The Health Care Blog – Page 236 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

Above the Fold

More About Balancing Business, Humanity, and Restraint in Cancer Care

Dec 1, 2018

By HAROLD POLLACK

I published a column in Kaiser Health News about the challenge of cost control in cancer care. KHN needed to cut one section for space, which notes that oncology has become an ecosystem of multi-billion-dollar public, private, and nonprofit ventures in pharmaceutical development, imaging, acute care, and more. This ecosystem draws upon and then reinforces broader cultural biases that promote overly aggressive approaches to diagnosis and care. I wanted to add some more discussion, and one revealing advertising table….

Consider the issue of routine mammography for younger women. In questioning the benefits of such screening, the United States Preventive Services Task Force ran afoul of Americans’ powerful draw to the notion of early detection in confronting an especially frightening disease. The USPSTF committed some political blunders in its approach to this freighted and genuinely complicated issue. It should have anticipated the powerful political, cultural, and commercial resistance it was likely to encounter.

In American popular culture–though not in the epidemiological data–breast cancer is often depicted as a young woman’s disease. A terrific 1998 paper by Paula Lantz and Karen Booth examined magazine depictions of breast cancer. Lantz and Booth concluded that “the increase in incidence is commonly portrayed as a mysterious, unexplained epidemic occurring primarily among young, professional women in their prime years.” Public service announcements concerning mammography and breast cancer show similar patterns. These announcements, with their myriad images of beautiful young swimmers, emphasize that one in nine women will be diagnosed with breast cancer. The PSAs do not emphasize that only about 12 percent of breast cancer patients are diagnosed before age 45.

Vesalius, Hooke, Hood and Steve Jobs

Dec 1, 2018

By ALEX EPSTEIN

Has Steve Jobs and his company altered the practice of medicine as significantly as Vesalius, Hooke, Hood and other giants in the field?

A radical supposition perhaps. One that I am not altogether comfortable with. Yet there is no denying the impact of the technologies adopted as a result of his touch.

Medical practitioners these days employ easy to use mobile/connected devices to learn, to stream, to take CME, or monitor patients, prescribe, ensure compliance, download and consume digital media, or just communicate and collaborate more robustly. Even crowd sourcing solutions to medical conundrums has become a concept mainstream institutions are embracing.

That the world’s data more and more exists in the palm of your hand – instantly accessible from the office to the operating room to any remote corner of the world – is due in large measure to devices and markets either pioneered by or made user friendly by Steve Jobs and Apple.

The CSI Effect Hits Medicine

Dec 1, 2018

By EVAN FALCHUK

I’m in Israel, home to some of the most innovative care in the world. Doctors here wanted to know if the high-tech tests that are an increasing part of their work helps. A couple of weeks ago, they published their results.

It turns out that in about 90% of cases, it didn’t matter.

A physical exam, the patient’s history, and the basic set of tests that doctors have done for decades was almost always all that was needed to get a diagnosis. As one of the doctors in the study put it, “ basic clinical skills remain a powerful tool, sufficient for achieving an accurate diagnosis in most cases.”

The conventional wisdom is that doctors – at least in the U.S. – order extra tests to protect themselves from getting sued. But this study was done in Israel, where the problem of medical malpractice is nothing like it is in the U.S. American-style defensive medicine can’t be the reason doctors in Israel use so many diagnostic tests.

HIT Trends Summary for August 2011

Dec 1, 2018

By MICHAEL LAKE

This is a summary of the HIT Trends report for August 2011. You can get the current issue or subscribe here.

Incentives driving the EMR market. According to a report by Sage Healthcare, most physicians (65%) buying EMRs are doing so because of federal incentives. The biggest obstacle is still cost with 32% of non-users saying it’s the number one issue. This is creating a mainstream market, even in solo practices, which report over 30% EMR adoption rates in a new survey by SK&A.

Incentives may also be driving hospital implementation of computerized physician order entry (CPOE). 80% of hospitals still lack CPOE capabilities as of last year. Meaningful use requires providers to order at least one medication for 30% of unique hospital patients. In a new KLAS report, CPOE projects have more than doubled, being led by Cerner and Epic.

It is a likely unintended consequence that the incentives are speeding the dominance of market leaders.

Huddle of One

Dec 1, 2018

By dinosaur, md

There’s nothing new under the sun, or in medicine. I’m not talking about monoclonal antibody targeted chemotherapy; I’m talking about taking care of patients, and specifically about running a medical practice. Not even the incursion advent of all our fancy new electronics has (or should have) a fundamental effect on how we take care of our patients. The latest thing to come down the pike is the so-called Patient Centered Medical Home, a collection of policies, procedures, and practice re-structuring (webinars, templates, guidelines, etc. all available at low, low prices, of course) that essentially makes large group practices function like a solo doc from the patient’s point of view.

Because the buzzword of this new model is “teamwork”, we’re all supposed to begin the day with a brilliant new concept called the “huddle“:

The team huddle is promoted by many clinicians and practice coaches as an innovative approach to support medical home transformation through visit pre-planning, team building and communication, and workflow redesign.

