Patrick's shared items in Google Reader

Before you ask a doctor out on a date

Kevin — Tue, 12 May 2009 12:00:01 PDT

Not your doctor, for obvious ethical and legal reasons, but what about your friend's physician?

Doc Gurley looks at the pertinent issues when considering dating a doctor. Including, of course, how much debt you're looking at taking on.

"Nowadays, the myth of the rich doctor has tumbled faster than a Madoff investment scheme," she writes. "More accurately, that’s true if your doc is a primary care, internist, pediatrician or family medicine type. For those professions, we’re not just talking dismal future earnings, either. A graduate from a pricey private medical school could be $300,000 in debt when handed a diploma - and then have to start a 4-6 year mandatory job (residency) that pays, per hour, less than minimum wage."

Also worth thinking about, does it matter if the physician is wearing a wedding band, or not? And, do single female-physicians really scare off potential dates?

Insurers Expand Primary Care: an Argument for Obama’s Plan

Maggie Mahar — Fri, 09 Jan 2009 17:35:27 PST

Imagine appointments with your primary care doctor that last 30 minutes—or longer. What if you could e-mail her when you need a prescription refill? If you have a two-minute question, she encourages you to call; she or a nurse practitioner will come to the phone. If they’re busy, they’ll return your call within a few hours.

A recent story in the Seattle Post-Intelligencer offers hope for primary care by focusing on an innovative program at Group Health Cooperative, a nonprofit health care system headquartered in the state of Washington. Under the new program, patients see their doctors less often, but when they do, it is a meaningful encounter. And in between appointments, doctors are paid to communicate with patients in other ways.

A multi-specialty integrated health care system, Group Health, like Kaiser Permanente, provides both healthcare and insurance. Group Health’s doctors work on salary, so there are no financial incentives to “do more.” And because Group Health is both the insurer and the caregiver, the payer and the health care provider are not adversaries: they are on the same team.

By creating its own small revolution in primary care, GroupHealth is demonstrating that private sector insurers can be part of the solution to our healthcare crisis. In this case, the key is paying doctors for the time they spend e-mailing patients, returning phone calls, and doing research on their behalf. Because doctors are on salary, they are paid for everything they do—not just for the number of patients they manage to “see” in a given day.

In a two-year experiment, Group Health is encouraging doctors to spend more time in face-to face appointments with patients. Given the finite number of hours on a physicians’ calendar, this means seeing patients less frequently. But doctors also keep in touch with patients by phone and e-mail.

As a result, a doctor like Dr. Patricia Boika can spend a half hour, or more, with the patient she sees. Before she became part of this program, “The practice had become a dismal treadmill, with too many patients and not enough time, double-bookings and harried visits, and paperwork lugged home every night,” Boika, who has been a family doctor for 28 years, told the Post-Intelligencer.

"’It was an assembly line of people she recalls. ‘You were just slammed. You had to tell yourself, “It's really OK to take one minute to go to the bathroom.”

“But, these days,” the paper observes, “Boiko, who practices at Group Health Cooperative's Factoria center, does medicine the way she intended.”

Group Health has found its medical home pilot project in Factoria so successful that it is rolling the idea out to all 26 of its medical centers.

“A similar concept will guide a new family-medicine residency clinic that Swedish Medical Center is opening next year in Ballard,” the Intelligencer reports. “Like Group Health, it will allot 30 to 60 minutes for a visit, instead of 15 minutes.

“And while some family doctors oversee 2,000 to 2,500 patients, doctors at the new clinic will have a panel of only 1,700 to 1,800 patients.”

"’It almost sounds impossible,’” Carol Cordy, Swedish's medical and residency-site director of the new clinic told the newspaper. “‘How can you see 10 patients a day instead of 25, and still make ends meet?’"

“That is the question,” the paper adds. “The challenge for medical-home advocates is the country's fee-for-service system, which pays doctors for visits and procedures, but not for phone calls, e-mails or time to research a condition.

“There's this motivation to see more patients so you make more money,” Cordy confides.

But Swedish Medical Center, which uses outside insurers, has found a group willing to pay a monthly fee for each patient rather than fee-for-service. Again, payers and providers are collaborating.

Maybe this can happen only in what some healthcare reformers describe as “Canada South”: the Northwest (running from Washington and Oregon across to Iowa) and Northern New England (Maine, Vermont and New Hampshire.) But I like to think that the rest of the country can catch on to the idea that healthcare is not a competitive sport. It should be a team effort.

What the Best Private Insurers Bring to the Party

Many single-payer advocates believe that private insurers should not be included in national health reform: a government program that some call “Medicare –for- All” should provide all coverage. This, they say, is the only way to deliver effective, affordable care.

But I am impressed by the “hybrid” plans that both president-elect Barack Obama and Senate Finance Chairman Max Baucus have proposed—plans that include both a public sector option and private insurers. Here it is worth noting that the hybrid model is the norm in most of Europe, where the cost of healthcare is much lower, and outcomes are generally better than in the U.S. Only the U.K. and Canada offer a pure “single-payer” system and there is no evidence that their health care systems are superior.

As the Seattle Post-Intelligencer piece suggests, the best private sector insurers can bring innovative solutions to the table. Of course there is no reason why the government cannot run equally imaginative pilot projects. In fact, Medicare already is investigating alternative ways to pay providers. But keeping honest insurers in the mix should ensure greater variety.

Moreover, a system that includes both private sector and public sector insurers guards against the danger that, with a changing of the guard in Washington, a single-payer system could become something quite different from the program that today’s healthcare reformers envision.

Lessons Learned From PBS

Here I think of PBS. In theory, PBS was supposed to be “the people’s television.” And in many ways, for many years, it was—and sometimes still is. But compare PBS’ programming to the best of HBO. PBS has been captured by conservative forces that would never air programs like Deadwood or The Wire–television dramas that have taken the norm to a level of acting, writing and political thinking that rivals the best films. Ultimately HBO became the network which offered programming that you won’t see on commercial television.

For news, compare PBS to BBC. Frontline still does some excellent programming and Bill Moyers remains the Ted Kennedy of PBS. But you only have to look at the folks raising funds on televisoin during the network’s membership drives to realize that these are not disruptive innovators.

Just as PBS was co-opted by politics, a single-payer healthcare system could become a political football. Imagine that, in a backlash against the Obama administration, Jeb Bush is elected president in 2016. Clinging to his coattails, a horde of conservative Congressmen come to Washington. (If you think this couldn’t happen, remember how surprised you were when [name your least favorite politician] was re-elected.)

