The Health Care Blog – Page 237 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

Above the Fold

The Meaningful Use Song (with Apologies to Gilbert & Sullivan)

Dec 1, 2018

By MARGARET POLANECZKY, MD

As billing compliance leader in my department, I’ve been charged with getting my colleagues on board with Electronic Medical Record Meaningful Use. (What does meaningful use have to do with billing? It’s complicated, but the codes up until now have been reported along with billing codes, so it sort of fell into my lap. Lucky me…)

Generally, meaningful use refers to using the EMR in a way that harnesses its immense power to store and retrieve data in a way that makes sense and potentially improves clincal outcomes- by checking for drug interactions in real time, for example, or to track blood sugars, blood pressure or other data, or to allow for electronic prescriptions and shared data between clinicians using common language.

Specifically, when we say “meaningful use” these days, we are referrring to the list of meaningful use standards developed by CMS – a very specific list of 25 objectives, along with defined quality measures (like percent of women getting mammograms) that will be used to report and track health outcomes in practices using EMRs.

CMS is offering financial incentives to medical practices to use their EMR in a meaningful manner this year. We will be reporting data starting in October 1 to CMS, and must meet 20 of the 25 meaningful use objectives and report outcomes on chosen quality measures to qualify for the incentive payment. In addition, we are reporting separately to the government on the use of electronic prescribing, and face possible penalties for docs who are still stuck on paper. In time, our outcomes on the quality measures will be reported to the public on the CMS website.

Does Meaningful Use Improve Clinical Outcomes?

That’s the 20 billion dollar (the amount 2009 Hi-Tech Act allocated to the meaningful use incentive program) question. We really don’t know as yet whether or not EMR use itself favorably impacts patient care. Some studies say EMR usedoes not improve health outcomes, but more recent studies of diabetes care and in low resource areas have suggested that EMR use may be beneficial.

We also have no idea if docs who attain meaningful use are better docs than those who don’t. Despite this, the CMS website will have clear implications as to the outcomes of doctor’s practices in terms of standard quality measures. It’s a bit worrisome to me, especially since so many of the outcomes are driven by patient compliance (a word I know a lot of my readers don’t like, but there it is…) Not to mention the thorny issue of using mammogram screening in women over 40 as an outcome measure when we just decided that it is no longer recommendedto routinely perform it in everyone. (Don’t get me started on that issue again…)

Overall, I think meaningful use is a step in the right direction

I do see meaningful use as an attempt to rein in the wild, wild west of EMR development to try to create some standardized functionality and communication. It’s also a way to begin to corral the freestyle and autonomous EMR use that has evolved among early EMR users, who did what they needed to do to get their work done during the evolution of the EMR around them, but who now need to step back and reassess how well (or not) they are using this powerful tool that has been foisted upon them.

But my god, this whole process has been painful.

And so damned complicated, I needed a song to keep it straight. Ergo that parody up there, which actually covers all 25 meaningful use requirements as defined by CMS. (or at least as I see them…)

Of course, I could have just learned the Meaningful Yoose Rap. But please… me singing rap?

Margaret Polaneczky, MD, is a board certified obstetrician-gynecologist and Associate Professor of Clinical Obstetrics and Gynecology at Weill Medical College of Cornell University in New York City. Her blog, The Blog That Ate Manhattan, started out as a food blog and eventually evolved to cover food, medicine, her life and her opinions, and an occasional silly song. This post originally appeared at TBTAM.

The White Coat

Dec 1, 2018

By DINOSAUR MD

I have not worn a white coat since I opened my own practice more than twenty years ago.

Not that I had anything against white coats in principle. I wore my short white one in med school with pride, and the longer one in residency too; their pockets filled to bursting with the 4 x 6 inch six-ring binder emblazoned with my name in gold, courtesy of Burroughs-Wellcome, the long-defunct pharma giant, which had presented one to each medical student in the US for many years, as well as assorted pens, note cards, alcohol wipes, hemoccult cards, and so forth. I even had a tiny teddy bear pinned to my lapel, my own way of personalizing the impersonal.

