to some incorrect answers, and diagnose-yourself websites will give you answers that are much too broad to use practically in legal practice.  Once you have familiarized yourself with the general topic on Wikipedia, you can then go back to your search engine of choice for more specific terms and weed out the wrong information.  Starting on PubMed or GoogleScholar probably isn’t the best idea either because most of what you’re reading will be highly technical and the articles you find will likely be about novel uses or instances of whatever you’re searching.  Another fantastic source is UpToDate, an evidence-based Wikipedia-like source for healthcare providers, but many people may not have access to all the information on this site.

5. Physicians don’t know as much as you’d expect them to about the health insurance system.  (Note: I have only the utmost respect for healthcare providers and understand that the quantity of information they are expected to retain is nothing short of ridiculous.  See Atul Gawande’s Complications for an interesting perspective on society’s unrealistic and unattainable expectations of modern medicine.) They receive almost no formal training on health insurance and, realistically, don’t need to know much about it on a day-to-day basis.  Little to none of their day is spent looking through the details of coverage or payments.  I write this only to emphasize that talking to a physician about your client’s insurance is likely not the best use of anyone’s time.  Unless your client has particular conditions that would make the provider aware of his insurance, such as an inability to pay for necessary medications, the client’s health insurance probably has never crossed the provider’s mind.  This is most applicable to providers in academic and public institutions.  Providers in private practice may handle more of their billing and insurance work.

To give a more concrete example of medical education on medical malpractice, an exam question on the topic would look something like this:

Question
A scenario of possible medical malpractice is described. What is the patient’s burden of proof?
Answer Choices
(A) Preponderance of the evidence
(B) Beyond reasonable doubt
(C) XYZ
(D) None of the above

What medical student has any idea what the above actually means in practice?  (What law student does?)  The student will memorize the phrase preponderance of the evidence and possibly understand, incorrectly, that patients have a very low burden to bear based on the explanation “more likely than not,” and then move on.  What all this does is leave physicians with the idea that suing doctors is an easy, get-rich-quick pastime of lawyers.  In fact, when I told my physician husband that I was writing a blog post on lawyers and medicine, his response was, “Are you writing about how you’re all out to get us?”

My take-home message on the point is this: As a lawyer, when speaking with physicians, be upfront about what information you need and why you need it.  After introducing yourself as a law student, lawyer, or as part of a law firm, be quick to note why you are calling.  If you need information about your client, make sure to send your HIPAA release form first and note that you are representing the client.  The physician may worry you are trying to sneak one past her and get information about an opposing party.  If you forget to send your release form and the physician accidentally gives you information, send the release immediately afterward and be by your phone for when she calls to confirm that you have clearance.  If you think you and the physician are on the same advocate-wavelength and that a release form is not necessary, you are mistaken.  The physician will spend the rest of her afternoon imagining you smugly sitting in your office, pleased with yourself that you tricked a doctor into divulging confidential information and surrounded by the briefs that will eventually be used in suing her.  I have seen this happen.

1. Always refer to a physician as “Dr.”  This is a really obvious one, but it has to be said, especially if you plan on working with the physician on your case.  Think of an MD or DO as more like a Judge or Honorable than a JD in terms of the importance of the title.  In medical school, I once saw Dr. S return an e-mail addressed to “Ms. S” saying only, “Why does it say Ms. S?”  It was as if she thought the e-mail had reached her in error.  Ms. S was not her name.
2. As a corollary, any other health care provider with a doctorate should also be referred to as a doctor.  This means those with a PhD, PsyD, DNP, DDS, OD, etc.  If you don’t know if a health care provider is a nurse (non-doctorate) or a doctor, you should probably just call them doctor until they correct you.
3. In law, we give medical records significant weight as evidence because we believe that people generally tell the truth to their providers since that is in their best interest.  As such, you should know how to read and interpret common terms in the records as a starting point in understanding your clients and cases.

