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Flipping the Doctor’s Office

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By Thomas Goetz

Consider the doctor’s office: the sanctum of care in American medicine, where a patient enters with a need — a question or an ailment or a concern — and leaves with an answer, a diagnosis or a treatment. That room, with its emblematic atmosphere of exam table and tiny sink and bottles of antiseptic, is in many ways the engine of our health care system, the locus of all our collective knowledge and all our collective resources. It’s where health care happens.

But in a less sentimental light, the doctor’s office doesn’t seem so exalted. Yes, it remains the essential hub for clinical care. But what occurs in that room isn’t exactly ideal, nor state-of-the-art. The doctor-patient encounter is fraught with tension, asymmetrical information, and flat-out incomprehension. It is a high-cost, high-resource encounter with surprisingly limited value and limited returns. It is too cursory to be exhaustive (the infamous fifteen-minute median office visit), too infrequent to create an honest relationship (one or two times a year visits at best), and too anonymous to be personal (the average primary care doc has more than 2,300 patients).

At best, it offers a rare personal connection between doctor and patient. At worst, it is theater. The doctor pretends she remembers the patient, and that she has actually had the time to read the patient’s chart in full; the patient pretends that he hasn’t spent hours on the Internet trying to diagnosis himsef, half-admitting what he’s really doing day to day, and pretending he won’t second- guess the doctor’s orders the moment he gets back to a computer.

As woeful as that sounds, we know that there’s real value here. This encounter can be meaningful; it should and must be meaningful. The doctor is a necessary interface to medicine, and his office is a source of care, expertise, and trust. The patient is eager and receptive to learning, primed for guidance and direction. Pragmatically, the doctor’s visit is a powerful part of modern medicine. The problem is that we, collectively, are not optimizing this resource; we have not reconsidered and re-evaluated how we might exploit the visit to its full advantage.

So how can we improve this situation? How can we fix this thing?
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What You Need to Know About Obamacare Scams

By Sean Boulger

The FTC has found that healthcare fraud has been on the rise lately, and will likely continue to increase until October. Let’s talk about how to spot the scams and avoid any problems when you’re ready to make the switch over to Obamacare.

The Obamacare Card Scam

One of the most popular healthcare scams that’s  been circulating as October 1st approaches is known as the “Obamacare card.” It’s a technique used by fraudsters to steal consumers’ credit card information and social security numbers.

How does the Obamacare card scam work? Basically, victims get a phone call from someone claiming to represent the government. The caller informs them that they need this insurance card to be eligible for coverage under the Affordable Care Act, or they may say the Obamacare card provides extra discounts. They ask for private personal information so they can send you the card.

But there’s no such thing as an Obamacare card — you’re just giving your info to scammers and identity thieves.

The health insurance marketplace goes into effect in October, and the FTC expects the number of related scams to rise in the meantime.

The Information Update Scam
Another popular scam involves fraudsters posing as Medicare officials. These fake Medicare representatives call consumers and say they’re updating or verifying personal information. The consumers are told that they might face some sort of consequence if they don’t comply.

The Sacramento Bee has more:

“…impostors claiming to be from Medicare told consumers they needed to hand over their personal or financial information in order to continue eligibility because ‘change is on the horizon.’

But nothing in the Affordable Care Act threatens existing benefits or medicare Enrollees…”

In other words, you shouldn’t be getting any Medicare calls because of the Affordable Care Act. If you have concerns about your Medicare benefits, don’t respond to a cold-caller. Instead, contact your Medicare representatives directly.
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The Samurai Physician’s Teachings on the Way of Health

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By Country Doctor

Every now and then the title of a book influences your thinking even before you read the first page.

That was the case for me with Thomas Moore’s “Care of the Soul” and with “Shadow Syndromes” by Ratley and Johnson. The titles of those two books jolted my mind into thinking about the human condition in ways I hadn’t done before and the contents of the books only echoed the thoughts the titles had provoked the instant I saw them.

This time, it wasn’t the title, “Cultivating Chi”, but the subtitle, “A Samurai Physician’s Teachings on the Way of Health“. The book was written by Kaibara Ekiken (1630-1714) in the last year of his life, and is a new translation and review by William Scott Wilson. The original version of the book was called the Yojokun.

