The Health Care Blog – Page 756 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

Above the Fold

Patients Lie

Jan 26, 2011• 14

By DAVIS LIU, MD

The most common question first year medical students ask me is how do they become efficient at taking a patient history. Can they skip certain parts of taking the patient history and avoid asking about a social history, whether a patient drinks, smokes, uses drugs, or is sexually active?

When can they stop asking about the review of systems, a list of questions asked about each organ system? A comprehensive history is used in the emergency room, hospital, or during an annual physical, not in urgent care or an outpatient appointment, right?

Wrong.

Patients lie and don’t even know it. It’s not that they mean to. In fact, they are trying to be helpful when giving a history of their symptoms. Medical students concerns about taking a fast history reflects two things. First is the reality of the limited amount of face time with patients, which unfortunately seems to be even less than the past. Second, more importantly, is their fascination and desire to get started on real medicine — what are the diagnoses, treatments, and tests that must be learned to be a good doctor.

In fact, what they realize after working with me is that the most important part of being a doctor is talking to patients and listening. Taking a good history is the essential part of being a good doctor.

Here are two examples of patients who I saw during the winter. The practice is busy this time of year. I’m often running late. Like many encounters, I’ve never met these patients before. In many ways, it can feel like an urgent care practice. Which patient is lying? Can you tell?

Health 2.0 Spring Conference Update

Jan 25, 2011

The Health 2.0 Conference, run by THCB founder Matthew Holt and colleague Indu Subaiya, announced additions to the lineup of its spring conference in San Diego. The Future of Research panel will focus on the emergence of user-generated content and patient involvement, and the impact on research and clinical practice. The panel of experts includes:

Susan Love, MD, pioneer cancer surgeon
George Lundberg, MD, former Editor JAMA, Editor in Chief, Cancer Commons
Gilles Frydman, founder of ACOR
Josh Sommer, Chordoma Foundation
Paul Wallace, Kaiser Permanente and the Society for Participatory Medicine
Deborah Estrin, Professor of Computer Science, UCLA

Health 2.0 will feature cutting edge applications in the areas of prevention, wellness, exercise and diet. Among the presenters scheduled to speak:

Lindsey Volckmann, Keas
Brian Witlin, Shopwell
Hemi Weingarten, Fooducate
Will Roesenzwieg, Physic Ventures
Abbe Don, IDEO
Arnie Milstein, Clinical Excellence Research Center at Stanford University

For additional details, please see the Health 2.0 web site.

Rip Van Doctor

Jan 25, 2011• 2

By BOB WACHTER, MD

Cindy Fenton is one of the best doctors I know, a superb clinician-educator who was directing the UCSF Department of Medicine’s educational programs when, in 2001, she stepped off the academic treadmill to raise her three children. With her youngest now in first grade, I recently managed to coax her back into clinical medicine. In early January she spent two weeks as an attending physician on the general medicine service at UCSF Medical Center, after a decade’s absence.

I asked Cindy for her observations, knowing that they’d be astute – and that sometimes the best way to truly see something is to step away from it, then view it again through fresh eyes. Some excerpts from her note to me are in italics (with irrelevant clinical facts changed to please the HIPAA gods); my comments follow:

The patients seemed sicker, the service busier, the residents’ abilities at about the same high level. There were far fewer “private” type admissions than I remember previously – mostly pulmonary transplant patients and some private GI patients. Even on these patients, the subspecialty attendings welcomed the medicine team’s input, so the dynamic seemed more positive.

Advances in Connected Health Sensor Technologies

Jan 25, 2011• 7

By JOSEPH KVEDAR

Most of the time I write about the psychology of patient, consumer or provider adoption. This is not an accident. The psychology of adoption is the next big hurdle for connected health to overcome. We have good evidence that connected health solutions can be engaging and sticky for patients, leading to improved self-care. Likewise, we have evidence that enriching data coming from patients to providers can lead to better care decisions and that these decisions, made and delivered in the moment of need, are the other half of the magic of connected health. Further we have a sense that those patients who are not interested in the level of engagement that connected health demands often have worse outcomes and therefore cost the system more.

But today, I want to talk about technology. Most of the time, I write from the perspective of a technology vision that includes continuous (or near continuous) sensing of multiple physiologic signals. These signals are flawlessly transmitted to a computing environment where decision support can be applied to aid in improved communication with patients and improved decision making by providers. The state of the art today is not so elegant.

We use multiple different sensors, both wired and wireless, communicating via a large variety of aggregator devices that then transmit the sensor outputs to us via the Internet. The environment is both user-unfriendly and error prone, which increases the technical support resources required. We have the strong sense that some individuals drop out of programs because the technology is too challenging for them, so we miss them before we can turn them on to the benefits of a connected health experience.

The marketplace for sensors is changing in a number of exciting, dynamic ways. First, a number of sensors are coming to market that have embedded mobile chips right in them. They are sold in the same way as the Amazon Kindle (the wireless connectivity is bundled in the price of the device).

Reflections on the Certification Experience

Jan 25, 2011

By JOHN HALAMKA, MD

On Friday, January 21, 2011, Beth Israel Deaconess Medical Center completed the certification of its enterprise EHR technologies via the CCHIT EHR Alternative Certification for Hospitals (EACH) program. Here's the press release. As I've written about previously, BIDMC (like many academic health centers) has a combination of built and bought technologies that collectively provide interoperability, clinical functionality, and security. We demonstrated all our Intersystems Cache-based hospital systems and our Microsoft SQL Server-based business intelligence systems.