• First, as the wife of a physician, I can personally attest to the fact that writing, typing, or dictating medical charts is not a physician’s favorite activity.   Because of this, you will find numerous abbreviations and acronyms littered throughout the records.  While you don’t need to know or memorize what each of these mean, you may need to know how to look them up.  Unfortunately, the same set of letters can often stand for many very different things, so you’re will need to do more than just search the abbreviation or acronym itself.  For example, search “PE medical acronym” may not get you the correct answer.  You should include the words around the term itself and what type of file it was in to get more accurate results.  Searching “PE emergency room” versus “PE annual check up” will help your quickly determine whether your client had a life-threatening embolism or a routine physical exam.   Sounds silly, but you might be surprised at how often one-word searches are done in this context and how unreliable they can be.
• Here are some of the basic headings that you will find in a medical chart and what they mean:
  CC – chief complaint.  This is the patient’s main issue.
  HPI – history of present illness. This is essentially the patient’s answer to the question, “So what brings you in today?”
  PMH/PSH – past medical/surgical history.
  ROS – review of systems. This is when the provider asks the patient questions upon questions pertaining to how he feels generally, if he’s had any changes in weight, any coughing, any pain, etc.
  PE – physical exam.  This will probably be followed by several other acronyms or other half-words.  If it looks like there are only acronyms, such as “HEENT PERRLA CVP RRR CTA,” then the findings were probably all normal.  If there was something abnormal you should, in theory, be able to read about it in plain English.  WNL means “within normal limits,” but, and this is my bioethics side kicking in here, it is sometimes disparagingly also referred to as meaning “we never looked.”  Thus, it might be a good idea not to have your entire case turn on one WNL in the record.  This is doubly true if the provider simply circles the entire physical exam form and writes one large WNL.
  A – assessment.  This is where the provider writes what she thinks is going on, including a differential diagnosis (DDx).  The differential diagnosis is the list of possible causes of the patient’s symptoms (what the patient reported) and signs (what the provider noticed or measured).  The patient is not necessarily being diagnosed with everything, or anything, listed.
  P – plan.  Here, the provider notes what she and the patient are going to do to treat the patient’s condition.  The provider may note that she is recommending a certain prescription, but it does not guarantee that the patient filled or took that medication.
• One term of art that is crucial to understand is the use of the word historian.  When a provider describes what type of historian a patient is, she is making a credibility assessment.  For example, if your client was noted to be a poor historian, then you should take everything he reported as suspect unless corroborated elsewhere. He may be a poor historian due to age, drugs (prescription or otherwise), mental impairment, or because his story to his provider was obviously inconsistent.  This term is used without any attempt to make a normative judgment on his character. It is simply a way to communicate to others reading the report the possibility that not everything the patient reported is true.

These are all my tips for now, but I will be sure to update this list if I come across anything else that I find may be helpful as the semester progresses.  As always, I would love to hear any feedback or thoughts in the comments section below.

These are all my tips for now, but I will be sure to update this list if I come across anything else that I find may be helpful as the semester progresses. As always, I would love to hear any feedback or thoughts in the comments section below.

By THCBist

There is no doubt there are some obnoxious people throwing around arrogant/naive ideas. However, the “creative destruction” and “disruptive innovation” that has been most impactful has come from physician-entrepreneurs. Often, they are the most provocative and hard-hitting in their language. It seems loosely similar to how the most virulent anti-smokers are former smokers. They want others who they can relate to experience the liberation they’ve experienced.

I wouldn’t assume ill-intent from these MD-entrepreneurs using direct language. They simply were fed up with what they experienced as “broken” and stepped up with approaches that have out-performed. I’m thinking about the MD-entrepreneurs and innovators who have led CareMore, Nuka Model of Care, Qliance, Iora Health, MedLion, Healthcare Partners, etc. Sometimes to catalyze change, one must use stark, hard-hitting language. That doesn’t seem like a foreign concept to the many excellent MDs I’ve known over the years. I have enormous respect for any entrepreneur, especially one coming from tradition-bound professions who are willing to stick their neck out and endure enormous personal financial risk. Bob Margolis shared how his colleagues referred to him as a “communist” and his team-based model as “communism” yet Bob’s org achieved far better outcomes. He had the last laugh when that “communist” sold his business for $4.4B last year.

