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Above the Fold

What I Need

Aug 29, 2013• 18

By Rob Lamberts, MD

So, the question has been raised: why am I doing this? Why re-invent the EMR wheel? What is so different about what I am doing that makes it necessary to go through such a painful venture? I ask myself this same question, actually.

Here’s my answer to that question:

What medical records offer:
High focus on capturing billing codes so physicians can be paid maximum for the minimum amount of work.

What I need:
No focus on billing codes, instead a focus on work-flow.

What medical records offer:
Complex documentation to satisfy the E/M coding rules put forth by CMS.This assures physicians are not at risk of fraud allegation should there be an audit. It results in massive over-documentation and obfuscation of pertinent information.

What I need:
Documentation should only be for the sake of patient care. I need to know what went on and what the patient’s story is at any given time.

What medical records offer:
Focus on acute care and reminders centered around the patient in the office (which is the place where the majority of the care happens, since that is the only place it is reimbursed)

What I need:
Focus on chronic care, communication tools, and patient reminders for all patients, regardless of whether they are in the office or not. My goal is to keep them out of the office because they are healthy.

What medical records offer:
Patient access to information is fully at the physician’s discretion through the use of a “portal,” where patients are given access to limited to what the doctor actively sends them.

Is Big Sugar the Next Liability Target?

Aug 29, 2013• 15

By Vik Khanna

Growing paranoia is the hallmark of the aging process for me. Although I am a generally affable sort (I know, it doesn’t always seem that way from my writing), I am also a fairly suspicious person. I am starting to think that all the food industry’s sweet talk about the innocence of sugar is really just icing on a toxic cake and that we’ve all been sold a bill of goods. In particular, I wonder — and part of me hopes — that Big Sugar might soon replace Big Tobacco as the favorite target of our most underappreciated and misunderstood national resource…the plaintiff’s bar. There is no question we eat way too much sugar and that the increase in consumption has coincided nicely with both our rise in obesity and decline in health status even though we are living longer.

Not that I think the Tobacco Settlement (TS) was great social policy. You can read my full view here; but, to summarize, as an immigrant and a person of color, a part of me resents the TS because all it did is push the burden of fulfillment of the financial terms into the hearts and lungs of people in Africa, Asia, and Latin America. The smug satisfaction of tobacco opponents in the US and their glib dismissal of the impact on predominantly poor people of color around the world is first order racism.

Any analogous move against Big Sugar (BS) could be quite interesting. There is, of course, the delectable duality of “what did they know and when did they know it?”. Recently published opinions and data have forced me to think harder about just what goes on in the labs of companies like Coca Cola, Pepsi, Kellogg’s, Nestle, Domino, Mars, Hershey’s, etc. No doubt BS defenders will say that sugar is “all natural” (ahem, so is tobacco), and safe when used as intended…and, that is where things will start to go awry for them.

Backdated

Aug 28, 2013

Do you use mobile apps to track your health? Do you wish for the ‘one health app to rule them all’? Your wish might be granted soon, and Samsung believes it can beat Apple in this race.

Watch here to see if they are right:

This conversation around the future of digital health innovation is beginning at the Voice of The Body event on Wednesday, May 28th, 2014 at 10:30 AM.

Join the conversation on Twitter with @VoiceofTheBody using #VOTB

The Return of the Greater Common Good

Aug 27, 2013• 40

By Robert Reich

Congress is in recess, but you’d hardly know it. This has been the most do-nothing, gridlocked Congress in decades. But the recess at least offers a pause in the ongoing partisan fighting that’s sure to resume in a few weeks.

It also offers an opportunity to step back and ask ourselves what’s really at stake.

A society — any society —- is defined as a set of mutual benefits and duties embodied most visibly in public institutions: public schools, public libraries, public transportation, public hospitals, public parks, public museums, public recreation, public universities, and so on.

Public institutions are supported by all taxpayers, and are available to all. If the tax system is progressive, those who are better off (and who, presumably, have benefitted from many of these same public institutions) help pay for everyone else.

“Privatize” means “Pay for it yourself.” The practical consequence of this in an economy whose wealth and income are now more concentrated than at any time in the past 90 years is to make high-quality public goods available to fewer and fewer.

In fact, much of what’s called “public” is increasingly a private good paid for by users — ever-higher tolls on public highways and public bridges, higher tuitions at so-called public universities, higher admission fees at public parks and public museums.

Much of the rest of what’s considered “public” has become so shoddy that those who can afford to do so find private alternatives. As public schools deteriorate, the upper-middle class and wealthy send their kids to private ones. As public pools and playgrounds decay, the better-off buy memberships in private tennis and swimming clubs. As public hospitals decline, the well-off pay premium rates for private care.

