The Health Care Blog – Page 598 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

Above the Fold

“Unaccountable” An Important, Courageous and Deeply Flawed Book

Nov 5, 2012• 16

By ROBERT WACHTER, MD

In his new book, Unaccountable: What Hospitals Won’t Tell You and How Transparency Can Revolutionize Health Care, Johns Hopkins surgeon Marty Makary promises a “powerful, no-nonsense, nonpartisan prescription for reforming our broken health care system.” And he partly delivers, with an insider’s and relatively unvarnished view of many of the flaws in modern hospitals. Underlying these problems, he believes, is an utter lack of transparency, the sunshine that could disinfect the stink.

The thesis is important, the honesty is admirable, and the timing seems right. Yet I found the book disappointing, sometimes maddeningly so. My hopes were high, and my letdown was large. If your political leanings are like mine, think Obama and the first debate.

Makary hits the ground running, with the memorable tales of two surgeons he encountered during his training: the charming but utterly incompetent Dr. Westchester (known as HODAD, for “Hands of Death and Destruction”) and the misanthropic “Raptor,” a technical virtuoso who was a horse’s ass. Of course, all the clinicians at their hospital knew which of these doctors they would see if they needed surgery, but none of the patients did. (Of HODAD, Makary writes, “His patients absolutely worshipped him… They had no way of connecting their extended hospitalizations, excessive surgery time, or preventable complications with the bungling, amateurish, borderline malpractice moves we on the staff all witnessed.”)

This is compelling stuff, and through stories like these Makary introduces several themes that echo throughout the book:

1) There are lots of bad apples out there.

2) Patients have no way of knowing who these bad apples are.

3) Clinicians do know, but are too intimidated to speak up.

4) If patients simply had more data, particularly the results of patient safety culture surveys, things would get much better.

The Election and Healthcare IT

Nov 5, 2012• 4

By JOHN HALAMKA, MD

Tomorrow the Presidential election process comes to an end and the advertising will finally stop. We’ll all be relieved. I especially look forward to a quiet dinner at home without robotic election-related calls.

What about healthcare IT? Will differences in the Obama and Romney platforms impact the momentum of Meaningful Use?

Here’s what I believe.

The Obama Healthcare IT platform builds on what we’ve created over the past few years. It will continue to leverage the federal advisory committees (Policy and Standards) to engage a wide array of stakeholders. It will persist the progression to Meaningful Use Stage 3 and possibly future stages. It will embrace certification now the temporary certification process has been replaced with a permanent one. It will support the initiatives of the Standards and Interoperability framework (S&I), although the end of stimulus funds from ARRA means that ONC will move some of the S&I initiatives to private/public partnerships. It will support the current leadership at ONC – Farzad and his delegates such as Steve Posnack, Doug Fridsma, and Judy Murphy.

The Romney Healthcare IT platform notes that Healthcare IT is an issue which has broad bipartisan support. No one argues that a foundation of healthcare IT implemented properly is essential for accountable care organizations. Quality, safety, and efficiency all benefit from the process enhancement afforded by healthcare IT. Michael Leavitt, former Secretary of HHS and chair of the American Health Information Community (AHIC) will lead the Romney transition team and Leavitt has years of experience with healthcare IT issues from the early days of ONC. As Governor of Massachusetts, Romney supported the early EHR rollout efforts of the Massachusetts eHealth Collaborative.

Physician Assisted Suicide in Massachusetts

Nov 4, 2012• 7

By Holly Fernandez Lynch

Next Tuesday, those of us registered in Massachusetts will have the opportunity to vote on “Question 2″ – prescribing medication to end life, otherwise known as physician-assisted suicide.

As described by the state secretary, “This proposed law would allow a physician licensed in Massachusetts to prescribe medication, at a terminally ill patient’s request, to end that patient’s life. To qualify, a patient would have to be an adult resident who (1) is medically determined to be mentally capable of making and communicating health care decisions; (2) has been diagnosed by attending and consulting physicians as having an incurable, irreversible disease that will, within reasonable medical judgment, cause death within six months; and (3) voluntarily expresses a wish to die and has made an informed decision.”

There are, of course, a number of other safeguards built in, such as the need to make the request twice, separated by 15 days, in the presence of witnesses. However, there could probably be stronger safeguards to protect individuals who are experiencing depression and anxiety, and might have preferable alternatives to physician-assisted death.

Vote No On Physician-Assisted Suicide

Nov 4, 2012• 3

By Mary Louise Ashur, MD

“I will give no deadly medicine to any one if asked, nor suggest any such counsel.” This is an excerpt from The Hippocratic Oath – the oath that guides my practice as a physician. On the November ballot, the Massachusetts Question 2 about physician assisted suicide, runs contrary to the foundation of medical practice. Since the 5th century BC when Hippocrates crafted the oath, the notion of Physician Assisted Suicide (PAS) has been debated in Western Society and repeatedly rejected as a violation of civilized behavior.