The comments from these MD-entrepreneurs is they feel they aren’t doing their MD friends any favors by candy-coating what is widely recognized as a system that isn’t close to reaching its full potential. In contrast, the orgs those MD-entrepreneurs are running are the reigning “Triple Aim Champs” that we should celebrate — colorful language or not. Often the most impactful entrepreneurs aren’t particularly “polite” in their language — Steve Jobs, Bill Gates, Larry Ellison et al called it like they saw it. What’s wrong with that?

By DAVID SHAYWITZ, MD

Since 2011, I’ve written extensively about digital health in this column, motivated by my excitement for the subject and my conviction around its potential. Going forward, I anticipate writing far less about digital health – paradoxically, due to its very growth. I simply lack the bandwidth to continue to follow digital health developments while remaining gainfully employed in a role unrelated to this space.

I remain profoundly optimistic about the future of digital health, and I am convinced it can play a transformative role in shaping the future of healthcare. I suspect we will come to discover that technology’s most important role in healthcare lies not in replacing humans with computers, but rather through motivating, enhancing, and supporting vital, health-promoting relationships between people.

Meanwhile, here are several recently-published books that readers interested in digital health may want to check out:

Big Data: A Revolution That Will Transform How We Live, Work, And Think

Authors: Viktor Mayer-Schönberger (Oxford Professor) and Kenneth Cukier, Data Editor of The Economist.

One-liner: Big data: how the world changes when you start to think about N=all.

Why read? Approachable and engaging overview of important, often-intimidating subject.

Caveat: Discussions of health implications tend to conflate promise with demonstrated results – though a small quibble in context of a wonderful read.

Continue reading…

By

Governments around the world have started to rely on more digital government services. Ideally these new websites offer fast and efficient solutions. But the shaky rollout of HealthCare.gov served as a prime example of how digital government is not always good government. A new report from the Boston Consulting Group describes how different countries are approaching digital government. The authors surveyed over 12,000 users about their experiences and satisfaction with using online government services. The survey collected results from 12 different countries, including the U.S., the U.K., Australia, and France. The report finds that satisfaction varies throughout the world.

Throughout both the developed and developing world governments are expanding their online offerings. The average respondent had access to 10 different digital government services. These services include more frequently used services like community consultation, employment services, and health care. Developed countries reported higher levels of satisfaction with these digital services than developing nations. Across the spectrum of developed and developing nations, four out of five users believe that online services provided by the government have improved.

Satisfaction varied across countries. 56 percent of Malaysians and 52 percent of Indonesians perceived online government services to be far worse than private services. 60 percent of users in the United Arab Emirates and 53 percent of those in Saudi Arabia were most satisfied with online government services.  Americans favor private services by a large margin (42 to 22).

The report also describes areas where users believe governments can improve. One third of users reported having no problems or issues with the online services. Those surveyed were most interested in easy to access services rather than new ones. Users want simpler and easier-to-use websites (51 percent), greater reassurances on the privacy of information (47 percent), and more personalized or tailored services (34 percent).

There is clear evidence that users want to see online services continue to grow and develop. For example despite the rocky launch of Healthcare.gov, Americans reported the highest rates of satisfaction (55 percent) with searching for, registering for, or accessing health care services. American users also reported the highest levels of satisfaction in other categories such as participating in community consultation/online surveys (58 percent), accessing cultural, heritage, or similar facilities (66 percent), and searching, registering, or accessing health care records (57 percent).