The Most Effective Obamacare Delay is Defunding

Aug 27, 2013• 14

By Chris Jacobs

There is nothing controversial about stopping Obamacare. A majority of Americans dislike the law and want it repealed. Obamacare is disastrous for individuals, businesses, and doctors alike. It is unaffordable and unworkable, and the Obama Administration has also made it unfair by giving its pet interest groups waivers and opt-outs.

Conservatives are also united behind full repeal of Obamacare, despite what you may hear from the media and liberal operatives. The debate right now is on how this goal is best achieved.

Debate is healthy for society, and also for a movement. Conservatives should not want to become the empty echo chamber that has become the liberal political/media/academic establishment.

With that in mind, let’s turn to the debate over how to save the country from Obamacare. Our view is that the most effective way to delay Obamacare is to cut off funding. Congress can halt Obamacare’s disastrous impact by defunding it entirely before the law’s health insurance exchanges take effect on October 1.

This approach would prevent further implementation of the law; it is the only tactic that fully achieves the objective that advocates of delay seek to accomplish.

Some conservatives believe they can achieve delay without defunding by postponing the individual mandate and employer mandate for one year while leaving firmly in place the massive federal spending on Obamacare’s new health care entitlements—$48 billion next year, and nearly $1.8 trillion over 10 years. Others, acknowledging that a delay of the mandate is insufficient, are now calling for Congress to delay the mandates and the new entitlements.

An “F” for Quality

Aug 27, 2013• 13

By Ken Covinsky, MD

Huge numbers of older persons transition from hospitals to the nursing home. Often, an older hospitalized patient needs skilled nursing care before they are ready to return home. In other cases, a nursing home patient who needed hospitalization is returning to the nursing home. Older patients and their families certainly hope that great communication between the hospital and nursing home would assure a seamless transition in care.

But a rather stunning study in the Journal of the American Geriatrics Society suggests the quality of communication between the hospital and the nursing home is horrendous. The study was led by researchers from the University of Wisconsin, including nurse researcher, Dr. Barbara King and Geriatrician Dr. Amy Kind.

The authors conducted interviews and focus groups with 27 front line nurses in skilled nursing facilities. These nurses noted that very difficult transitions were the norm. Sadly, when asked to give the details of a good transition, none of the nurses were able to think of an example.

Most of the nurses felt that they were left clueless about what happened to the their patient in the hospital. They lacked essential details about their patient’s clinical status. The problem was not the lack of paper work that accompanied the patient. In fact, nurses often received reams of paper work, often over 80 pages. The problem is that the paper work was generally full of meaningless gibberish such as surgical flow sheets that told little about what was actually going on.

Often the transfer information had errors, conflicted with what the facility was told before the transfer, and lacked accurate information about medications.

EveryMove Launches the EveryMove 100 Health Insurance Index

Aug 27, 2013• 3

By Russell Benaroya

If you spend time with health insurance companies there is a lot of discussion about the impact that mobile and social will have on their business ranging from how they market to how they empower consumers to better manage their health. These discussions are not just tactical. They strike at the heart of the transformation that health insurance companies are making to stay competitive, relevant, and attractive for the consumer who is ever more confused, skeptical and apathetic but increasingly powerful. Which health insurance companies are making the early investments in consumer engagement? The EveryMove 100 Health Insurance Index™ launched today to dive into that conversation.

The EveryMove 100 is a list of the top 100 health insurance companies that are making significant strides in engaging with consumers to help them take better control of their health as a partner in health versus just a processor of medical claims. The intent here is to extend the influence of the consumer as they wade into new territory as individually empowered decision makers, whether through state, federal or employer exchanges. The Index evaluated over 50 data elements and over 300 health insurance companies to determine the ranking.

The five primary categories the Index evaluated included:

Social media presence and interactions (breadth and depth of engagement)
Mobile investments (mobile web and app ecosystem)
Website statistics (popularity ranking, refreshed content)
Customer support access (availability/ease of access)
Current consumer satisfaction (what are current members saying)

As you can see this is not an index designed to pass judgment on the quality of the network, timeliness of paying claims, care management efficacy, or other operational metrics. Plenty of other rankings will provide that insight and they are important. The EveryMove 100 is about which health insurance companies are making the investments to win the hearts and minds of the consumer who is going to look for a health insurance partner that makes them feel connected, important, and part of the solution.

Should a Doctor Prescribe Drugs that are Unapproved by the FDA?

Aug 26, 2013• 7

By Juliet Mavromatis, MD

Here’s an interesting clinical dilemma brought to my attention by another physician.