Radical!

One problem: how do I do that all by myself? I mean, here’s what I generally do every day:

Make sure to arrive at least 30-60 minutes before the first scheduled patient
Look over the schedule to get a sense of the day, who’s coming, who may need extra time, any new patients
Double-checking that rooms are re-stocked with key supplies (ie, three paps on the schedule; wasn’t the speculum drawer low the other day? Couple of well baby visits; enough needles for all their shots? Better top up the bin from the supply closet.)
Looking over the charts (now electronically; previously the paper ones — adding pages, seeing whose insurance info needs updating, etc.)
Go over all the above with staff whenever they arrive (usually after me)

I’ve always just called it “getting ready for the day,” an organizational strategy for business management that’s called “being prepared” in most other occupations. But now it has a new name: the Huddle. Complete with instructional videos, for chrissakes.

As far as “patient-centered-ness” goes, I’ve used a somewhat different set of concepts from Day One called “Customer Service”. Having people instead of machines answering the phone, same-day appointments, personally communicating test results; all Disney-level customer service, now re-named things like “Open Access”, have been integral to my practice from the git-go.

Why is it happening? One of the oldest reasons in the world, of course: money to be made. I’m sure there are too many doctors and medical practices out there who, sadly, need this kind of help. Sadder still, they have to be force-fed it under the guise of running a “more efficient” practice.

Whatever happened to good old common sense? Next thing you know they’ll be all over us making sure we wash our hands. (Joke intended.) Seriously, though. This whole thing about co-opting perfectly sensible things from other industries for medicine — checklists, for example — and carrying on as if having re-invented the wheel is getting old.

The Impact of 9/11 on Healthcare IT

Dec 1, 2018

By JOHN HALAMKA, MD

On September 11, 2001, I was sitting in my Harvard Clinical Research Institute office (I was CIO there from 2001-2007 as part of my Harvard Medical School CIO duties). A staff member ran into my office and told me that a plane had crashed into a World Trade Center Tower. This sounded like a horrible accident. Then, the second tower was hit and we knew this disaster was planned. News of the Pentagon and Pennsylvania crashes trickled in. I gathered all the staff and told them to focus on their families and personal safety, to go home and stay in touch virtually as we learned more about the day’s events.

What impact has 9/11 had on my healthcare IT world since then?

9/11 had a profound impact on our culture, making us all understand our vulnerability.

The loss of life gave us an appreciation of the preciousness of each day we have on the planet, putting the problems of our work lives in perspective.

The loss of infrastructure, including many data centers, was a wake up call that redundancy goes beyond servers, networks, and storage. Whole buildings can disappear in an instant through natural or manmade disaster.

One Word Can Save Your Life: Too Simplistic

Dec 1, 2018

By DAVIS LIU, MD

Newsweek has a very provocative and yet incredibly too simplistic piece for the public and patients on its cover story – One Word Can Save Your Life: No! – New research shows how some common tests and procedures aren’t just expensive, but can do more harm than good.

The piece is actually well written and highlights facts that have been apparent for some time. More intervention and treatment isn’t necessarily better. Having a cardiac catheterization or open heart surgery for patients with stable heart disease and mild chest pain isn’t better than diet, exercise, and the prescription medication treatment. PSA, the blood test previously suggested by many professional organizations, isn’t helpful to screen for prostate cancer, even though the value of the test was questioned years ago. Antibiotics for sinus infection? Usually not helpful.

Certainly doctors do bear part of the blame. If patients are getting routine colonoscopies sooner than every 10 years or are getting them despite being quite a bit older (80 and older) and frail, then clearly patients should say no to more care. More isn’t better. (Whether a patient has the conviction to do so is another story. When my auto mechanic says it is time to change the brakes or change the oil, who am I to say no?)

Must Waiting Be Inherent To Medical Care?

Dec 1, 2018

By LISA GUALTIERI

“By the time you see the doctor, you’re either dead or you’re better,” my mother-in-law told me. She had to have multiple tests, all with long waits to get the appointments and the results, before her health insurer would allow her to make an appointment with a specialist.

“Waiting is the bane of the medical system,” a former student, an R.N., concurred. Advances in medicine and technology have improved medical outcomes, but have often resulted in more waiting at a time when every other aspect of life is speeding up. Waiting is a systemic problem exacerbated by advances in medicine and by health care reform.

