Archive for the 'Healthcare' Category

Why Electronic Medical Records are hated by doctors and nurses

Published May 16, 2013 Healthcare 2 Comments
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Shirie Leng, MD is a practicing anesthesiologist at Beth Israel Deaconess Medical Center in Boston. She blogs regularly at Medicine for Real – one of our top ten healthcare blogs. This post was so good I don’t see how to summarize it – please read the original here A Top Ten List for EMR and subscribe to Medicine for Real – Dr. Leng will give you an insider’s perspective on healthcare – as practiced at the top level. You don’t want to think about what goes on at the “average hospital”.

February 14, 2013
Today I’m doing anesthesia for colonoscopies and upper GI scopes. Nowadays we have three board-certified anesthesiologists doing anesthesia for GI procedures every single day at my institution. I’ll probably do 8 cases today. I will sign into a computer or electronically sign something 32 times. I have to type my user name and password into 3 different systems 24 times. I’m doing essentially the same thing with each case, but each case has to have the same information entered separately. I have to do these things, but my department also pays four full-time masters-level trained nurses to enter patient information and medical histories into the computer system, sometimes transcribed from a different computer system. Ironically, I will also generate about 50 pages of paper, since the computer record has to be printed out. Twice.

No wonder everyone hates electronic medical records (EMR)! I don’t know anything about computers, and I don’t know what systems other hospitals have. I may be dreaming of a world that doesn’t exist or that world is here and I haven’t heard about it. Nevertheless, here’s my wish list for a system that doctors would actually want to use:

1. ELIMINATE THE USER NAMES AND PASSWORDS. You can’t tell me that in this day of retinal scans and hand-held computers that there isn’t a better way to secure data. What if each person had their own iPad that you only have to sign into ONCE a day that automatically signs your charts. If you’re worried about people leaving them sitting around use a retinal scan or fingerprint instant recognition system.

2. ELIMINATE THE PAPER. If you’re going to have full-time people entering data for you, why print it out? It’s on the computer for anyone to access.

3. ALL DATA SYSTEMS MUST BE COMPATIBLE. You can’t have patient data entered in one place that doesn’t automatically import into another place. If my anesthesia record can’t talk to the hospital OMR, I have to RE-TYPE everything in, which is completely ridiculous.

4. EVERYBODY HAS TO USE THE SAME SYSTEM. Everybody, state-wide. Right now, electronic records from a nearby hospital are not available at my hospital, even though the two hospitals are right across the street from each other.

5. DON’T MAKE ME TURN THE PAGE. All the important information about a patient should be on the first page you open when you look up a patient. I shouldn’t have to click six different tabs. Specific to anesthesia, all the relevant data about the patient including what medications they have received during the case should be automatically displayed on the screen when you start a case. Specific to primary care, all the latest labs and data, recent appointments with specialists, current med list and anything else the doctor wants to see commonly should be right on the first screen.

6. DON’T MAKE ME HAVE TO REPEAT MYSELF. If I do eight cases the same way, with the same documentation required for each case, I still have to enter that documentation each time. If I’m seeing 20 patients in primary care clinic and the rules require the same documentation for each person, I shouldn’t have to enter that documentation each time.

7. INVEST IN DEVELOPMENT OF REALLY GOOD VOICE-RECOGNITION SOFTWARE. If I’m sitting across from a patient, I want to look at them and talk to them, not talk to them and look at a computer screen. If my mother didn’t make me take typing in high school, I don’t want to have to spend 3 hours after-hours every evening pecking my conversations with my patients into a computer, or worse, checking boxes electronically.

8. GET RID OF THE WIRES. In this day of wireless, why am I still tripping over monitoring wires and untangling cords? My spin bike at the gym can pick up my heart rate without a wire. Why can’t my anesthesia monitor?

9. IF YOU NEED A TYPIST, HIRE A TYPIST. Every time a new rule or documentation requirement pops up, which in my institution is daily, it is always laid on the nurses to add that to their computer records. Nurses used to be nurses. Now they are data-entry specialists. Their checklist and pre-operative paperwork is longer than mine. And they aren’t doing any diagnosis or treatment.