If we had a single-payer system, today’s health care reformers might be astonished by just how quickly its priorities could be re-aligned. Conservatives in Congress might well slash subsidies while creating a “consumer-driven” single-payer system that leaves Americans free to choose (or forced to choose) the healthcare they can afford from a menu of policies. This could mean unlimited end-of-life care for those who can afford gilt-edged insurance—and Medicaid -for-all for the rest of us. Some conservatives might even call for a vote on whether abortion should still be covered.

At that point, many Americans would be grateful to have alternatives to government insurance. No doubt, insurers such as Kaiser and Group Health would step up the plate. Let me be clear: I deeply believe that healthcare is a public good—and that government should be the guardian of the public good. But this is true only when we have good government. As recent experience demonstrates, this is not something we can count on.

National Health Reform—No Single Solution

In addition, the more I think about it, the more I realize that unrolling national health reform will be a process that will require many experiments. Some will succeed; some will fail. Disruptive innovation calls for a variety of players thinking outside of the box.

After all, this is a big country and I’m becoming convinced that what works in one region may not work in another. The basics of universal coverage should be uniform. Everywhere, we must have patient-centered healthcare based on medical evidence. Coverage should be equitable, and providers should be paid for value, not the volume of what they do. That said, healthcare for all could take many forms, just as it does in Europe.

While large, integrated, multi-specialty centers work well in Western states, fully- funded, well-staffed community clinics might prove better suited to densely populated cities on the East Coast. Ideally, these clinics would offer services eighteen hours a day, seven days a week. In addition to primary care they would offer specialty care ranging from cardiology to obstetrics, ophthalmology, gynecology, pediatrics and physical therapy—as well as counseling services for those addicted to tobacco, alcohol or drugs.

Today, both affluent and low-income patients find themselves in the ER when they can’t get an appointment with a doctor. A neighborhood clinic that is staffed with M.D.s and nurse-practitioners could keep patients out of ERs, while providing the disease management and preventive services that we associate with a “medical home.” Insurers could experiment with different payment models. Some might offer salaries that let doctors follow the Group Cooperative model; others might make monthly per- patient payments, bundling bonuses for good outcomes to be shared by everyone who saw that patient. Some private practice specialists might work part-time in the clinic; others might be paid to collaborate with the clinic’s primary care physicians, making room in their schedules to take the clinic’s referrals in a timely fashion while consulting with the clinic’s doctors to co-ordinate patient care. Finally, clinics might offer flex schedules and part-time salaries for the many physicians and RNs who do not want to work full-time. In this way, they could bring some nurses out of early retirement.

This is just one model. Imaginative insurers would find different ways of delivering care and paying for value. And this is one reason why I find the “hybrid” insurance system proposed by the new administration so appealing. As both Obama and Baucus envision it, private sector insurers would compete, on a level playing field, with a public sector “Medicare-for-All” alternative.

Fair Competition between Public and Private Insurers

Make no mistake, leveling the playing field means regulating insurers. Private insurers should be required to insure anyone who applies, without regard to pre-existing conditions. And insurers must charge everyone in a given community—young or old, healthy or sick—the same price for a policy. Insurers have agreed on the first point, not on the second.

This is one reason why the insurance industry is pushing for reform Now. If we forge ahead, Congress won’t have time to work out the details of regulating the industry and requiring fair pricing.

But Congress must pause and fight this battle. If insurers are allowed to charge sicker, older customers more, many sick patients will find their premiums unaffordable. At that point, either we follow Massachusetts’ example, and “exempt” some of our oldest and sickest citizens from universal coverage—or taxpayers pick up the tab in the form of exorbitant subsidies. This is not how insurance is supposed to work. Insurance is about spreading risk. In this case, rather than letting insurers set prices for sicker patients we should insist that they charge everyone in a community the same premium, spreading the cost of caring for the old and the sick through the insurance pool, just as we do with Medicare. (Meanwhile, the government would provide subsidies for those who cannot afford the community rate.)

Fair competition between the private sector and the public sector also means that all insurers must offer coverage that meets the high standard set by the Medicare-for- alternative. No more surprises in the fine print. Policies would cover surgery and rehab after surgery, pregnancy and all complications during pregnancy.

Alternatively, Congress could give everyone a voucher which entitles them to the same high quality, comprehensive insurance. Individuals would pay nothing for the voucher; the cost would be financed collectively, through our taxes. I have written about this plan on HealthBeat here and, here).

Again, it will take time to consider the alternatives. Congress must not let the insurance lobby hi-jack the process. Insurers are hungry for 45 million new customers, many coming to the market with a government subsidy in hand. But we need to ensure that they receive equitable, effective care at a reasonable price.

If Congress sets strict rules, some insurers may decide that they do not want to play the game. Those who rely on “cherry-picking” healthy patients to stay in business—while selling many of them skimpy policies filled with holes—won’t be able to survive in a market where they have to compete on a level field. But others, that are able to compete on quality, will stick around and add value to the system.

The Rules of the New Administration’s Proposals

Many voters still seem hazy on the details of the president-elect Obama’s proposal for healthcare reform. Somehow the campaign never managed to spell out how his plan works—presumably because strategists who are more interested in politics than policy believed that voters wouldn’t be interested in the wonky details.

But now that various group are proposing their own quick fix, “magic bullet” solutions, it is imperative that the public understand the president-elect’s hybrid plan.

Here are the rules of the game:

Employees who have employer-based private-sector insurance can keep the insurance that they know. (It would be a shame to force anyone to give up Group Health.)

Meanwhile, the self-employed, the unemployed, and those working for an employer who does not offer insurance will be able to buy insurance through a National Health Insurance Exchange ) where they can choose between private sector and public sector options. Small employers also will be able to go to the Exchange to buy subsidized insurance for their employees. Some small employers will be exempt, but their employees will have access to the Exchange.

Large and medium-sized employers will be asked to either “play” or “pay.” They can choose between offering insurance to their employees (playing), or contributing a percentage of payroll into a common pool that helps fund universal coverage (paying)
If the “Medicare-for-All” public sector insurance is able to offer better coverage for less—as many hope—some employers may well decide that, rather than “playing” (and continuing to try to oversee private health insurance for their employees) they would rather “pay.” In that case, their employees would be free to go the Exchange where they can choose between private and public plans. If the public sector plan proves popular, no doubt many employees will lobby their employers for this alternative.

In this way, the nation might well move from employer-based insurance to a system where employees choose their own insurance. But under the administration’s plan, this would happen only if employers and employees choose to give up employer-sponsored insurance, not as the result of a government edict.

