THCB

Categories

Above the Fold

The Office Visit Revisited

• 13

By Rob Lamberts, MD

A patient calls or emails me with a problem. I talk with them over the course of a few days, using whatever form of communication works best.  Eventually, they need to come to the office to be seen – either for something needing to be done in-person (examination, procedure, or lab test), or because of the advantages of face-to-face communication.  At the visit, I not only deal with one problem, but there are other issues needing to be addressed.  Finally, after the visit, follow-up on the problem continues until it is either resolved, or at least is not causing much trouble.

So how do I document that?

In the past I would’ve had a clear structure for the “office visit” and separate “encounters” for the documentation of the communication done outside of the office.  The latter would be done largely with narrative of the conversation, and some direct quotes from the patient.  The former, the “office visit” would include:

  • A re-telling of the story of the “chief complaint” and what’s been happening that caused this encounter to be necessary.
  • A sifting through other symptoms and past-problems to see if there is any information hidden there that may be useful.
  • A documentation of past problems (already in the record) to support the thought process documented later in the visit.
  • An overview of the physical exam, again to support the  decisions made as a result of the visit.
  • A discussion of my thoughts on what I think is going on.
  • A telling of my plan on how to deal with this.
  • A list of any advice given, tests ordered, medications changed, prescriptions written, and follow-up as the details of that plan.
  • A signature at the end, attesting to the validity of what is contained in the note.

But here’s the problem: it’s not real.  I don’t make all of my decisions based on the visit, and the patient’s story is not limited to what they tell me.  Details may be left out because they are forgotten, questions aren’t asked, or things just haven’t happened yet.  This signed and sealed unit of care, represented as a full story, actually represents only fragments of the story, of many stories actually, and only as a moment on the continuum of the patient’s care.
Continue reading…

Blood Pressure Monitoring, Telemedicine, and Automated Hovering: A Future Model for Disease Management?

• 7

By Mike Miesen

Use of an at-home telemonitoring blood pressure device significantly reduced out-of-control high blood pressure, according to a recent study in the Journal of the American Medical Association. It’s another data point showing the potential of telemedicine to have a profound effect on American medicine, by positively modifying health behaviors, providing real-time data to clinicians through “automated hovering,” and helping Americans get and stay healthy – all of which holds the promise of bending the cost curve.

Led by Karen Margolis, MD, MPH, a Senior Investigator at Health Partners Institute for Education and Research, the cluster-randomized study investigated whether using a cloud-connected, at-home blood pressure monitor paired with pharmacist and case manager support would lead to controlled blood pressure more than typical care, which involved check-ups with a physician.

Those using the telemonitoring device were 90% more likely to have controlled blood pressure at both the six and twelve-month checkups than the control group (57.2% and 30%, respectively), and had, on average, statistically significant lower systolic and diastolic readings.
Continue reading…

What Happens In New York Stays In New York

• 4

By David Dranove

While sitting in the crowded waiting room of a medical specialist’s office I was forced to listen to the television set directly over my head. Cranked up so that everyone could listen above the din of conversation, Wolf Blitzer introduced a video clip of the President hailing the latest news from New York about health insurance exchanges.

Speaking as if he was still on the campaign trail, the President’s words came through loud and clear over the television: thanks to his health reform, premiums in the New York exchange would be half that of premiums in the individual market. This was a model the entire nation should embrace.

No one heard me mutter under my breath that this was a model for New York and a small handful of other states that previously regulated their individual insurance markets effectively out of existence.

What the President undoubtedly knows, but dared not say, is that New York’s individual insurance market is unlike any other state. In New York, insurers cannot charge higher premiums to high risk enrollees.

————————————————————————-
Health 2.0 EDU offers online classes with the world’s top experts in health care and information technology. Tuesday, July 23rd at 3pm/6pm ET join Alteryx ‘s George Mathew as he explains Customer Analytics: Leveraging Data Blending & Predictive Modeling for Member/Patient Satisfaction. Sign up here.
————————————————————————-

As a result of this aggressive community rating, high risk individuals are disproportionately represented in New York’s individual policy risk pools. This drives up premiums, which drives away low risks, driving premiums even higher. Insurers in New York are counting on the purchase mandate, combined with purchase subsidies, to lure low risks into the pool.