10. TRIPLE BACK-UP THE SYSTEM. Computers crash. Paper doesn’t. There’s got to be a way to make the system rock-solid reliable.

There are a mind-boggling number of rent-seeking interests in the US medical system. I would really like to know the true story of how Google’s effort to offer free EMR was defeated by these interests. Google knows how to build, operate and refine such systems at scale – and FAST. What we have now is a complete mess – which will take decades to rationalize.

A physician’s solution for excessive care

Published May 13, 2013 Healthcare 2 Comments
“Please Sir, I want some more.”

Rob Lamberts, MD is a very thoughtful and practical primary-care physician. Here are Rob's most important rules to battle excessive treatment (and the associated risks):

Americans have been viewing health care the same way, always wanting more: more antibiotics, more technology, more robots doing more surgery, more expensive treatments for more diseases. The result: health care costs more in America than anywhere else. Some folks think that our “more” approach makes our health care “the best in the world,” after all, where else can you get so many tests just by asking. MRI’s for back pain, x-rays for coughs, blood tests for anyone who dons the door of the ER. ”Tests for everyone!” shouts the bartender. “Tests are on the house! ”

They aren’t, of course, and we are paying the price for “more.” This hunger for “more” is fueled by the media’s fascination for the “latest thing,” the long disproved idea that technology will solve everything, and docs who aren’t willing to take time to explain why it’s actually better to do less. It’s hard to do, when we are paid more to spend less time with patients, and when the system is willing to pay for more and more.

There is a voice against this: the “Choosing Wisely” campaign, which argues against unnecessary treatments and tests. This is a welcome voice of reason in the cacophony of cries for “more.” Yet the battle goes against the irresistible tide of our payment system. The root problem is this: there are a whole lot of people whose jobs depend on America’s addiction to “more.” The payment system has created an ecosystem that thrives off of waste (of which I once wrote an allegorical fantasy). True health care reform will be catastrophic to many who work in health care, with many very nice and hard-working Americans losing their jobs at the ACO factory, at Meaningful Use Inc., and even at Stents-R-Us hospital here in my home town.

This is what you get when you make disease more profitable than health, when we treat problems instead of people. The simple fact that our system would be destroyed if everyone got healthy should tell us something is terribly wrong. Doctors want their offices full, not empty. The goal of every patient – to be healthy and to stay away from the doctor – goes directly against the economics of “more.”

I have always tried to be a non-test orderer. I was trained well by docs who believed it weak-minded and bad care to blithely order tests and prescribe medications without a well-defined reason. This has always made it harder for me, as it’s far more time-consuming to explain why a drug or test is not needed than to simply order it. But in my new world, one in which an empty office is a good thing, I’ve found my patients much more open to my aversion to “more.” The main reason for this is that I am giving them more of me. More of me means they can call if they don’t get better, or if their symptoms develop. They know I won’t force them to take more of their time and spend more of their money to get my attention.

Ultimately, I want my patients to see as few doctors, be sick as infrequently, and be on as few drugs as possible. I hope to wage an all-out assault on “more.”

  • Never order a test that doesn’t help you decide something important. Ordering tests “just to know” does much more harm than good.
  • Use consultants only to do things you can’t. Orthopedists will aways give an NSAID and physical therapy for problems, so I don’t send patients to them unless they’ve failed those treatments (where appropriate). I am just as good at ordering PT, and am more careful with NSAID prescriptions than they are.
  • Don’t give a patient a drug without explaining to them why they need it. If I can’t make a good case for a drug, I shouldn’t be giving it. This is not simply “to lower your cholesterol,” or “to treat your blood pressure,” but because doing so will raise your life-expectency.
  • Remember the number that really matters: how many birthdays a person gets to celebrate in health. I don’t care about blood pressure, LDL, or even A1c if treating it doesn’t raise the birthday total.
  • Don’t forget about another number: how much money patients have in their wallets. There’s no point in ordering a drug they can’t afford, or making them pay for a test they don’t need (even when they ask for either).