In the end, National Health Reform cannot be imposed on the nation, deus ex machina. Considering the options, experimenting with alternatives, battling the lobbyists—all of this will be part of a lengthy, sometimes bloody, often difficult political process. As the latest Congressional Budget Office report makes clear, there will be many trade-offs. “Cost-containment lite proposals will not be enough.”

No doubt more than one piece of legislation will be required. Those who want to move quickly would like to side-step the hard decisions. Lobbyists, in particular, would like to skip over discussions about cost-cutting and regulation.

But as David Mechanic points out in The Truth About Health Care: “At some point we as a nation will have to decide whether we wish to design our health care system primarily to satisfy those who profit from it or to protect the health and welfare of all Americans.”

That time has come.

Alzheimer’s Disease: The Basics

Niko Karvounis — Wed, 31 Dec 2008 07:43:41 PST

Earlier this month newspapers reported that Columbo—that is, actor Peter Falk—has Alzheimer’s Disease. Usually, when news breaks that a celebrity is suffering from a serious medical condition, there’s a flurry of coverage discussing the nature of the disease. Hopefully, the pattern will hold in Falk’s sad case—because Alzheimer’s is both a terrifying disease and a greater public health issue than most of us realize.

Indeed, the incidence of Alzheimer’s Disease (AD), is rising. According to the Centers for Disease Control and Prevention, in 2006 Alzheimer’s disease was the sixth-leading cause of death in the U.S., killing 72,914 people. Another startling number: Alzheimer’s as a cause of death has skyrocketed in recent years, increasing by 33 percent between 2000 and 2004.

So What Is It?

A progressive brain disorder, AD literally shrinks the brain, eroding individuals’ memory, language, and their ability to coordinate basic motor skills like swallowing, walking, and bladder control. These deficiencies can lead to other serious problems: an inability to swallow can cause food to be inhaled, which can lead to pneumonia; not walking can lead to painful bedsores prone to infection; and incontinence can also lead to infections.

In other words, Alzheimer’s is a frightening disease that gradually can take over the mind and body. Unfortunately, there is no known cure, and currently no medical tests that allow us to diagnose the disease with 100 percent certainty—doctors need to cut open the brain in order to tell for sure that it’s afflicted with AD.

Further, no one knows for sure what causes Alzheimer’s, though researchers do have some understanding about what happens to the brain during the disease. The culprits are two abnormal structures called plaques and tangles, which together kill nerve cells in the brain. Plaques build up between nerve cells and deposit proteins that impede normal neurological functions; tangles are knots of protein that build up in brain cells and collapse the structures needed to transport vital nutrients across the brain.

Doctors aren’t entirely sure what causes the growth of plaques and tangles. Genes might play a role, but researchers don’t know just how—or how much—they matter. That’s due in part to the fact that Alzheimer’s, when it’s genetic, is not caused by a single gene, but rather mutations on multiple chromosomes. Sadly, this information is not as useful as it may seem: according to the National Institute of Aging (NIA), less than 10 percent of AD patients have “familial Alzheimer’s”, i.e. a genetically inherited form of the disease. Onset of familial AD is early, before the age of 65. The other 90+ percent of Alzheimer cases are late-onset (after 65), and according to the NIA, this form of the disease “has no known cause and shows no obvious inheritance pattern.” Researchers have a hunch that genes play some sort of role in late-onset AD, but “only one risk factor gene has been identified so far” and it’s not enough to account for the entire disease.

Why Is It on the Rise?

Currently, there are about 5 million people with AD; by 2050, that number will hit 16 million, making for a more than three-fold increase—in a large part because there will be more people over the age of 65, when Alzheimer’s is most likely to hit. In fact, people over 85 are the fastest growing segment of the population, meaning the number of Americans at increased risk of the disease is growing quickly. And thanks to medical progress that has reduced death rates from other diseases, people are living longer than ever—which means they’re living long enough to be at risk for Alzheimer’s. (Indeed, as Alzheimer’s-related deaths increased between 2000 and 2004, the number of deaths caused by heart disease, breast cancer, and strokes all decreased).

Another factor behind the rise in Alzheimer’s is the fact that researchers have expanded their definition of what constitutes an AD-attributable death. Before 1999, if someone with Alzheimer’s contracted pneumonia as a result of not being able to take care of themselves and died from the infection, their cause of death would be considered pneumonia. But in 1999, such deaths were reclassified as Alzheimer-caused, since it was AD that made them susceptible to the condition in the first place. This change partially explains sky-rocketing AD rates

It’s important to put AD in context. It’s still responsible for far fewer deaths than the diseases ahead of it in the mortality rankings. According to the CDC, in 2006, heart disease killed 629,191 people; cancer killed 560,102; respiratory diseases like emphysema and bronchitis killed 124,614; and unintentional injuries killed 117,748. In other words, more people died in an accident than died from AD.

Still, as America age older and researchers find Alzheimer’s behind more and more deaths—even when the immediate cause is sickness, frailty, or infections—our health care system will shell out more and more money to treat the disease. Indeed, the number of Medicare claims for treatment of Alzheimer's disease shot up by 250 percent during the 1990s and is expected to increase by 300 percent over the next 10 years. Further, Medicare spending on Alzheimer's disease is expected to triple from $62 billion in 2000 to $189 billion by 2015.

Risk and Prevention

The uncertainty surrounding the causes of Alzheimer’s is reflected in the confusion as to what does and doesn’t help to prevent, or reduce the risk of contracting, the disease. Reading through the literature on Alzheimer’s is like talking to a split personality.

A few years ago, some studies suggested that taking pain relievers such as Advil and Aleve could prevent Alzheimer’s because these anti-inflammants were thought to reduce the brain inflammation that may occur during the disease’s growth. Newer studies in Neurology and the British Medical Journal, however, argue emphatically that this is not the case. They note that “over-the-counter [remedies] and prescription pain reliever[s]…[do] nothing to prevent Alzheimer’s disease” and “that aspirin d[oes] nothing to prevent memory loss in older women.”

In 2000, a study in the Archives of Neurology suggested that statins cut the risk of developing Alzheimer's disease by as much as 73 percent; in 2007, University of Washington researchers discovered that the brains of deceased Alzheimer’s patients who took statins during life had fewer plaques and tangles than AD patients who didn’t take the cholesterol-lowering drugs. But in January of this year, a Neurology study declared that there was absolutely no connection between statins and Alzheimer’s.