She was asked to refill a prescription for a drug called domperidone to help a patient with lactation. Domperidone is not FDA approved in the United States for any indication. However, in Europe and in Canada it is approved as a promotility agent for patients with a condition called gastroparesis, which causes the stomach to empty very slowly and results in chronic nausea and vomiting. As a side effect the drug is also known to increase the production of prolactin, a hormone that stimulates milk production. In the case of this physician’s patient, she had adopted a child and found that the medication had effectively enabled her to produce milk and nurse, with seemingly no untoward effects. It’s unclear who had initially prescribed the drug, but various online lactation support forums discuss it as an option for women who have trouble with lactation.

The questions: Is it legal, ethical or good medical practice for a physician in the United States to write a prescription for domperidone for a patient who has been using it for lactation with good results? How about for gastroparesis? Where does one get the drug? Is it even legal to sell the drug in the United States?

I’ve cared for at least two patients who have used domperidone. In both instances it was ordered by prescription from an overseas source by a local gastroenterologist. In these two cases my patients had tried just about everything on the market in the United States for gastroparesis and were still struggling with debilitating symptoms. In one case, my patient had required hospitalizations and ultimately a feeding tube because of intractable vomiting. The drug was ineffective in both patients and it was eventually discontinued.

Why Doctors Should Stay Out of the Business of Building EHRs

Aug 26, 2013• 30

By Fred Trotter

The original Hipoocratic Oath states:

I will not use the knife, not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work.

One modern version reads:

I will not be ashamed to say “I know not,” nor will I fail to call in my colleagues when the skills of another are needed for a patient’s recovery.

The idea here is that a doctor needs to recognize when another practitioner has a skill that they do not, and that they must refrain from “practice” when another person has demonstrable expertise in that area of practice.

It is now 2013. It is time for doctors to stop “writing their own EHR” from scratch. They need to bow out of this in favor of people who have developed expertise in the area.

I just found out about another doctor who has decided to write his own EHR, because he has not been able to find one that supports his new direct pay business model adequately. In the distant past I encountered a doctor who believed that his “Microsoft Word Templates” qualified as an EHR system. This is a letter to any doctor who feels like they are comfortable starting from-scratch software development for an EHR in 2013 or later.

You might believe yourself to be an EHR expert.

Are you sure about that? Are you sure that you are not just an EHR expert user?

This difference is not unlike your relationship with your favorite thoracic surgeon. Or for that matter, your relationship with the person who built your car. The fact that you are capable of expertly evaluating and using EHR products does not mean you are qualified to build one. Just like the fact that you are qualified to treat a patient who has recently had heart surgery or to discern when a patient might need heart surgery does not make you qualified to perform that heart surgery. Similarly, the fact that you can drive, or even repair your automobile, does not provide you with the expertise you need to build a car from scratch.

The ethical situation that you are putting yourself in by developing your own EHR is fairly tenuous. Performing heart surgery without being a heart surgeon, building and driving your own car without being an automotive engineer and a doctor coding their own EHR system from scratch all have the same fundamental problem: You might be smart enough to pull it off, but if you don’t you can really mess up another person’s life. Make no mistake, you can kill someone with a shoddy EHR just as easily as by performing medical procedures that you are not qualified for or by driving a car that is not road-safe.

Caregiver Corps: Tapping a Nation of Caring People

Aug 26, 2013• 8

By Janice Lynch Schuster

For better or worse, Twitter can change the world. I got a whiff of that potential last spring,while participating in a regular Twitter chat (#eldercarechat), someone raised (Tweeted?) the question of what we want government to do to improve thelives of the nation’s 60 million caregivers, and added that weneeded something like a PeaceCorps for family caregivers. That idea resonated with me—and with what I myself need at thisjuncture in my life. My young adult children, five between the ages of 19 and 23, struggle to find work—regular work, much less meaningful work—so that they can pay their bills, including college tuition and loans.

My 92-year old grandmother has moved to Alaska to be with my aunt, and spends many of her days alone, her mind still longing for human connections, her body unable to gether there. What if we could buildsomething akin to the Peace Corps,a national program that could simultaneously address a spectrum of issues, such as workforce development, economic security, intergenerational respect, skillbuilding, and national service?

What if a program existed that could, for instance, employ my 20-something kids, rely on the skills and experience of retirees, like my own 69-year-old parents,and provide companionship to mygrandmother?What if we had a CaregiverCorps? I tweeted. Within a day, I had launched a petition to the White House calling for Americato create such a Corps. Within a month, the New Old Age blog of The New York Times had featured the idea.

Even now, late summer, the idea continues to be discussed: mentioned in the Times, and talked about online. Moving from something as ephemeral as a Tweet to somethingas enduring as a national program, of course, will take more than a season. To that end, I have spent subsequent months writing about the idea for various online platforms, and networking with individuals and organizations who are intrigued by the possibility. Anne Montgomery, my colleague at the Center for Elder Care and Advanced Illness at Altarum Institute and a veteran Hill staffer, has done the same.