The images of a samurai – a self-disciplined warrior, somehow both noble master and devoted servant – juxtaposed with the idea of “physician” were a novel constellation to me. I can’t say I was able to predict exactly what the book contained, but I had an idea, and found the book in many ways inspiring.

The translator, in his foreword, points out the ancient sources of Ekiken’s inspiration during his long life as a physician. Perhaps the most notable of them was “The Yellow Emperor’s Classic on Medicine”, from around 2500 B.C., which Ekiken himself lamented people weren’t reading in the original Chinese in the early 1700′s, but in Japanese translation. One of his favorite quotes was:

“Listen, treating a disease that has already developed, or trying to bring order to disruptions that have already begun, is like digging a well after you’ve become thirsty, or making weapons after the battle is over. Wouldn’t it already be too late?”

Ekiken’s own words, in 1714, really describe Disease Prevention the way we now see it:

“The first principle of the Way of Nurturing Life is avoiding overexposure to things that can damage your body. These can be divided into two categories: inner desires and negative external influences.

Inner desires encompass the desires for food, drink, sex, sleep, and excessive talking as well as the desires of the seven emotions – joy, anger, anxiety, yearning, sorrow, fear and astonishment. (I see in this a reference toarchetypal or somatic medicine.)

The negative external influences comprise the four dispositions of Nature: wind, cold, heat and humidity.

If you restrain the inner desires, they will diminish.

If you are aware of the negative external influences and their effects, you can keep them at bay.

Following both of these rules of thumb, you will avoid damaging your health, be free from disease, and be able to maintain and even increase your natural life span.”

On the topic of Restraint, the Yellow Emperor text states:

In the remote past, those who understood the Way followed the patterns of yin and yang, harmonized these with nurturing practices, put limits on their eating and drinking, and did not recklessly overexert themselves. Thus, body and spirit interacted well, they lived out their naturally given years, and only left this world after a hundred years or more.
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Five Potential Healthcare Applications for Google Glass

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By John Halamka, MD

Last week I had the opportunity to test Google Glass.

It’s basically an Android smartphone (without the cellular transmitter) capable of running Android apps, built into a pair of glasses.  The small prism “screen” displays video at half HD resolution.  The sound features use bone conduction, so only the wearer can hear audio output.   It has a motion sensitive accelerometer for gestural commands.    It has a microphone to support voice commands.   The right temple is a touch pad.  It has WiFi and Bluetooth.   Battery power lasts about a day per charge.

Of course, there have been parodies of the user experience but I believe that clinicians can successfully use Google Glass to improve quality, safety, and efficiency in a manner that is less bothersome to the patients than a clinician staring at a keyboard.

Here are few examples:

1.  Meaningful Use Stage 2 for Hospitals – Electronic Medication Admission Records must include the use of “assistive technology” to ensure the right dose of the right medication is given via the right route to the right patient at the right time.   Today, many hospitals unit dose bar code every medication – a painful process.   Imagine instead that a nurse puts on a pair of glasses, walks in the room and wi-fi geolocation shows the nurse a picture of the patient in the room who should be receiving medications.  Then, pictures of the medications will be shown one at a time.  The temple touch user interface could be used to scroll through medication pictures and even indicate that they were administered.

2.  Clinical documentation – All of us are trying hard to document the clinical encounter using templates, macros, voice recognition, natural language processing and clinical documentation improvement tools.     However, our documentation models may misalign with the ways patients communicate and doctors conceptualize medical information per Ross Koppel’s excellent JAMIA article.  Maybe the best clinical documentation is real time video of the patient encounter, captured from the vantage point of the clinician’s Google Glass.   Every audio/visual cue that the clinician sees and hears will be faithfully recorded.

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Why You Should Care About the Drugs Your Doctor Prescribes

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By Charles Ornstein & Tracy Weber

The following column appears today on THCB, in the op-ed pages of the Los Angeles Times and at ProPublica.

Your doctor hands you a prescription for a blood pressure drug. But is it the right one for you?

You’re searching for a new primary care physician or a specialist. Is there a way you can know whether the doctor is more partial to expensive, brand-name drugs than his peers?