If adopted, MA Question 2 would legalize PAS for terminally ill patients who have fewer than six months to live. The assumptions underlying this question are erroneous. In 27 years as a primary care physician, I have never told a patient how long he or she has to live. An individual lifespan is scientifically impossible to predict with exactness. Time and time again, standards in medical literature that project survival for particular diagnoses are wrong. Today in my practice, I have numerous vibrant patients who have long outlived calculated life spans. This is not only for people with cancer, but diseases like multiple sclerosis, chronic obstructive pulmonary disease, kidney failure and heart failure. I never tell my patients how long they have to live. Why? Because the best prediction is based on old literature and past practice. New therapies combined with preventive and behavioral medicine change the true experience of each disease.

What motivates some people to elect PAS? Those who support Question 2 typically cite the patient’s right to self-determination and desire to avoid pain. But, the little we know from pre-death interviews in states such as Oregon, Montana and Washington shows otherwise. Some patients claim that it is their inability to do what they want to do that motivates their desire for death. Not wanting to burden loved ones can also motivate the choice to elect suicide. For my work as a physician, part of the job is helping patients and families to adjust to new circumstances. People who fear losing control of basic bodily functions can grow to realize that their humanity is about so much more than those acts. Despite new limitations, they can still fulfill significant roles in their communities and families. Furthermore, clinical depression is present in at least 25 percent of people with chronic illness. Depressed people think about suicide. Depression, however, is treatable. Question 2 does not mandate that the patient submit to evaluation and therapy for depression. Furthermore alleviating pain and suffering is the objective of all doctors. Some even specialize in hospice and palliative care.

The Doctor as Patient

Nov 4, 2012

By James Salwitz, MD

Terry is a particularly difficult patient. She is not hard because of her cancer, which is in remission, nor is there a problem with pain, of which she has little, and Terry is not particularly demanding for the nursing staff. No the real problem, the challenge, the thing that makes her so difficult is that Terry is married. Terry is married to Dr. P and he is a particularly difficult man.

Terry’s husband loves Terry very much. He wants her to have the very best care. Dr. P makes certain that all the doctors know everything that is going on, all the time; he makes sure the nurses are on top of every detail; he demands the best from the all the hospital staff. In fact, Dr. P works so hard to control Terry’s care, to stay on top of her case, to monitor every moment, it is nearly impossible to take care of Terry.

There are many challenges for doctors taking care of other doctors or their families, or, in reverse, there are many challenges for doctors when they seek care for themselves and their families. The result of this conflict is often inferior medical care. Therefore, wanting to honor and help doctors get good quality treatment let us take a moment to review the doctor verses doctor verses medical system dilemma.

First, it is hard for doctors to decide where to go for medical care. If you stay in the same community where you practice you lose some privacy and perhaps even respect in the physician community. Who do you chose and how do you avoid offending the other physicians you do not use? If you leave your own area, you lose the convenience and familiarity of getting care close to home.

Doctorology: Communication. It’s All Good

Nov 3, 2012• 6

By Dinosaur, MD

“Doctor’s office; please hold.”

You’ll never hear that when you call me. Never. You’ll also never get an automated answering system (I’m just referring to office hours, of course. Evenings and weekends the phone goes to Google Voice. More on

that below.) We are also in the middle of a communication revolution. There are now so many other ways patients can contact me other than the telephone, the silly thing is almost becoming obsolete. I took amoment the other day just to go through all the various ways patients contact me.

Telephone

Still the most reliable fallback. Most synchronous form of communication: both parties willing and able to talk in real time. After hours, Google Voice (free) transcribes messages and texts them to my smart phone. As a rule, patients do not call my cell phone, although I’m not shy about giving out the number. Then again, those who have my cell number usually use it for…

Texting

At the moment, it’s just a few patients, but I anticipate more and more of them will partake as time goes on. It doesn’t happen very often, and so far it’s never been inappropriate. Med refill requests and pictures of kids’ rashes have been the mainstay so far. I like it. By it’s very nature, the people choosing to text me understand the limitations of synchronicity, ie, they don’t get bent out of shape if I don’t answer them right away, and they understand that it’s just for relatively minor issues. I also use it to communicate simple quick questions to specialists with all the same mutual understandings (minor issues only; response time unimportant).

Healthcare Law on the Ballot

Nov 2, 2012• 10

By David Merritt

Ezra Klein is right. In a recent Washington Post column, the left-leaning policy wonk laid plain that the future of ObamaCare is at stake in next week’s elections. If President Obama wins and Democrats hold the Senate, the Affordable Care Act will survive. If Mitt Romney wins and Republicans take the Senate, the law is dead. It is the starkest of differences.

How likely is each scenario? At this moment Democrats have the advantage. According to Real Clear Politics, the president is running slightly ahead in six out of ten battleground states. He could actually lose seven of these, but still be reelected if he hangs onto Ohio, Wisconsin, and Iowa.