 

Printable ‘bionic’ ear melds electronics and biology

Published May 13, 2013 Healthcare Leave a Comment
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This Princeton University press release merits some further investigation. Progress in bionics is accelerating faster than we realized. Example from the end of the bulletin:

(…) Creating organs using 3-D printers is a recent advance; several groups have reported using the technology for this purpose in the past few months. But this is the first time that researchers have demonstrated that 3-D printing is an effective strategy for interweaving tissue with electronics.

The technique allowed the researchers to combine the antenna electronics with tissue within the highly complex topology of a human ear. The researchers used an ordinary 3-D printer to combine a matrix of hydrogel and calf cells with silver nanoparticles that form an antenna. The calf cells later developed into cartilage.

Manu Mannoor, a graduate student in McAlpine's lab and the paper's lead author, said that additive manufacturing opens new ways to think about the integration of electronics with biological tissue and makes possible the creation of true bionic organs in form and function. He said that it may be possible to integrate sensors into a variety of biological tissues; for example, a doctor could replace a patient's torn knee meniscus with a bionic one to monitor strain on the new cartilage during physical activities to prevent another tear.

I'll have that new meniscus please.

Finally: US opens access to healthcare costs database

Published May 10, 2013 Healthcare Leave a Comment

WaPo has a brief summary of the data release.

For joint replacements, which are the most common hospital procedure for Medicare patients, prices ranged from a low of $5,304 in Ada, Okla., to $223,373 in Monterey, Calif. The average charge across the 427,207 Medicare patients’ joint replacements was $52,063.

Much more important is access to the hospital quality and safety data. When…?

Finally: US opens access to healthcare costs database

Published May 10, 2013 Healthcare Leave a Comment

WaPo has a brief summary of the data release.

For joint replacements, which are the most common hospital procedure for Medicare patients, prices ranged from a low of $5,304 in Ada, Okla., to $223,373 in Monterey, Calif. The average charge across the 427,207 Medicare patients’ joint replacements was $52,063.

It's true – the view is better in Monterey!

It's great to see the beginings of medical transparency. Even more important is transparency of the hospital quality and safety data. When…?

Anti-vaccine activists responsible for the Swansea measles outbreak

Published April 11, 2013 Healthcare 2 Comments
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Andrew Wakefield should be rotting in a prison cell. But he is not – he is making big bucks speaking to groups of anti-vaxxers. Telegraph Science reporter Tom Chivers updates with this lead:

MMR does not cause autism. The Swansea measles outbreak shows the damage this idiotic scare has caused.

(…) 

Last week the US Centers for Disease Control (CDC) released the results of a study which put to rest the last claim of the anti-vaccination brigade: that multi-vaccination jabs such as MMR overload the child’s immune system. The study, which examined 1,000 children who had had their jabs, either all together or spread out over several months, found that the children who had autistic-spectrum disorders were no more likely to have had more jabs, or a more concentrated programme of them, than those who did not. “Our study found no relationship with the number of vaccine antigens received and overall ASD [Autistic Spectrum Disorder]” the study’s lead author, Frank de Stefano, said.

Of course, this hasn’t satisfied the “anti-vaxers”; one, writing on the website Age of Autism, claimed that “The [CDC] study is to science what the movie Ishtar [a notorious box-office flop] was to cinema.”

According to a small, but vociferous, part of the population, vaccines do cause autism, and to hell with the evidence. If the fact that there was no sudden increase in autism in Britain after the introduction of the MMR in 1988 (as several studies have shown) didn’t convince them, then the CDC study has no chance. What’s far more worrying than the hard core of campaigners is the large number of parents who, after years of reading headlines linking the two, are understandably concerned about vaccinating their children.