When I went out on my own, though, I made the conscious decision not to wear one. I confess that all these years later, I don’t completely recall my thought processes on the subject. It seemed pretentious, especially since I was the only doctor in the office and therefore not easily confused with other staffers. Little kids were scared of them, held the common wisdom. I decided that I wanted to project a warmer, less formal tone now that I was out on my own and could do whatever I wanted. Don’t get me wrong: I took pains to remain quite professional. I wore skirts, hose, and heels (sensible low ones, of course) at all times.

Patients noticed, and often commented. My explanations were accepted. It was my style, and I’ve always been comfortable with it. Even when a broken foot 10 years agoled me to begin wearing slacks instead of skirts, I never even considered wearing a white coat.

A SOCIAL Approach to Health Reform

Dec 1, 2018

By Richard Reece, MD

Every Sunday, I read the Sunday NYT in search of ideas for a blog. Today is no exception. I found the idea in Thomas Friedman’s column, “The New IT Revolution,” in which he holds forth as follows,

“The latest phase in the IT revolution is being driven by the convergence of social media- Facebook, Twitter, LinkedIn, Groupon, Zynga- with the proliferation of cheap wireless connectivity and Web-enabled smart phones and “the cloud” – those enormous server farms that hold and constantly update thousands of software applications, which are then downloaded (as if from a cloud) to make them into incredibly powerful devices that can perform myriad tasks.”

The SOCIAL Acronym

Friedman then goes on to quote Marc Benioff, founder of Salesforce.com, who describes this phase of the IT revolution with the acronym SOCIAL.

• S is for Speed – This means physicians and patients can find anything and everything about health care (and each other),

. O is for Open – This means physicians are out in the open and can no longer hide their results or reputation.

• C is for Collaboration – This means physicians must organize among themselves or affiliated hospitals or into loosely coupled teams to take on the new challenges posed by society in general and health reform in particular.

• I is for Individuals – This means anyone – physicians, patients, and entreprenuers – as individuals can reach around the globe to start something or collaborate or consolidate to improve care – faster, deeper, and cheaper – as individuals.

• A is for Alignment – physicians with each other or with supportive health organizations to make sure all your ships are sailing in the same direction.

• L is for Leadership – This means physician leaders are going to have to mixs top-down and bottom-up forces – from public and private sectors – to provide what is best for themselves, patients, and society.

Is the Era of Off-Label Promotion Over?

Dec 1, 2018

By MERRILL GOOZNER

The question arises in the wake of yesterday’s news that the government and GlaxoSmithKline settled a string of lawsuits charging the company with illegal promotion of prescription drugs for unapproved uses. The $3 billion settlement represented just a small fraction of the sales to patients for whom the off-label prescriptions either caused harm or did little or no good.

Glaxo’s chief executive Andrew Witty, in a prepared statement, assured the public that his company has “fundamentally changed our procedures for compliance, marketing and selling in the U.S. to ensure that we operate with high standards of integrity.”

Judging by the number of seminars and conferences over the past few years designed to help companies meet the legal requirements for promoting drugs, there would certainly appear to be a lot more attention being paid these days to staying within the law. There have been 165 settlements between the government and drug companies over the last two decades, and the more recent settlements — $2.3 billion from Pfizer and $1.4 billion from Eli Lilly — have achieved blockbuster status (a word usually reserved for drug sales above $1 billion). While that is affordable for the highly profitable industry, settlements of that size do tend to capture the attention of top company officials and begin to tip the risk-reward ratio for illegal activity toward better compliance with the letter of the law.

Cold Hard Facts or Cold Hard Doctors?

Dec 1, 2018

By Andrew Robinson

I was first diagnosed with leukemia while travelling on a vacation in 1994. I had a persistent respiratory infection so I went to a local emergency room to get an antibiotic. I had the usual tests, including a blood test. A doctor came into the room where I was waiting and introduced himself as an oncologist. He told me that the blood test showed that I had “a terminal and incurable form of leukemia” and “less than five years to live.” Just like that. He also added that I didn’t need to rush back to New York, as there was nothing to be done.

A few months later, I sat in an office in New York of an oncologist who specialized in my form of leukemia. His manner was soft-spoken and warm. He told me that although there was no cure for my disease, there were a number of relatively mild chemotherapies that were effective in extending patients’ lives for many years, and that given developments in research, during the additional time there may well be a cure for my illness.