This most recent study tracked new cases of Alzheimer’s disease amongst a cohort of 929 religious officials. When the study started, the average participant was 75 years old. Only 13 percent were taking statins. Participants underwent regular checkups and took mental skills tests every year for up to 12 years. During that time, 191 of them developed Alzheimer's disease—and taking statins “didn't affect the odds of getting Alzheimer's disease or milder mental decline.” Further, statins didn't affect Alzheimer's-related brain plaque as observed in post-mortem autopsies.

More backpedaling: a 2002 study from the Netherlands found that “one to three drinks of alcohol per day had a significantly lower risk of dementia (including Alzheimer's) than did abstainers.” Subsequent 2005 research from Saint Louis University strengthened this claim. But in 2008, another team of researchers from Florida’s Mount Sinai Medical Center found that people who have “had more than two drinks a day developed [Alzheimer’s] almost five years earlier than lighter drinkers.”

Clearly, there are still a lot of unanswered questions surrounding Alzheimer’s—but there are a few measures that have consistently been proven to help fight AD. One is mental activity that keeps brain functions sharp: a 2003 study from the Albert Einstein School of Medicine found that playing chess, checkers, or a musical instrument reduced risk of Alzheimer’s amongst a cohort of 469 people over the course of 21 years. Such activities either delay onset of the disease by strengthening mental faculties or “may even create new brain cells in areas affected by Alzheimer’s.”

The more formal long-term development of mental acuity—i.e. education—is also helpful. People with higher levels of education (at least 15 years) have consistently been shown to have a “cognitive reserve” of extra neural connections, which allows their brain to handle more plaques and tangles without showing Alzheimer symptoms. Conversely, “people who don't finish high school are at a higher risk of developing dementia and Alzheimer's disease compared to people with more education, regardless of lifestyle choices and [other] characteristics,” according to a 2007 study from Finland.

Another good bet is eating well and exercising. There’s a rapidly growing body of evidence that a Mediterranean diet (fruits, vegetables, beans, grains, nuts, olive oil and fatty fish) reduces Alzheimer’s risk by providing the body with a lot of vitamins E and C and omega-3 fatty acids. At the same time, high-fat diets (like fast food) have been linked to increased risk of Alzheimer’s.

With regards to exercise, a 2006 study from the University of Washington concluded that “regular exercise reduces the risk of dementia and Alzheimer's disease by up to 40 percent,” and exercise has been shown to reduce brain shrinkage in people in the early stages of the disease. In 2005, Dr. Ronald Petersen, director of the Alzheimer's Research Center at the Mayo Clinic, told ABC News that "regular physical exercise is probably the best means we have of preventing Alzheimer's disease today, better than medications, better than intellectual activity, better than supplements and diet." This is because exercise improves brain function by boosting blood flow to areas of the brain used for memory.

Next Steps

Given what we know—and what we don’t know—about Alzheimer’s, it is clearly a condition that’s waiting for a break through. But how to help this breakthrough along? It’ll be tough, thanks to the inherent difficulties of researching AD: the brain is a mysterious, complex thing, and researchers have a hard time dealing with the proteins related to AD because they have a unique, fluid structure.

On the other hand, it’s clear that we could be doing more to support Alzheimer’s research. In 2007, the National Institutes of Health allocated a paltry $644 million to AD research, as opposed to $2.9 billion to HIV/AIDS—which kills only about 22 percent as many people. Meanwhile, prostate cancer is responsible for only 38 percent as many deaths as is Alzheimer’s, but receives significantly more funding.

To a certain extent, these discrepancies probably have something to do with the power—or lack thereof—of advocacy groups surrounding particular diseases. NIH funding is appropriated by Congress, and part of this process involves allocating budgets to the NIH’s “sub-institutes,” each of which specialize in distinct fields, such as the National of Aging and the National Cancer Institute. As you can imagine, the Institutes that deal with higher-profile diseases tend to receive larger sums. In 2007, for example, Congress gave 4.6 times more money to the National Cancer Institute than it did the NIA—the federal government’s main source of Alzheimer’s research support.

In other words, Alzheimer’s is not near the top of the NIH funding hierarchy—and with 85 percent of the NIH budget going to supporting scientists at universities and medical centers around the country, this is important. Worse, total funding for the NIH has stalled under the Bush Administration: since 2003, NIH’s budget has remained essentially flat.

"Even as substantial advances appear within our grasp—including breakthroughs in Alzheimer's disease, lung cancer and depression—they are at risk of slipping away because the NIH is experiencing a dangerous slowdown in funding," warned a March report from a group of top universities including Harvard, Brown, Duke and UCLA.

The NIH is a particularly important resource for AD research because drug companies are dropping the ball when it comes to the disease. They’ve been too quick to peddle new treatments that just don’t work. This past summer, Wyeth Pharmaceutical admitted that a drug it was pushing as an AD wonder-drug “failed to show an overall benefit in cognitive function for Alzheimer’s patients”; in June, a genetics company called Myriad announced that there was “virtually no difference between the treatment group and the placebo group” in trials that it ran for its AD drug Flurizan. “I think we have seen companies rushing things a bit,” Rudi Tanzi, a neurologist at Massachusetts General Hospital, told the Wall Street Journal. “It’s because Alzheimer’s is such a huge medical need. Companies are rushing to get the first drugs out the door.” But first doesn’t necessarily mean best—or even effective.

In contrast to drug companies, the NIH takes a long-term approach to disease research, and it will likely play an important role in any Alzheimer’s break-through—as long as it’s allocating the resources it needs to investigate this mysterious, heart-breaking disease.

News 11/12/08

Mr. HIStalk — Tue, 11 Nov 2008 19:32:06 PST

From The PACS Designer: "Re: digitally connected patient. TPD last year made HIStalkers aware of a new method being developed to capture patient information from remote locations. The first applications were seen in ambulances where patient info was sent to the hospital while transporting the patient. The Digitally Connected Patient or DCP provides caregivers with information about the patient’s condition and warns when conditions change that can cause harm to the patient. Now, the Cleveland Clinic Foundation has partnered with Microsoft on a pilot study to send patient data from the home to the hospital’s eCleveland Clinic MyChart and then to HealthVault to provide a more complete PHR of the patient experience." Link.

From A CSC Executive: "Re: NPfIT. You mentioned that CSC, Accenture, and Fujitsu slunk away from NPfIT. Could you update the note to remove the CSC? As the article mentions, CSC is still one of the major contractors and we took over additional responsibility when we picked up Accenture’s regions." My apologies. I’ve corrected that slip-up. Accenture and Fujitsu bailed out, but CSC is running a big piece of the project and not complaining about it as far as I know.

From Doogie Howitzer: "Re: Digital HealthCare & Productivity. It’s going down the tubes after two more issues." I can’t say I’ve ever read it either online or on paper, but maybe someone will miss it.