The process was rigorous, requiring us to follow over 500 pages of scripts and implementation guides in a single 8 hour demonstration.

The staff at CCHIT were remarkable, educating us about the NIST script requirements, emphasizing the need to prepare, and clarifying aspects of the NIST scripts that were ambiguous or seemed clinically unusual.

NIST did a great job creating test scripts rapidly enough to enable vendors and hospitals to certify systems in time for meaningful use attestation. However, there are a few oddities in the scripts that are only discoverable during pilots in real hospital and eligible provider clinical settings. I strongly recommend that for all future certification, NIST pilot their scripts before they are issued for general use.

The $1000 Coding Error

Jan 24, 2011• 31

By MICHAELA DINAN

As a graduate student in the health field I often get phone calls from various family members and friends asking what I happen to know about different drugs, procedures, and devices. I was having one such conversation with my younger sister last spring. She had just completed her undergraduate education, started a new job, and was very proudly financially self-sufficient for the first time.

We were talking about birth control. Her yearly exam was coming up and she was considering the therapeutic and cost efficacy of different forms of contraceptive. I had recently attended a class where the intrauterine device had been discussed as a cheap, effective form of contraceptive that is underutilized in the United States. A few strokes of the keyboard and my sister and I were able to find that with no insurance, the hormonal IUD costs $843.60. We quickly calculated that at 20 bucks a month for the pill, after 5 years, the IUD would end up being significantly cheaper – even before taking her insurance in to account.

A few weeks later my sister excitedly told me that she had discussed the IUD with her doctor who had informed her that it would only cost around $200 with her type of insurance. She had already scheduled her appointment to have it placed.

EHR Product Management

Jan 24, 2011• 17

By MARGALIT GUR-ARIE

It has become politically incorrect to refer to EHRs as products. Instead, EHRs are now “technologies” as evident in all ONC and CMS published rules and regulations. This subtle change in terminology was intended to encourage, yes you guessed it, Innovation. It was supposed to signal an open market for alternatives to existing EHR products in the form of modular approaches, open platforms, mobile applications and web-based software-as-a-service. Naturally, the industry is obliging and all efforts now are geared towards creating stuff that runs on iPads, preferably “cloud” based and with minimal utility. The new stuff looks very cool and promises to become even cooler, so what’s the problem?

The problem is that these new things do not solve any problems. Traditional product innovation concentrated on identifying problems, designing solutions and then selecting technologies that were capable of enabling those solutions. New technologies were usually born out of the necessity to solve a burning problem and those with enough applicability to larger markets became blockbusters. Every frying-pan today sports technology first invented in the process of creating refrigerants and later used for nuclear destruction (Teflon). Every large enterprise embarking on cost cutting, new markets acquisition, or general improvements, should know all too well that selecting a “cool” technology first, and then attempting to find a good use for it, is recipe for failure.

PCAST HIT Report Becomes a Political Piñata

Jan 23, 2011• 3

By VINCE KURAITIS, JD

The PCAST Report on Health IT has become a political piñata.

Early Feedback on PCAST

Like many of my colleagues, I was taken aback by the release of the Report in early December 2010 — I didn’t know quite what to make of it. Response in the first week of release after Report was:

Limited. The first commentaries were primarily by technical and/or clinical bloggers. The mainstream HIT world had remarkably little initial reaction to the Report.
Respectful of the imprimatur of “The President’s” Report and noting some of the big names associated with the report (e.g., Google’s Eric Schmidt and Microsoft’s Craig Mundie.)
Focused on technical and/or clinical perspectives around two broad themes.
- The vision is on target: “extraordinary”, “breathtakingly innovative”.
- These guys didn’t do all their technical homework. The range varies, but the message is consistent.

Today’s POV on PCAST

What a difference a six weeks makes.

The Office of the National Coordinator for Health IT (ONC) requested comments on the Report. The comments were due by January 19 and a number of influential organizations have already made their comments public.

After having read 10 early commentaries submitted to ONC, I’ll (admittedly subjectively) divide them into 3 schools of thought:

1) PCAST is a frontal attack on mainstream clinical, technical, and economic stakeholders in existing U.S. health IT. While there are some good ideas in the report, almost all of them are already in the works. Bury PCAST ASAP.

Obtaining Meaningful Use Stimulus Payments

Jan 23, 2011• 4

By JOHN HALAMKA, MD

Many clinicians and hospitals have asked me about the exact steps to obtain stimulus payments.

On January 3, 2011, CMS began registering clinicians for participation in meaningful use programs. Every region of the United States has Regional Extension Centers which can help answer any questions. Here’s an overview of the steps you need to take.

1. Choose between Medicare and Medicaid programs. If you qualify, Medicaid offers greater incentives and does not require you to achieve meaningful use before stimulus payments begin.
a. To qualify for Medicaid, 30% of your patient encounters must be Medicaid patients. (20% for pediatricians)
b. To qualify for Medicare, keep in mind that meaningful use payments are made at 75% of Medicare allowable charges for covered professional services in the calendar year of payment, per the payment maximums below:

Year 1 $18,000
Year 2 $12,000
Year 3 $8000
Year 4 $4000
Year 5 $2000

Thus, a total of $44,000 is available at maximum, but could be less if your allowable Medicare charges are less than

Year 1 $24,000
Year 2 $16,000
Year 3 $10,667
Year 4 $5333
Year 5 $2667