It turns out that the second doctor was correct. Five years after being diagnosed, bone marrow transplants became available for people my age with chronic leukemia. I had a transplant and a few years after that there was no longer any sign of the disease.

When I inquired with physician friends about my experience with the first doctor, they spoke of doctors’ fear of instilling in patients “false hope.” In my interactions with many cancer patients, I have yet to hear of any patient who felt they were given false hope. But there were many instances of patients, like myself, who were filled with “false despair.”

Now, I can’t imagine how difficult it must be to be an oncologist, to have to tell patients that they have a terminal illness, to see them go through brutal chemotherapies, to see them die. According to one estimate, during the course of their career, an oncologist will break bad news to their patients almost 20,000 times – from first diagnosis to the news that death is near. Yet, many doctors who approach this task in a cold-hearted manner seem to justify themselves with a “tell it like it is” philosophy. Easy for them, devastating for us.

Medical science readily acknowledges the placebo effect – that many patients who believe they are getting an effective medicine show improvement in their condition even when they are in fact not getting the medicine, but are instead receiving a harmless substitute. If the effect of a patient’s positive expectations can so profoundly affect his health, what then is the impact when a patient is, from the outset, given the difficult news about having cancer in a manner that so discourages his spirit?

Most lay people know the fundamental maxim of Hippocrates to physicians throughout the centuries: “First, do no harm.” This has always been understood to have to do with the medicines and treatments that physicians prescribe. In this day and age it applies equally to how doctors talk to and act toward their patients.

Andrew Robinson was a successful New York trial attorney when he was diagnosed with leukemia and told he had less than five years to live. That was more than 15 years ago. He is the founder and CEO of Patient2Patient, a company that develops disease specific guides to help patients learn how to locate and use medical information and resources on the Internet. This post first appeared at Prepared Patient Forum.

New Physicians, Rethink Your Career Path Before Your First Job

Dec 1, 2018

By Melissa Byington

I recently came across an online discussion started by a graduating resident who was looking for advice on how to combat burnout. While the replies that followed offered all sorts of ideas, everyone seemed to agree that a rigorous schedule and stress and strain on work-life balance is par for the course.

Somebody even quipped that when practicing medicine, you can enjoy two of the following in any combination: 1) live where you want; 2) earn what you want; and 3) specialize in what you want, but it’s not possible to enjoy all three.

While many physicians would agree with that belief, I’d like to suggest considering locum tenens – this option proves that enjoying all three is possible.

Locum tenens is a highly respected practice alternative that offers physicians a full spectrum of professional opportunities in every type of practice across the country. Hospitals and healthcare facilities use locum tenens to cover for planned or sudden staff vacancies, and to strategically prepare for the highs and lows of patient demand. It’s become an especially attractive alternative for new physicians; among other things, it offers the opportunity to:

· Gain real-world experience and build skill set

· “Road test” different practice settings, options and locations so you can make informed decisions about which is right for you

· Get an insider’s view of practice management and economics

· Enjoy a flexible schedule so you can take time off to travel or pursue interests outside of medicine

· Fill in the gap between residency and fellowship

· Pay off medical school loans before making more financial commitments

· Spend more time practicing medicine and forgo the politics

Don’t gamble with your career

Practicing medicine as a locum tenens buys you time to find your dream job while building up your CV. By working at a variety of practice models, you are demonstrating the ability to adapt to all different practice settings which can give you an edge over competing job candidates when the time is right.

If locum tenens interests you, it’s well worth your time to research healthcare staffing firms to help you find and prepare for job opportunities. Key considerations should include the company’s breadth of resources and contacts, as well as its reputation for integrity and customer service. Of course, pay is important but it’s only part of the picture; you want to be covered from travel and housing to licensure, credentialing and malpractice. A good resource to help you get started is the National Association of Locum Tenens Organizations (NALTO), an industry organization that ensures the fair practices and collaboration of physician staffing organizations.

Locum tenens is a career choice that puts new physicians in the driver’s seat. The work-life balance that eluded your predecessors is now within your reach—yes, you can have it all!