A 2011 American survey found that more than one in five people still thought that vaccines can cause autism; another found that 10 per cent of parents delay or refuse vaccination for their children for that reason. Things are no better here: at the height of the scare, in the early 2000s, vaccination levels in Britain dropped to just 73 per cent.

Dr Ben Goldacre, the author of Bad Pharma, who has written extensively about autism and vaccination, says: “Health scares are like toothpaste: once they’re out, it’s very hard to get them back in the tube. They catch fire fast, because they’re so seductive to journalists. (…) .”

(…) This is a genuine threat. In 1998, pre-Wakefield, there were just 56 cases of measles in Britain. In 2008 there were 1,348. In 2006 a child died of the disease for the first time since 1992; another died two years later – casualties of the MMR hysteria. Before the introduction of the vaccine in 1988, about half a million children caught the disease every year in this country and around 100 died: in about one in 1,000 cases, measles leads to encephalitis, a swelling of the brain, which can lead to blindness, deafness or brain damage, and sometimes death. The virus also causes pneumonia.

Are you as angry as we are? Good, what are you doing about it?

More…

Doctors and nurse practitioners: We’re failing the reality test

Published April 10, 2013 Healthcare 1 Comment
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Yul Ejnes practices internal medicine in Cranston, Rhode Island, and is the Immediate Past Chair, Board of Regents, American College of Physicians. Dr. Ejnes just published what looks to me to be a very honest perspective on the controversial subject of medical care by NPP, or “non-physician providers”.

I don’t make my living as a physician, so it’s easy for me to see much-expanded use of NPPs as way to better and less costly medical care. See what you think.

(…) 

My practice uses NPPs to increase our patients’ access to care. Our patients can see NPPs for urgent visits, follow up of chronic conditions such as diabetes and hypertension, and preventive services. Our NPPs do not have their own patient panels because we prefer that every patient in the practice have a primary physician. Our preference is based more on logistics than our judgment of the NPPs’ ability to manage a panel of selected patients. However, some of our patients take matters into their own hands and find a way to see the NPP for all of their problems. I don’t view that as a threat but see it as an affirmation that we have a team of providers that patients feel comfortable seeing. Some patients, on the other hand, refuse to see anyone but a physician. That is their choice. When they request an appointment, we make clear who they can see and what their credentials are.

Our NPPs see patients independently. When they have a question, they ask one of the physicians. In a typical day, that might happen once or twice, usually because the patient is complicated or has an unclear presentation. Often, the NPP will recommend that such patients follow up with one of the physicians. That isn’t surprising given the differences in training and expertise. On the other hand, sometimes one physician will ask another for help with an exam finding or a management question. One of my NPPs worked in a dermatology office for many years, and sometimes I will ask her to look at a rash that I can’t figure out. When we are not sure of something, we ask for help, regardless of our title.

Physicians review and cosign every office note from an NPP visit. There are a few reasons for that, including billing requirements, but it also helps us to keep up to speed with what is happening with our patients. That stated, there are very few occasions that I read an NPP’s note and disagree with the care provided, and most of those disagreements are more over style than substance. I suspect that if I reviewed my physician colleagues’ notes I would have similar disagreements from time to time.

 (…) 

Transparency through video recording in medicine: improve quality, decrease waste in health care through increased accountability

Published April 4, 2013 Healthcare 2 Comments

In medicine, the problems of wide variations in quality and poor compliance with evidence-based care are well known. More education is not the solution for these problems. Knowledge is abundant, but implementation of knowledge often lags. This Viewpoint explores whether use of an existing technology, video recording of medical procedures, can improve quality of care.

Although the World Health Organization’s hand washing declaration and aggressive global awareness campaign has been long established, behavior change among health care workers remains a persistent struggle. For instance, at Long Island’s North Shore University Hospital, hand washing compliance rates were consistently low despite educational efforts. In response to these low rates, the hospital took an assertive approach to solving the problem by installing cameras to monitor hand washing rates. The outcome data were reported to the staff and as a result, compliance increased from 6.5% to 81.6%,1 demonstrating the potential power of this technology in the medical setting.