Some of the ways we wait:

Wait to see if the symptoms go away or get worse. We all struggle with these decisions: do we need to be seen about the fever, back pain, or rash? Sometimes we wait because of denial or hopelessness; sometimes because of the cost or availability of medical care. I make decisions about when I need to see the doctor by asking myself if, under the same circumstances, I would take one of my children to the doctor.
Wait to get an appointment scheduled. I’ve made appointments for a sick child by channeling an old friend who could be relentless: “That is not acceptable. I need an appointment today.” Obnoxious but it sometimes worked. The rest of the time, though, the period between making and having an appointment can feel very long.
Wait to get to the appointment. Doctors and hospitals are more abundant in Greater Boston, where I live, than in other places, although traffic and parking can be problematic. Melody Smith Jones described a man’s six hour commute to see a doctor.
Wait to be seen by the doctor. It isn’t called the waiting room for nothing.Dr. Atul Gawande wrote in The Checklist Manifesto about people in the waiting room getting irate when he was running two hours behind on a hectic day. Being irate – or anxious or bored – is unlikely to increase the quality of physician-patient communication.
Wait in the examining room. At least in a waiting room you are dressed. If it is cold and you are wearing a paper or cloth johnny, distractions don’t work as well and examining rooms have fewer than waiting rooms.
See the doctor. Nowadays, as my mother-in-law recounted, you have to wait for the doctor to review your records before even looking at you. I find it surprising that physician rating systems give equal weight to wait times as they do to “communicates” and “listens”, when the latter are so much more important.
Wait in the lab. The selection of magazines is skimpier. You may be reviewing what you were told not to eat or drink: will that cup of black coffee skew the results?
Wait for lab results. If there are any non-routine reasons for testing, this can be interminable. I leave a lab asking when results will be ready and then I call. A former student told me about using Harvard Vanguard’sMyHealth Online. She said, “I love getting the lab results immediately online but I can see how those without clinical training could be overwhelmed or confused by the data and how to interpret them.”
Wait for the doctor’s interpretation of lab results. Lab results can be hard to decipher without clinical training, as my student said above. Even when I know results are available and the doctor has seen them, it can take many phone calls to obtain the doctor’s message via the secretary. Asking the doctor follow-up questions takes even longer. These are waits with a cell phone never turned off so you don’t miss the call.
Loop. You think you’re done but you may need to see a specialist, get a second opinion, or have more tests. As my mother-in-law pointed out, this process can be controlled more by insurance companies than by doctors’ availability. Another type of waiting also takes place now: waiting to get better. A friend bemoaned how she “couldn’t wait” for her black eye resulting from a fall to clear up because she was tired of people staring at her.

Requiem for the CLASS Act

Dec 1, 2018

By Trudy Lieberman

On Friday, the stepchild of health reform died at the hands of the Obama administration, and the obits for the troubled long-term care program were mostly similar recitations of why the administration was not going forward to implement that portion of the Affordable Care Act, how it was part of Ted Kennedy’s legacy, and how gleeful Republicans were at its demise.

The media amply quoted Senators Mitch McConnell of Kentucky and John Thune of South Dakota. Thune’s quote in The New York Times, “the Obama administration ignored repeated warnings about the financial solvency of this massive new entitlement,” gives a flavor of what they said.

The CLASS Act, short for the Community Living Assistance Services and Support Act, was a voluntary program where people could join a government plan to pre-fund some of the long-term care they might need in the future. Under the plan they would pay premiums during their working years. If they later became disabled and needed assistance, they would be entitled to a daily cash benefit of say, $50, that they could use to buy services such as a personal care attendant, home improvements that would let them stay in their house, or even to help pay nursing home costs.

Supporters saw the CLASS Act as a first step toward a national long-term care insurance program like those in other countries. Whatever its technical flaws, supporters argued that it would begin to solve the dilemma millions of families face—how to pay for a loved one’s care. Many politicians and the insurance industry weren’t keen on that idea since it could also be a first step to a publicly-financed insurance program (anathema to insurance sellers) and might cut into the market for long-term insurance, a product that has never really become a big seller primarily because of its high cost. The CLASS Act barely made it into the final bill.

Bucking the Established

Dec 1, 2018

By DR. WES

“Out with the old, in with the new!”

Who’s your doctor? Do you have one?

If you have one, you aren’t that interesting to them any longer because you’re “established.” This is not the fault of your doctor, but because of government rules for paying doctors: “new patient” visits pay better than “established patient” visits. “New patients” have a much better chance of needing new procedures, so they are even more special. Add to that the fact that more and more patients are going to need to become part of the “system” soon, and “new patients” quickly achieve the health care value trifecta.

Sorry. Those are the rules.

The higher payments made by insurers and government agencies for new patients was meant to offset the longer amount of time and cognitive challenges of dealing with a new patient that enters the doctors office. There is no question that there is more work to do when a new patient enters a medical facility: entering demographic data on a computer, actually taking a set of vital signs, performing a careful history and physical. But thanks to the explosion of ancillary health care assistants, imaging studies, the availability of the internet, and a constant push to do more in less time, doctors work differently today than they once did. Much of the data gathering is accomplished before the patient enters the office, imaging studies and baseline testing often occurs before a patient is even seen (remember those tests “required” for “quality” care?). Furthermore, because limitations for the frequency of testing has been imposed by government regulators, health care systems leap at the opportunity to “direct” doctors to order tests the moment the test might be needed. As such, “new patients” become particularly valuable to health care systems compared to “established” ones.