From Lou Loomis: "Re: Microsoft. In reference to your news on 11/7 about Microsoft, the attached was taken last weekend in Toronto. Several of us watched as the billboard operator added some patches to his Windows PC, rebooted, and then started the billboard software again. For reference, this billboard was about 3 stories high!!"

From Ouch: "Re: MEDITECH’s financials." Link. Q3 revenue was up, but net income went from a $27 million gain to a $21 million loss as the company wrote off $50 million worth of investment securities with permanently impaired value (maybe someone who was better in accounting class can help me interpret their numbers, which seem to look good other than the investment hit).

From FormerCT: "Re: layoff. Heard that HealthPort, formerely Companion Technologies, recently held another round of layoffs, its second since August, in an effort to improve the bottom line. The investors paid $40 million to buy Companion from Blue Cross and are having trouble turning a profit, let alone a return." Unverified.

From Stuck: "Re: Sage Healthcare. Mark Ryan, senior VP of customer services and support, has resigned." Unverified. He’s still on their Web page.

From Brother Windy: "Re: wherethemoneygoes.com. Any idea what happened to it?" The author of the site that railed against the financial excesses of non-profit hospitals, a caustic former Chicago reporter nicknamed Low Blow Joe, was outed as a paid shill for insurance big shot and health savings accounts advocate J. Patrick Rooney, who died in September. He also ran a vicious anti-Obama site for Rooney. Without Rooney’s paycheck, the site is apparently defunct.

From Wompa1: "Re: WHO report on world healthcare. This excellent analysis from The Cato Institute puts armchair musings to shame." Link (warning: PDF).

Proof that newspapers are not only getting skinnier, they’re also getting sloppier. This business journal story covers a local hospital’s EMR implementation, managing to (a) not give the hospital’s name except as ‘Harrison’ (it’s Harrison Medical Center); (b) not provide a location for either the hospital or the publication itself, except to say Kitsap (it’s in Bremerton, WA); and (c) not spell the vendor’s name correctly (Eclypsis instead of Eclipsys).

I mentioned that Sonitor was one of a handful of technologies that impressed me at HIMSS (disclaimer: they’re a sponsor now, but weren’t then). Anyway, I ran across the interesting slide above on RTLS opportunities from products like theirs.

I mentioned a few days back that I kind of liked Carol, "the Travelocity of healthcare," even though I’m totally unsold on all the brash consumer-driven healthcare startups trying to cash out before the bubble bursts again altruistically improve society’s health through consumer empowerment. Anyway, Carol cuts a fourth of its staff and changes its business model to focus on provider consulting and software, ditching the idea of letting consumers compare providers themselves. There’s $30 million in VC money shot to hell.

DR Systems claims it invented PACS and is going after other vendors, claiming patent infringement. Want to know what it costs to make them go away? Now you do: Emageon’s 10-Q says they paid DR Systems $1 million (it looks like a deal at $1,000 until you realize they’re omitting thousands).

Healthia Consulting, the force behind what some folks called the hottest event at HIMSS (the HIStalk party), will be rebranded under the Ingenix Consulting banner. Ingenix now has over 1,000 consultants from its several acquisitions and is serving providers, employers, insurers, pharma, and the public sector. Check out (and click) their new ad to your left to review their offerings.

The CEO and IT Director of 24-bed Eastern Plumas Health Care (CA) make a board pitch (unanimously approved) for a clinical system from Dairyland Healthcare Solutions (now called Healthland). Total cost with software, hardware, and implementation will be $322,500.

Scripps Health (CA) interim CIO Patric Thomas gets the job permanently.

Capsule announces 10 new DataCaptor medical device connectivity sales.

Patricia Lavely of Memorial University Medical Center is named CIO of the Year by the Georgia CIO Leadership Association.

Premise gets some big-name new customers for its patient flow solutions: Children’s Hospital Boston, Hospital for Special Surgery, and UCSF Medical Center.

IBA’s iSoft announces the launch of its Lorenzo system to the rest of the non-NPfIT world, taking shots at Cerner and other vendors in the press release. IBA says the potential market is in the billions and it expects to double revenue as a result.

The White Stone Group, which offers systems that document and track the business and clinical communications of hospitals, gets a nice profile in the Knoxville business paper.

The Longstreet Clinic, PC of Gainesville, GA wins a statewide e-Technology Award for its EMR implementation.

Catholic Health Initiatives will implement NCR’s MediKiosks to reduce patient wait time.

UPMC will use its patient database to create a voluntary registry for patients to be alerted about clinical trials.

The Wall Street Journal weighs in on ICD-10 in an article called Why We Need 1,170 Codes for Angioplasty. They seem to conclude that it’s cumbersome but probably necessary given the limits of ICD-9.

E-mail me.

HERtalk by Inga

From Lola Falana: “Re: HCIT funding. MDs could buck up and do CPOE. The now-tired ‘time is money’ excuse ignores that they have the equivalent of a gun in their hand with paper orders. They could come on board tomorrow at zero cost to them and get back the OE time with order sets, reduced calls, and other time-wasters. The culture is already changing with younger clinicians and increasingly onerous third-party, data-intensive reporting for compliance and reimbursement. I know MDs want subsidies, but let’s start with what we can do now with CPOE and Stark. We can adopt a patient safety culture without waiting for Barack. The whole country, including HCIT, needs change.” I agree that mandates may be the answer, though nominal penalties like 2% probably won’t be enough.

AARP, Business Roundtable, Service Employees Union, and National Federation of Independent Business send an open letter urging President-elect Obama and Congress to build on the SCHIP, to promote preventive care, and to advance HIT adoption. The four groups are part of an organization called Divided We Fail, aimed at promoting healthcare reform now.

A report concludes that excess installed capacity and initiatives to reduce health care costs will negatively affect sales of CT systems, MRI, and nuclear medicine scanners over the next five years.

A study finds that when patients receive treatment alerts along with their physicians, compliance increases by 12.5%, with the greatest improvement in diagnostic recommendations.

St. David’s HealthCare (TX) blames the economic downturn on its decision to lay off 50 employees in non-bedside, non-patient care areas.

The Ventura County, CA newspaper reports that the local county clinic system had 44,000 more patients in the last year while hospital procedures are down about 9% over last year.

Another sign of the times: Starbucks reports a 97% fall in profit (and a 50% drop in stock price over the last year). I’m not sure I could carry on if I didn’t know I could find a Starbucks within a five-minute drive just about anywhere I am, so I hope Howard Schultz figures it out.