Melissa Byington is president of the locum tenens division of CompHealth, the nation’s leading provider of temporary and permanent physician staffing. She is also a current board member and past president of NALTO.

Violence in the Media Does Matter

Dec 1, 2018

“A thousand studies over the past 40 years have shown that viewing violence in the media changes children’s behavior,” said Michael Rich, MD, Associate Professor of Pediatrics, Harvard Medical School aka the Mediatrician.

Dr. Rich who founded and serves as the Director of the Center on Media and Child Health at Children’s Hospital, Boston reports that viewing violence in the media causes:
1) increased feelings of fear and anxiety in the viewer,
2) desensitizes the viewer, particularly to conflict resolution methods other than violence, and
3) increases the aggressive behavior of the viewer.

A compelling demonstration of the latter was a video taken by hidden camera of toddlers dancing, singing, and shaking maracas after watching a Barney cartoon, and the same toddlers doing karate kicks and tackles on each other after watching a Power Rangers cartoon. (Yes, the girls too.)

Other tidbits that may comfort, or not, us parents and grandparents who wonder about the opportunities and pitfalls of current electronic media include:

1) NO significant learning occurs from viewing a screen until the child is 30 months old. Baby Einstein videos are entertaining, amusing, and hold the child’s attention, but the child under 2 ½ is NOT getting an academic head start on KG. The American Academy of Pediatrics recommends no TV viewing under the age of 2 years., primarily because it substitutes for “more interactive activities that promote brain development”; ie. free play and social interactions.

2) 53% of 2-4 year olds use computers. 39% of 2-4 year olds have Apps and know how to use them on smartphones and iPads.

3) The reason that the kids are so much better at operating the iPads, iPhones, and other smartphones is that these devices are designed to be intuitive. Our adult knowledge retards our intuition. The kids, not burdened with pre-conceived frameworks, enjoy a much faster learning curve. On the downside, the fact that my grandchildren can learn to use these devices so quickly is because the software is designed to be very intuitive and NOT because my offspring are “above average.” Dr. Rich calls kids “Digital Natives” while we adults are “Digital Immigrants.”

4) After 3 years of age ALL media is educational. Studies show that toddlers learn commercial logos, retain the image, and are able to identify them in another context; ie. the grocery store or restaurant.

5) Sesame Street viewing between the ages of 3 and 5 is associated with better school performance and social skills compared to children who did not watch Sesame Street. The differences persist to the age of 17. One of the problems now is that the current demographic of Sesame Street viewers is from 18 months to 3 years of age.

6) 47% of 5-8 year olds have a TV in their bedroom. Studies show that the TV reduces the quantity and quality (flashing lights and changing sounds puts the sleeper “on alert”) of sleep and apparently doubles the risk of developing obesity.

What happens as the kids get older?

1) The average use of electronic media by children ages 8-18 yrs is 7 ½ hours per day, and that study was done before the cell phone “explosion”.

2) The average number of text messages for high school kids is 300-500 per DAY. Those messages have got to be short like “LOL”, “DIY”, or “PRW” , but they count as messages.

3) Vewing sexual content in the media advances the first sexual experience by about 2 years.

4) 58% of high school kids who have experienced electronic cyberbullying have NOT revealed it to their parents because “they wouldn’t understand how it all works.”

5) 85% of teenagers take their cell phone to bed at night. They are never “not connected”. “You never know what people might be texting about you.”

What can you do?

Dr. Rich has some very “simple” and practical recommendations:

1) Remove your child’s computer from his/her room and put it on the dining room table because it is now in a “public place” and the child will self-monitor his/her own use.

2) Move the computers from the dining room table once each day and have a family meal, the single most important influence on children for learning good role models and avoidance of high-risk behavior.

3) If you don’t want your child to use his/her device during meals or family gatherings PUT YOURS DOWN. “Kids hear about 1% of what we say, but see 100% of what we do.”

4) Take the TV out of his/her bedroom, and set the rule that all cell phones rest (recharge) in the kitchen overnight.

5) Increase free play outdoors. Being “Huck Finn with mud between his toes” may better prepare your child for successful problem solving in the modern world than time at video games. (Unless your child aspires to be an Israeli tank driver or a U.S. drone controller.)