While key Senate races have tightened, such as Tommy Thompson in Wisconsin, Democrats have a slight advantage there too. If the elections were held today, Republicans would fall two seats short.

What would this future look like? Implementing ObamaCare would be accelerated. HHS and states will have less than fourteen months to finalize major provisions of the law before they take effect on January 1, 2014.

Thousands of pages of regulation will be released shortly after the election, on everything from IRS rules for employers to essential health benefits to covering pre-existing conditions. It remains to be seen how prescriptive these regulations would be.

State officials will have to submit a blueprint for their insurance exchanges by November 16th. They will need to decide if they will create and exchange and how it will be designed.

They will also have to decide whether to expand their Medicaid programs, and they’ll need to determine essential health benefits and benchmark plans for the insurance options to be sold through their exchanges.

The Unheard Heart: A Metaphor For Medicine In the Digital Age

Nov 2, 2012• 10

By Clifton Meador, MD

A few months ago, a young cardiologist told me that he rarely listens to hearts anymore. In a strange way, I was not surprised.

He went on to tell me that he gets all the information he needs from echocardiograms, EKGs, MRIs, and catherizations. In the ICU, he can even measure cardiac output within seconds. He told me that these devices tell him vastly more than listening to out-of-date sounds via a long rubber tube attached to his ear.

There was even an element of disdain. He said, “There is absolutely nothing that listening to hearts can tell me that I don’t already know from technology. I have no need to listen. So I don’t do it much anymore.”

I began to wonder. I called my longtime friend and colleague, also a cardiologist. I knew him to be one of the best heart listeners. I asked him if he still listens to hearts. He answered, “Of course I do. I could not practice medicine if I didn’t. But you know every week, several patients tell me when I listen to their hearts that I am the first doctor ever to do that. Can you imagine that?”

Playing the devil’s advocate, I challenged my friend to tell me what he learned from listening to hearts.

He answered, “How could anyone not want to hear those murmurs, sometimes ever so soft, like whispers? Murmurs from the heart, even very faint ones, are trying to tell us significant things. Some sounds are very localized, even hidden or obscured by layers of air. And then there is the rhythm and the beat and the cadence that you cannot hear on the paper strip of the EKG. Also, careful listening is the only way to appreciate the rubs of friction if there are any. The devices are important, but the heart has its own spoken and unspoken language if you know how to listen.

Health Care Purchasers, Consumers Need Price Data if We Are Ever Going to Get to a System of Value-Based Care

Nov 2, 2012• 5

By Suzanne Delbanco

In a world where health care costs are rising and consumers are taking on a growing share, it is critical they have easy access to understandable information about the quality and cost of their care. While we have made decent strides in making quality data available, consumers still have little to no information about health care prices, making it difficult if not impossible for them to seek higher-value care. Numerous studies and articles have explored this problem, such as a recent UCSF study, highlighted in JAMA, which found routine appendectomies can cost as little as $1,529 or as much as $183,000. As PBGH Medical Director Dr. Arnie Milstein so eloquently stated in the Wall Street Journal, “Fantasy baseball managers have more information evaluating players for their teams than patients and referring physicians have in matters of life and death.”

Now Catalyst for Payment Reform (CPR), an independent, non-profit corporation working on behalf of large employers and other health care purchasers to catalyze improvements in how we pay for health services, has just released a suite of tools to catalyze price transparency. The suite includes a first-of-its-kind Statement by CPR Purchasers on Quality and Price Transparency in Health Care, endorsed by several partner organizations, that takes plans and providers to task: give us price data by January 2014.

Why Everything You Know About EHR Design Is Probably Wrong

Nov 1, 2012• 23

By Margalit Gur-Arie

Every time someone publishes an article or a paper or a blog post that has anything remotely to do with Electronic Health Records (EHR), there is usually a flurry of reactions in the comments section, now available in most publications, and these always include at least half a dozen anonymous statements, usually from clinicians, decrying the current state of EHR software, best summed up by a commenter on THCB: “It is the user interface stupid!… It has to be designed from the ground up to be an integral part of the patient care experience”. Can’t argue with that now, can you? Particularly when coming from a practicing physician.

And why argue at all? The user interface in any software product is the easiest thing to get right. All you need to do is apply some basic principles and tweak them based on talking to users, listening and observing them in their “natural habitat”. Having done exactly that, for an inordinate amount of time, and being aware that most EHR vendors were engaging in similar efforts, I found the growing discontent with EHR user interfaces somewhat inexplicable. The common wisdom in EHR vendor circles is that doctors are unique in how they work and whenever you have two doctors in a room, there are at least three different preferences in how the EHR should present itself. As a result, you will find that most mature EHRs have dozens of different ways of accomplishing the same thing. These are called “user preferences” and are as confusing as anything you’ve ever seen. Hence the notion that if you spend enough time configuring and customizing your EHR upfront, you will increase your chances of having a less traumatic EHR experience down the road. We were an industry like no other, doomed to build software for users with no common denominator, or so I came to believe, until one afternoon in the summer of 2006…..