Amid pressure from clinical staff critical of his management style, Northeast Health Systems (MA) CEO Stephen Laverty resigns. According to the Wicked Local Gloucester (great name for a newspaper), Laverty was focused on advancing HIT at this 100 Top Hospital. During his eight-year tenure, the hospital implemented a number of new technologies, including PACS, CPOE, and voice recognition.

Biopharmaceutical company Favrille and PHR developer MyMedicalRecords announce a merger.

ACS gets a $44 million deal to provide business outsourcing services for Florida Medicaid. ACS will be tasked with helping the agency save money on Medicaid bills by identifying possible private insurers.

Doctors in California, Nevada, and Hawaii claim that Medicare is late in paying them millions of dollars. The problems stem from May’s changeover to UPINs and September switch to a new claims processor.

E-mail Inga.

Veterans Day

Freedom is not free - thank a soldier or veteran and remember those who have given their lives. If you’re a veteran, on active duty, or serving in the reserves or National Guard, thank you.

In Flanders Fields
By John McCrae

In Flanders Fields the poppies blow
Between the crosses row on row
That mark our place; and in the sky
The larks, still bravely singing, fly
Scarce heard amid the guns below.

We are the Dead. Short days ago
We lived, felt dawn, saw sunset glow,
Loved and were loved, and now we lie
In Flanders fields.

Take up our quarrel with the foe:
To you from failing hands we throw
The torch; be yours to hold it high.
If ye break faith with us who die
We shall not sleep, though poppies grow
In Flanders fields.

Help a Wounded Veteran Recover

I like to think my problems are important, but only until I remember those soldiers who are coming back from terrible struggles in Iraq, Afghanistan, and other far-flung parts of the world. Kids are coming home horribly maimed and disfigured before they even had a chance to experience normal adult life. Despite their ruinous injuries, they might even consider themselves lucky because, unlike some of their fellow soldiers, they made it back.

I was struck today when I accidentally ran across Project Valour-IT, which is run by Soldiers’ Angels. The nonprofit group’s motto is, "May No Soldier Go Unloved." The project, originally named as Voice-Activated Laptops for OUR Injured Troops, supports severely wounded soldiers by providing them with voice-controlled laptops, whole-body video games for physical therapy rehabilitation, and personal GPS devices to help them relearn mobility with their impairments and physical challenges.

Donations go 100% toward the laptops - nobody in Soldiers’ Angels gets paid. They received this from a grateful soldier: "To Whom It May Concern, Hello, my name is LCpl. Andrew. I am a Marine that was wounded in Iraq and got medevaced to Brooke Army Medical Center in Ft. Sam Houston, Texas. I recently received a laptop. I was informed that it was you, the Soldier’s Angels that donated it. I can’t tell you how thankful I am to have support from organizations such as yourself. It really lets me know that there are people out there that still care about the troops and what they are sacrificing for this country. I appreciate what you have done for me and having this laptop is actually good therapy for my hand. Once again thank you and I am proud to serve this country knowing there are people like you that I am protecting. Sincerely, Andrew."

I was moved to do two things today. First, I donated $800 (anonymously), the amount needed to fully fund a soldier’s laptop. I spoke to the founder and she assures me it will be put to great use in one of the military hospitals. In fact, she invited me to visit either Bethesda or Brooke Army Medical Center to present it myself. If you want to donate that tax-deductible amount, you are also welcome to correspond or visit the recipient to encourage his or her recovery through moral support. They get a great deal from Best Buy on state-of-the-art laptops with all the assistive technology installed, ready for immediate use (she wanted me to thank Nuance for helping them out in the past with Dragon Naturally Speaking discounts, so here’s a shout out to them).

Second, Project Valour-IT is running a blog contest from now (Veterans Day) until Thanksgiving. You can donate any amount to help the cause. Donations aren’t tracked by blog, but rather by teams representing each military branch (it’s actually just for fun since all the money goes into the same pool, but it does spark friendly rivalries). I chose the Navy Team because: (a) I have been to Navy football games and the Midshipmen are the most disciplined and respectful students I’ve ever seen; (b) I will argue passionately that the Naval Academy is not only the most beautiful campus in the country, but is also in the top handful of colleges academically and competitively and maybe #1 when you count leadership; (c) Mrs. HIStalk’s father was a Marine; and (d) I can say I know a Navy Rear Admiral, Cindy Dullea of SCI Solutions. OK, it’s sketchy logic, but I had to pick one of the branches, so there you go.

If you would like to help Project Valour-IT, click the fundraising graphic I put up on your right, which will take you to a donation screen. Donate $250 or more and you’ll get a special gift. And, since I can’t see the donations and they aren’t tracked separately for HIStalk, please post a comment on this article (click the Comments link at the bottom) and just mention that you helped them out. Thank you for your support.

Substance abuse in anesthesiologists

noreply@blogger.com (Kevin) — Sun, 09 Nov 2008 19:47:54 PST

The Boston Globe has a front page story of an anesthesiology attending in Boston, recently found dead in a hospital closet:

There was a half-filled vial of propofol, a sedative used to put patients to sleep during surgery, and a syringe filled with midazolam, a powerful drug similar to Valium. There were empty vials of morphine, hydromorphone, and Demerol - addictive opiates capable of providing tremendous highs. And then there was one nearly empty vial of vecuronium - an intravenous muscle relaxant that, when taken at such a high dose, would shut down the body's respiratory system in roughly three minutes, leading to certain death.

A tragic fall from grace of a promising young doctor. Apparently 2 percent of anesthesiology residents suffer from substance abuse. Some hospitals, like Boston's Massachusetts General Hospital, perform random drug testing of their anesthesiologists. Should a program like this be expanded to hospitals nationwide?

Update:
Notes of an Anesthesioboist comments.

topics: anesthesiologist, addicted

Rehab Programs Extend Stays To 3 Months

Sarah Rubenstein — Mon, 10 Nov 2008 12:32:00 PST

For Steve Owens, 30 days in a drug-treatment program wasn’t enough.

Getty Images

“They would clean me up and I would start to get back on my feet again, mentally, physically and spiritually,” Owens told the Los Angeles Times. “Then I would get out and go right back where I came from — the same friends and the same places. With these rehabs, you just get started before they let you go.”

Drug and alcohol rehabilitation centers are increasingly recognizing that problem. Their solution is to encourage more patients to stay for as long as 90 days, rather than the usual 30, the LAT reports. A few examples from the article: For over a year, the Betty Ford Center has been offering a 90-day residential treatment program, and a third of clients have taken advantage of it. Promises Treatment Centers last year extended a young-adult program to 90 days from 30. Hazeldon has added beds to meet growing demand for 90-day treatment.