The report argues that governments should focus on adding and maintaining the value of those services constituents need and use most, rather than building content that may go to waste. Furthermore, there is a strong emphasis on building tools that incorporate concerns about the user experience into the design.  In the future as technology in the private sector improves, pressure on governments to deliver digital services will only increase.  Governments must develop the capacity to develop and maintain new service delivery websites and applications.

Find the full report here.

By

It was with much distress that I read the recent New York Times front page article by Benedict Carey about the heart wrenching plight of the Serpico family in their journey to get proper psychiatric treatment for their two sons. As a child and adolescent psychiatrist who has served children and families for more than 30 years, trained many child psychiatrists, and served as President of the American Academy of Child & Adolescent Psychiatry (2001-2003), I am deeply disturbed by the current psycho-pharmacologic practice of psychiatry.

Over the past decade, there have been amazing advances in medicine that have pushed the profession in the direction of utilizing more evidence-based practices.  This is easy to see in most specialties, such as cardiovascular medicine, where implementing the latest surgical best practices results in proven, tangible positive outcomes. Unfortunately, it is not that clear cut in the field of psychiatry.

Every other medical specialty claims an organ of interest – cardiologists have their heart, nephrologists have their kidneys, hepatologists have their livers, yet the brain remains a medical orphan.

In the “mental health” field we treat diseases of the brain, yet we shy away from claiming the brain as our organ of interest. The brain is the only organ that cannot be transplanted, nor can a person survive without it. People actually survive with mechanical hearts while awaiting heart transplants. The idea that a child can go into an inpatient unit with emotional and behavioral problems and simply be treated in five days with reckless medication trials, without any diagnostic tests that guide an understanding of the genesis of the problems, is preposterous. There is no evidence-based science to support such treatment. The “health” (misnomer?) insurance industry has been the driver of such treatments, and, unfortunately, psychiatry has capitulated instead of pushing back and advocating for appropriate time to evaluate, diagnose, and properly treat our patients. I do not think there is a nephrologist in the world that would accept fewer dialysis sessions for a patient in renal failure, or a cardiologist who would deny critical diagnostic testing simply because the insurance company decided they would not pay for it. Medical necessity should drive assessments—not the insurance industry.

Most inpatient units fail to do any psychological testing.  They typically do no testing to probe for language and communication problems, learning disabilities, or other cognitive challenges that may be at the root of the problem. Children with early traumatic experiences are not being diagnosed appropriately; instead behaviors associated with such trauma are targeted for treatment with medications. If the diagnosis is incorrect, then so is the treatment intervention.

Continue reading…

By SURESCRIPTS

Health information exchange. Connectivity. Interoperability. For the health IT crowd, these words have become staples in our vocabulary. Data exchange and accessibility are critical to improving care delivery and increasing efficiency, especially when patients move from one provider to another.

Patients’ digital expectations are growing too, their health records must be easy to share with other care providers in a secure manner. To keep up with industry demands, regulations and the pace of innovation, the entire healthcare ecosystem must continue to take steps forward in their respective – and collective – interconnectivity journeys.

According to a recent article from Health Affairs, 78 percent of office-based physicians reported adopting some form of EHR system in 2013, however only 14 percent electronically shared data with care providers or hospitals outside their own organization, which is one of the most critical pieces of the interoperability puzzle. The secure transfer of information between each stakeholder group is no longer nice to have, but a necessity – not only for the assurance of high quality care, but also for the improvement of healthcare overall.

But the journey isn’t easy, the challenges are great, and the questions are plentiful. How are hospitals going beyond compliance to take Meaningful Use from a regulation to a framework for connected success? How can you achieve seamless connectivity between disparate entities? How can tracking immunizations drive down costs for patients, providers and pharmacies, while improving population health?

To tackle these questions and more, please join Surescripts and a panel of experts – from Kaiser Permanente, Mt. Sinai and Walgreens – tomorrow September 23rd at the Health 2.0 fall conference, as we address “How a Connected Health Infrastructure and Data-Driven Solutions are Improving Quality, and Your Bottom Line.” Be sure to follow us @Surescripts on Twitter!