Or say you’ve got to find a nursing home for a loved one. Wouldn’t you want to know if the staff doctor regularly prescribes drugs known to be risky for seniors or overuses psychiatric drugs to sedate residents?

For most of us, evaluating a doctor’s prescribing habits is just about impossible. Even doctors themselves have little way of knowing whether their drug choices fall in line with those of their peers.

Once they graduate from medical schools, physicians often have a tough time keeping up with the latest clinical trials and sorting through the hype on new drugs. Seldom are they monitored to see if they are prescribing appropriately — and there isn’t even universal agreement on what good prescribing is.

This dearth of knowledge and insight matters for both patients and doctors. Drugs are complicated. Most come with side effects and risk-benefit calculations. What may work for one person may be absolutely inappropriate, or even harmful, for someone else.

Antipsychotics, for example, are invaluable to treat severe psychiatric conditions. But they are too often used to sedate older patients suffering from dementia — despite a “black-box” warning accompanying the drugs that they increase the risk of death in such patients.
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Really Meaningful Use

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By Rob Lamberts, MD

It has been nearly 6 months since I started my new practice, since I took the jump (or, more accurately, was pushed off the ledge) into a brave new world.  It seems very distant, like I should get Shirley MacLaine or Gwyneth Paltrow to help me channel my old sad self.  It is tempting.

I have a vague recollection, a memory shrouded in mist, where I pondered what seemed like a radical question: What would a health record look like if my only concern was patient care? This was a radical question because in my previous life I was an electronic health record aficionado.  I was good at EMR, which meant that I was really good at finding work-arounds:

  • How can I work around the requirements for bloated documents and produce records that are actually useful?  The goal of records in that previous life was to justify billing, not for patient care.
  • How can I work around the financial necessity to keep my schedule unreasonably full and keep my visits unreasonably short and still give good care?
  • How can I work around the fact that I am paid better when people are sick and still try to keep them healthy?
  • How can I work around the increased amount of my time devoted to qualifying for “meaningful use” and still give care that is meaningful?

Computers were all about automating the drudgery, organizing the chaos, and carving out a sliver of time so I could spend the extra minutes needed to give the care I wanted to give.  I was using them to give good care despite the real nature of the medical record: a vehicle for billing.

But that was my past life. Now I no longer have to worry about a Medicare audit (and the looming threat of an accusation of “fraud” for simply not obeying the impossible documentation rules).  I no longer have to keep my office full and my patients sick enough to pay the bills.  I am actually rewarded for handing problems early, for communicating well, and for keeping patients healthy and happy, as it keeps them paying the monthly subscription fee.

Ironically, in asking the question, what would a health record look like  if my only concern was patient care,  I was really asking the question: What does “meaningful use” of the record really look like?

Now this question is no longer a hypothetical; it is real.
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Bringing Nurses Into the Cost Containment Discussion

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By September Wallingford, RN

Why are nurses not usually integrated into the cost containment discussion? Why have we not been invited to the table? Likely, it is because we don’t have the power to order (or discontinue) tests, labs, or medications, all of which are major factors in the rising costs of care. Even so, a nursing perspective can be important and should be considered when doctors make treatment decisions.

For example, I recently treated a patient who had undergone abdominal surgery. Despite uncomplicated post-operative days 1 and 2, on day 3, he developed nausea, vomiting, and an increasingly distended abdomen. I administered intravenous anti-nausea medications, along with back rubs and cool cloths on his forehead. None of the treatments worked. While waiting for the doctor, I sat with the patient and spoke to him about the possibility of receiving a nasogastric tube to alleviate his symptoms. Given an understanding of the process, the patient agreed to this possibility and I paged the doctor once again. The doctor eventually placed the nasogastric tube, the tube was connected to suction, and out came a liter of gastric contents.