“There was a belief that 30 days was the right number,” David Sack, CEO of Promises, told the Times. “But there was absolutely no data to say 30 days was the right number. … What we’re seeing now is this much broader view for how to manage addiction. There isn’t this naive optimism that people will reach 30 days and they’ll be fine.”

The extra time comes with a price tag: At Betty Ford, the first month costs $24,000 and the next two months cost $8,000 each, according to the Times.

Addiction Extra: The Boston Globe had a story over the weekend about the anethesiologist and former employee of Beth Israel Deaconess Medical Center who was recently found deceased in a hospital closet there. The story looks at the issue of addiction among anesthesiologists, a group that may be especially susceptible to drug abuse problems.

What to do if you have a nose bleed

noreply@blogger.com (Kevin) — Wed, 05 Nov 2008 08:00:00 PST

Plastic surgeon Ramona Bates gives some information on what causes nose bleeds, and tips on what to do at home. The proper technique of applying pressure, and when to go to the hospital or call the doctor, are addressed.

Thanks for the good advice to a common problem.

What Makes Minnesota’s Mayo Clinic Different?

Maggie Mahar — Thu, 16 Oct 2008 06:29:57 PDT

After working at the Mayo Clinic in Rochester, Minnesota for nine years, Dr. Marc Patterson decided to change his life. In 2001, he moved to New York City to take a job as chief of pediatric neurology at New York-Presbyterian Hospital (NYPH).

This year, Patterson returned to the Big House on the Prairie. "Sometimes I miss New York,” he acknowledges, “but working in a system that actually functions is worth it."

Let me be clear: Patterson has many good things to say about NYPH and Columbia University Medical Center, the uptown campus where the worked. “I had a great experience, and fabulous colleagues,” Patterson told me. “Moreover, one of the reasons I moved back to Minnesota is because my family is there.”

Nevertheless, Patterson says: “There is a fundamental systemic difference between Columbia and the Mayo Clinic: Columbia is a traditional academic medical center; [research] that came through the med school provided the money to pay us. The hospital is a separate entity. By contrast, at Mayo, the hospital and the medical school are one. It’s an integrated organization.”

What difference does that make?

Patients Trump Research

“At Mayo the focus is on the patient. The needs of the patient come first. I think one of the Mayo brothers originally said it—and here, that really is the case,” says Patterson. “We also do high quality research at Mayo, and we have a graduate school of medicine. But research is not the primary focus.

“At most academic medical centers,” he continues, “medical research comes first; education of the students comes second. Clinical practice [caring for patients in the hospital and clinics] is not the priority.”

This isn’t to say that doctors at Columbia don’t strive to give patients the very best care possible. I am a long-time New Yorker, and if I were going to be hospitalized in Manhattan, I might well choose Columbia.

But, at Columbia, “while being an excellent clinician is great, it’s just not as highly regarded as being a brilliant researcher,” Patterson explains. “Here at Mayo, being a superb clinician is the sine qua none—if you’re not able to practice at the highest level, you won’t succeed here.”

I have heard the same story from other doctors at some of the nation’s top academic medical centers. If you want the money and the glory, you focus on research. You won’t become a star by being the best clinician, or even by being a top professor.

At Mayo, on the other hand, stardom is frowned up. “Mayo has been, from the beginning, a group practice,” says Patterson. “You really have to be a team player. People in administrative positions understand that everyone is an important member of the team.”

An Egalitarian Culture

You may have heard that at Mayo, doctors collaborate. But did you know that after their first five years all physicians within a single department are paid the same salary? During those first years, physicians receive "step raises" each year. After that, they top out ,and "he or she is paid just the same as someone who is internationally known and has been there for thirty years," says Patterson. ("Most could earn substantially more in private fee-for-service practice." he adds.)

“It doesn’t matter how much revenue you bring in,” Patterson explains, “or how many procedures you do. We’re all salaried staff—paid equally. This is very good for collegiality, and people working together,” he adds. “The culture here at Mayo doesn’t encourage egos. There is not the same cult of personality that you find at other places.”

At Columbia, by contrast, the pecking order is quite clear: even the furniture on the floor where a physician works tells him where he stands. “The floor we were on was perfectly fine,” Patterson recalls. “But if you walked up a few flights to ENT (ear nose and throat) surgery, it was a different world—dark wood paneling, different furniture… These surgeons bring in a much higher return for their time,” he points out, “and they do some things that require remarkable skill and training. At the same time, if a psychiatrist spends two hours with a patient, he may get $200, while all a dermatologist needs to do is get out the liquid nitrogen…”

The dermatologist can make $200 in a matter of minutes, just by zapping the harmless crusty brown patches on the back of a middle-aged patient commonly known as “barnacles of age.”

That celebrity turns on how much money a doctor brings in hardly unique to Columbia. “Traditional medical centers are much more hierarchical,” Patterson notes.

Mayo is the outlier. Its culture is unusual because it is based on “the very egalitarian ethic of the people who established the place,” says Patterson, “and the fact that we’re in Minnesota”—a state with a longtime egalitarian tradition. As a result, “people have the opportunity to develop skills in whatever they want to do. Our nurses are superb at doing spinal taps, and they teach our residents.”

“We are starting to make better use of nurse and nurse practitioners are being integrated into the teams,” he adds. “We also have a lot of physician assistants here—and they are extraordinary people.

“Turnover is very low. It’s unusual for people to leave here, and when they do, many like me, wind up coming back. You would be surprised—we celebrate many 35 and 40 year anniversaries. That fact that people stay so long is important to the success of the organization.”

Patterson does not sound as if he’s boasting. He didn’t found Mayo. He didn’t create the culture. He merely works there—and he is telling me why he likes it.

At the same time, in fairness I should report that the HealthBeat reader who introduced me to Patterson was an extremely successful physician at Mayo for many years, and ultimately decided to leave. The Mayo Clinic is not Nirvana for all fine physicians.

Yet I believe that there is much that health care reformers can learn by studying how Mayo operates. This is not to suggest that we should aim to replicate the model coast to coast, putting golden arches over every new clinic. There is, after all, a difference between healthcare and hamburgers. Healthcare is not a commodity,

A “Firewall” between the Money and the Doctors

Still, there are differences in the way Mayo is organized that are worth pondering. For instance, there are no “rainmakers” at Mayo, Patterson explains, because “there is a firewall between the physicians and the money. I don’t even know how much Mayo is paid for different things that I do. I know the billing code, but that’s all. The business office takes care of all of that.

“I also don’t know which patients are uninsured—and whether Mayo will have to absorb much of the cost of their care.”