Reference:
1) PriMed Continuing Medical Education Conference, Boston, October 29, 2011

Guidelines are in the Eye of the Beholder

Dec 1, 2018

By Dinosaur MD

Cancer. Just the word is scary. Actually, that’s the problem. Once you say that word, the average American will do anything — ANYTHING! — to just get it out of my body!!! Whether or not they have it, whatever the actual numerical chances of their ever developing it, no chance for detecting or treating it should ever be neglected. EVER! Ask any Med-mal lawyer. Better, ask any twelve average people off the street (ie, the ones who are going to wind up on a jury). “The doctor didn’t do every possible test/procedure, and now the patient has CANCER? String him up!”

Hence we have the new guidelines for PSA testing. (Given that many patients with prostate cancer have normal PSAs and lots of patients with high PSAs don’t have prostate cancer, it doesn’t seem semantically correct to call it “prostate cancer screening”.) Surprise! Turns out that not only does PSA testing not save lives, but that urologists don’t really care. Certainly not enough to stop recommending PSAs to just about everyone they can get their hands on.

Nor do breast surgeons have any intention of modifying their recommendations, not only in light of new understandings of the limitations of mammography, but even as their own treatment recommendations contract, becoming ever more targeted and less invasive. I recently heard a local surgeon speak about the progression from radical mastectomies to partial mastectomies to lumpectomies; from axillary node dissections to sentinel node sampling; from whole-breast radiation to intra-cavitary seeds. Listening to him, breast cancer therapy is becoming downright minimalist.

Yet at the end of the talk, when asked about the new recommendations for biennial mammography, his response was, “Every woman should have an annual mammogram starting at age 40. I mean, there are no downsides to mammography.” Never mind the psychological stress of extra views, ultrasounds, and false positives, not to mention the bruising and even skin tearing that I see far more often than I’d like. “No downsides”? Not for him, that’s for sure. When will they realize that mammography catches slower-growing cancers that would be treated just as easily if they were found a year later? Women die of aggressive tumors that pop up between annual mammograms, which by definition would not be detected by standard screening.

The gynecologists are no better. They all still insist on annual visits for paps to find cancers that take 10 years to grow (and then only in the presence of HPV) and pelvic exams that detect, well, nothing. Whether driven by legal concerns or patient insistence, scientifically unnecessary medical care is running rampant in this country, playing a pivotal role in bankrupting us in the Orwellian name of “the best medical care in the world”.

What to do, though?

Don Berwick, Martyr for Socialized Medicine

Dec 1, 2018

By Avik Roy

I have a piece up at National Review in which I reflect upon Don Berwick’s controversial tenure as Administrator of the Centers for Medicare and Medicaid Services, the 800-billion-dollar federal agency that dominates the American health-care landscape. Despite White House rhetoric to the contrary, I write, Berwick “wasn’t done in by Republican intransigence. He was done in by presidential cowardice. And therein lies a microcosm of everything that’s been wrong with Obamacare.”

The thing to understand about Don Berwick is that there are really two Don Berwicks. There’s the Don Berwick who, through the Institute for Healthcare Improvement, has focused on apolitical aspects of health delivery reform. Here’s what I wrote about Berwick in April 2010:

First, the good. Berwick is a serious and credible health-care analyst. In his capacities both as a Harvard professor and as founder and CEO of a Cambridge-based think-tank called the Institute for Healthcare Improvement, he has written extensively about health-care policy in all of the leading scholarly journals. His focus, in most of these writings, is on the quality and efficiency of health care: things like avoiding medical errors and unnecessary spending. He was granted an honorary knighthood by Queen Elizabeth for his role in shaping Tony Blair’s (mostly futile) attempts to modernize Britain’s National Health Service.

While he was a big supporter of Obamacare, Sir Donald acknowledges its core failing; in an October lecture, he said, “Health-care reform without attention to the nature and nurture of health care as a system is doomed. It will at best simply feed the beast, pouring precious resources into the overdevelopment of parts and never attending to the whole — that is, care as our patients, their families, and their communities experience it.” Indeed, if you put Berwick in a room with a leading market-oriented health-care analyst, the two would find broad areas of agreement as to where our health-care system fails patients.

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