The concept of measuring quality for learning is not a proposal to rewire hospitals and install cameras, but rather, a consideration that many applicable activities and procedures are already video based. For example, procedures ranging from cardiac stent placement to arthroscopic surgery are performed using sophisticated video equipment; however, the record button is often turned off. The potential to harness the data in these videos and drive quality improvement may be substantial.

At Indiana University, Rex et al2 decided to use the recording feature of colonoscopy video equipment to address the long-standing problem of quality variations in colonoscopies. Over several months, the investigators performed a blinded review of 98 colonoscopy videos performed by 7 gastroenterologists who were unaware that their procedures were being recorded. Procedure quality scores and mucosal inspection time data were collected based on established criteria. Wide variations in quality were found. The researchers then informed the gastroenterologists that their procedures were being video recorded and peer reviewed. Following the announcement, mean inspection time during colonoscopy increased by 49% and quality of mucosal inspection improved by 31%,2 suggesting a substantial improvement in quality because of the Hawthorne effect.

Peer review of videos can also enhance existing quality improvement efforts. For example, procedure videos can better inform morbidity and mortality conferences and sentinel event root-cause analyses that have traditionally relied on the notes of clinicians, which can be limited and even biased. Moreover, the exportability of video files can facilitate external review, allowing a peer reviewer removed from a local department’s politics to advise on what could have improved.

Full article

 

“Pioneer” Health Care Plans Circle the Wagons Against Pay-for-Performance

Published March 7, 2013 Healthcare Closed
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Megan McArdle at The Daily Beast: 

Last week, I wrote about the Cleveland Clinic, the widely respected medical center that the Obama administration hopes will become a model for health care system delivery under the new health law.  Accountable Care Organizations are supposed to simultaneously lower costs and improve outcomes by streamlining and integrating delivery services. It’s a step towards the promised land that all health care wonks dream of, where we pay for health rather than treatment.  

However, Cleveland, along with other model providers like Mayo and Intermountain, declined to become one of the ‘Pioneer ACOs’ that the Obama administration anointed to lead the way into the new promised land.  And now, it seems, many of the institutions that did agree to join the wagon train are saying that they’ll pull out if the administration tries to, well, pay them for performance rather than treatment.

(…) So far, pretty much every one of those promised improvements has underwhelmed, and the skeptics have been vindicated. The deficit-reduction has been cut in half by the need to reform some ill-advised inclusions, such as a long-term health care program whose costs exploded just outside of the 10-year budget window, and a frankly crazy plan to make everyone in America issue 1099s to any vendor who sold them goods for cash.

Of course, predictions are hard, especially about the future.  But I don’t think that the skeptics just got it right by accident. If health care reform were that easy, it wouldn’t be so hard. 

Read more.

Doctors warn over homeopathic ‘vaccines’

Published February 28, 2013 Healthcare 2 Comments
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Samantha Poling BBC: 

Homeopaths are offering “alternative vaccinations” which doctors say could leave patients vulnerable to potentially fatal diseases, a BBC investigation has found.

Three practitioners admitted giving patients a homeopathic medicine designed to replace the MMR vaccine.

Inverness-based Katie Jarvis said she only offered “Homeopathic Prophylaxis” to patients who expressed an interest.

But the discovery has prompted a shocked reaction from doctors.

(…) However, the BMA’s director of science and ethics, Dr Vivienne Nathanson, said: “Replacing proven vaccines, tested vaccines, vaccines that are used globally and we know are effective with homeopathic alternatives where there is no evidence of efficacy, no evidence of effectiveness, is extremely worrying because it could persuade families that their children are safe and protected when they’re not.

“And some of those children will go on to get the illness, and some of those children may go on to get permanent life-threatening sequelae, or even to die, and that’s a tragedy when the family think they’ve protected their children.”

(…) NHS Highland – the health board covering Inverness – said it was considering withdrawing funding for homeopathic preparations.

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