I then noticed that the doctor had put in an order for an abdominal x-ray to “check nasogastric tube placement.” Seeing this, I initiated a conversation with the doctor to discuss the patient’s symptomatic improvement as well as his current state of exhaustion. I assured the doctor that nurses would be at the patient’s bedside to monitor for signs and symptoms of tube malfunction. As a result, the doctor cancelled the x-ray, which not only eliminated an unnecessary test for the patient, but also reduced the cost associated with his care.
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The Affordable Care Act and the Death of Personal Responsibility

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By Vik Khanna

I was a chubby kid, which brought with it all manner of slights, both real and imagined.  My predicament was worsened because I came from an immigrant family, and my father was tormented by unrelenting and untreated bipolar disease.  When he was lucid, however, he taught essential lessons that neither he nor I knew at the time would become my life’s cornerstone: don’t trust the professions too much; advance your own cause through limitless learning; and, use exercise — all forms of it — as an irreplaceable lever for personal betterment.  My dad may have been out of it more often than not, but he swam, did calisthenics, played tennis, and boxed, and he walked vigorously right up until the end of his life.  I saw, I learned, I did (and still do).

Imagine, then, my chagrin at how the Affordable Care Act (ACA) effectively shears away the concept of personal responsibility and mastery of lifelong wellness skills  from the pursuit of actual health.  It was a huge missed opportunity to teach Americans about what’s first in the line of responsibility for good health.

Instead, the ACA’s philosophical foundation ignores the power that individuals have to impact their personal health trajectory, and it compels Americans to accept lifelong roles as patients in a system that many of them not only don’t want any part of but that they distrust and don’t understand.  It is exactly the opposite result that something called “health” reform should have produced.

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As the Debate Over Obamacare Implementation Rages, a Success on the IT Front

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By Ashish Jha, MD

Just a little over four years ago, President Obama, in his inaugural address, challenged us as a nation to “wield technology’s wonders to raise health care’s quality and lower its costs.”  This was an awe-inspiring, “we will go to the moon” moment for the healthcare delivery system.  But the next thought that ran through the minds of so many of us who work on health IT issues was this: how were we going to get there?

We were essentially starting from scratch.  Less than 1 in 10 hospitals had an electronic health record, and for ambulatory care physicians, the numbers weren’t much better – about 1 in 6 had an EHR.  Hospitals and physicians reported an array of challenges that were holding them back.  No nation our size with a healthcare system as complex as ours had even come close to universal EHR use.  Yet, the President was calling for this by just 2014.

And it was clear why.  The promise of EHRs was enormous and we knew that paper-based records were a disaster.  They lead to lots of errors and a lot of waste.  I have cared for patients using paper-based records and using electronic records – and I’m a much better clinician when I’m using an EHR.  In the weeks that followed Obama’s inaugural address, the U.S. Congress passed, and the President signed the Health Information Technology for Economic and Clinical Health Act, which contained a series of incentives and tools to drive adoption and “meaningful use” of EHRs. None of us knew whether the policy tools just handed to the Obama administration were going to be enough to climb the mountain to universal EHR use.  We were starting at sea level and had a long climb ahead.
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How Digital Technology is Transforming Value in Health Care

By Robin Friedlander, MD

Health 2.0 has collaborated with UC Berkeley’s Haas School of Business to offer a first of its kind executive education course to be held this October 3rd-5th in Berkeley, California.

How Digital Technology is transforming Value in Health Care is a three-day course for health care leaders and executives in health IT who will benefit from expert instruction, critical analysis, and high-level discussion around this rapidly changing and exponentially growing area. Digital technology impacts nearly all aspects of health care today, and yet so much of this technology is new to those at the front lines of improving care delivery, be they on the payor side, provider side or service side.

Professors including Bob Rogers PhD, chief data scientist at Apixio, Ann O’Leary, chief expert on the organization and financing of the health care system at Berkeley School of Law, and Jaspal Sandhu PhD, systemic innovation expert, will cover topics including big data, policy and regulatory issues in health IT, and patient-centered design.

The Health 2.0-Berkeley course is part of a larger initiative, Health 2.0 EDU, which is a response to widespread demand for a targeted, learning objectives-driven, and comprehensive education program for the health care and health IT communities. EDU brings draws upon Health 2.0’s seven year history of curating and presenting excellent content as well as its worldwide network of leaders in health care technology. Health 2.0 EDU also offers online courses and workshops through a new virtual learning center.

For those who plan to come to the Health 2.0 Fall Conference, registration for the Health 2.0-Berkeley course grants you a 50% discount for the conference ticket. Space is limited – you can register early here.

Robin Friedlander, MD is the senior director of consumer and academic programs at Health 2.0.

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