This is why they have lowered premiums.

Continue reading…

The EHR Debate: Fighting the Last War?

• 146

By Matthew Holt

Right now there’s a fierce debate going on for the hearts and minds of health IT. Finally American health care (well, half of it anyway) is using electronic medical records. But it’s not the panacea we were lead to believe. Costs haven’t gone down, health hasn’t markedly improved and the taxpayer/Chinese government is poorer. So too are many doctors and hospitals, and the main beneficiaries appear to be construction companies in Madison, Wisconsin.

Worse, those who promote the impact and importance of EMRs (Farzad Mostashari, Ashish Jha) are being attacked by Ross Koppel, Steve Soumerai, Scott SIlverstein and others who essentially say that EMRs are more dangerous and inefficient than paper.

This reminds me of the World War One British Army preparing to fight in the mud of Flanders with cavalry charges suited to the Boer War, the French Army in 1939 retreating to their WWI style trenches while the Germans flew over them, and (dare I say it) today’s TSA strip searching grandmothers looking for boxcutters.

Yes, we’re having the wrong fight by focusing on old problems. The EMRs that are producing the studies we’re fighting about are the current equivalent of 1990s EPR implementations. In general they’re hard to use and require lots of money and training to produce halfway decent results. The real improvements from IT came when user-centered tools came to consumers and then to business with Web 2.0 and new devices like the iPhone.

It may take months of training on Epic or Cerner to get a doctor or nurse to be three-quarters as productive as they used to be, but my two-year-old daughter can fire up an iPad and play games and watch videos with no training.What we’re seeing every day at Health 2.0 is a whole new generation of data-driven applications and devices that are going to make the health care user experience much more like the one my daughter has.

When we get there, the real improvements in both productivity and safety, as well as in quality and even cost, will emerge and we’ll wonder why we ever were having this fight.

More Work Is Needed on the Safety and Efficacy of Healthcare Information Technology

• 40

By Stephen Soumerai & Ross Koppel

If one were writing about the improvement of gastronomy in America, one would probably not celebrate “over 300 billion hamburgers served.”  But that’s very much the type of success Dr. Ashish Jha is celebrating in last week’s piece on recent US healthcare IT sales. Unfortunately, the proliferation of Big Macs does not reflect superior cuisine, and healthcare IT (HIT) sales do not equate with better healthcare or with better health. Quantity does not equal quality of care.

To be sure, Dr. Jha acknowledges the challenges of rolling out HIT throughout US hospitals. And he should be strongly commended for his admission that HIT doesn’t capture care by many specialists and doesn’t save money. In addition, Dr. Jha points to the general inability of hospitals, outpatient physicians and laboratories to transfer data among themselves as a reason for HIT’s meager results.

But this is a circular argument and not an excuse. It is the vendors’ insistence on isolated proprietary systems (and the government’s acquiescence to the vendors) that created this lack of communication (non-interoperability) which so limits one of HIT’s most valuable benefits.

In our opinion, the major concern is that the blog post fails to answer the question we ask our PhD students:

So what? What is the outcome?

This entire effort is fueled by $29 billion in government subsidies and incentives, and by trillions of dollars spent and to be spent by hospitals, doctors and others [1].

So where is the evidence to back up the government’s and industry’s promises of lower mortality, improved health and lower health care costs?

Single studies tell us little. Sadly, as many as 90% of health IT studies fail the minimal criteria of the respected international literature syntheses conducted by the Cochrane Collaboration.

In other words, studies with weak methodology or sweetheart evaluation arrangements just don’t count as evidence.
Continue reading…

Flipping the Doctor’s Office

• 14

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?
Continue reading…

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.
Continue reading…

The Samurai Physician’s Teachings on the Way of Health

• 7

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.
Continue reading…

Five Potential Healthcare Applications for Google Glass

• 12

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.

Continue reading…

Why You Should Care About the Drugs Your Doctor Prescribes

• 25

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.
Continue reading…

assetto corsa mods