Yet—and this is key—although Mayo’s doctors are not worrying about the dollar value of what they do, they are not more extravagant than other doctors in dispensing care. Quite the opposite: Extensive analysis of Medicare records done by researchers at Dartmouth University reveals that treatment at the Mayo Clinic in Rochester, Minnesota costs Medicare far less than when very similar patients are treated at other prestigious medical centers.

The chart below, from the “Executive Summary” of the 2008 Dartmouth Atlas is an eye-opener. It shows that when researchers compared how much Medicare spent per patient, on very similar chronically ill patients during the final two years of life at five top medical centers (UCLA, Johns Hopkins, Massachusetts General, the Cleveland Clinic and Mayo’s St. Mary’s hospital), the tab taxpayers paid varied widely,

While Medicare spent more than $93,000 per patient on those who were treated at UCLA Medical Center, patients at Mayo cost the government only half as much. As the bottom two-thirds of the chart shows, this is because, when compared to patients at other medical centers, those at Mayo spent fewer days in the hospital, saw fewer physicians and were less likely to wind up in the ICU.

Yet no one would suggest that Mayo scrimps when treating patients. The Clinic received stellar marks on established measures of the quality of care, and both patient satisfaction and doctor satisfaction were higher than at UCLA.

As HealthBeat has pointed out in the past, when it comes to healthcare, lower costs and higher quality often go hand in hand. Mayo’s patients are not hospitalized as long as patients at other medical centers—and don’t see as many specialists—because resources are used efficiently, and diagnoses are made quickly.

A Fully Integrated System

“Here at Mayo, we can do things in a week that take several weeks to organize in New York,” says Patterson. This is because Mayo is an integrated medical center.

For example, “In New York, each division has its own staff to make appointments. If I wanted several specialists to see a patient, I had to go through each of those divisions. At Mayo, we have a pediatric appointment office that makes all of the appointments for pediatric patients.”

Patterson still remembers “the frustrations of the system in New York…It took a lot of time to get things done. If you wanted something accelerated, we essentially had a trade and barter system—you would call in favors. We were always reinventing the wheel, rather than having a system in place.”

It didn’t help that the uptown campus and the downtown campus of New York/Presbyterian Hospital have different electronic medical record systems, “and neither of them is user-friendly,” Patterson recalls, sounding, just for a moment, a little glum.

How could one hospital have two EMR systems that don’t talk to each other? “When New York Hospital and Presbyterian Hospital merged in 1997 to form NYPH they had different systems,” he explains. Like many large medical centers, NYPH is now making major investments in pilot programs to move information out of “silos” and to “enable easier access to critical clinical information.” But as this 2008 NYPH presentation observes the project will take not only money, but “time” and “culture change.”

Meanwhile, at Mayo, “We have a unitary medical record and a very effective IT department,” says Patterson. “We developed our own software, and we can we dictate notes—we don’t have to type.” (This is a boon because, believe it or not, many doctors don’t know how to type.)

“In the hospital, what we dictate can be transcribed within about an hour.” Patterson adds. “In the clinic, it’s done by the next half-day. In the meantime, if someone needs to access your notes, they can dial in and listen to the dictation.”

Patients, Like Doctor, are Equal –and Many Need Charity Care

Some say that Mayo operates in a bubble that separates it from the real world. Their may be some truth to this. Certainly, Mayo has created a very special culture.

But the assertion that Mayo is “different” because the vast majority of its patients are very wealthy and thus easier to treat than the patients at most academic medical centers just isn’t true.

The Mayo Clinic in Minnesota sees many local patients. “And like New York, we have minorities—just different minorities,” Patterson explains. “At Columbia, I saw many Dominican patients who lived close to the hospital in Washington Heights” (a low-income neighborhood that is beginning to attract middle-class New Yorkers).

“At Mayo, we have Spanish speaking migrant workers” Patterson explains. (In the 1990s the number of foreign-born Latinos in Minnesota shot up from 9,200 to more than 62,000).

Surprisingly, Minnesota also is home to many refugees from Africa. Somalis began flowing into the state from refugee camps in the 1990s, in part because several well-organized faith-based Minnesota groups made them welcome, and in part because the economy was strong and jobs for immigrants who didn’t speak English were available. Today an estimated 30,000 Somalis reside in the state. “And they are not well off,” says Patterson, comparing them to the poor patients he saw in New York.

Minnesota has a history of active volunteerism regarding immigration and refugee resettlement, which helps explain why its foreign-born population more than doubled during the 1990s—from 110,000 to 240,000.

The immigrants include some 60,000 Hmong, an ethnic group that fled mountainous regions in Southeast Asia. Most of those who settled in Minnesota come from Laos. Some readers may recognize the Hmong from Anne Fadiman’s brilliant book The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures. From his years at the Mayo Clinic, Patterson is familiar with the cultural divide which make the Hmong difficult patients for many Western doctors. “They believe in supernatural forces,” he explains. Nevertheless Mayo treats them—and regularly advertises for Hmong interpreters.

Like most academic medical centers, Mayo treats a fair number of patients who cannot afford to pay their bills. In 2007 it spent $182 million providing charity care and covering the unpaid portion of Medicaid bills—plus another $352 million on “quantifiable benefits to the larger community” which included “non-billed services, in-kind donations and education.”

That year, 100,000 benefactors gave the Clinic a record $373 million—enough to pay for the benefits the Clinic provided for the community, but far from the amount that would be needed cover the charity care Mayo provided.

Although its $1.6 billion endowment gives Mayo a stable base, it is not awash in money. In 2007 it operated on a relatively slim margin of 2.9 percent; that year revenues grew by 9.6 while expenses rose by 8.5 percent, “due in part to Mayo investments in patient care and research activities, as well as information technology infrastructure,” the annual report explains.

When it comes to serving Medicaid patients, Mayo is generous with its time and talent. “Here, there is no distinction between Medicaid patients and other patients,” says Patterson. “I wouldn’t know whether they are on Medicaid, or have insurance from their employer. The business office knows that.”

At many academic medical centers, Medicaid patients are seen mainly by residents in a separate clinic. “At Mayo no one is seen only by residents. And we routinely spend 90 minutes with a new patent —going through X-rays, and a complete examination,” says Patterson. “At Columbia, we had private offices and a Medicaid clinic, I tried to give people 90 minutes, but in the clinic, it was hard to do that.”

Those who suggest that Mayo operates in a separate world often assume that it can afford to be so magnanimous when caring for indigent patients because so many of its beds are filled with Saudi Sheiks. Patterson acknowledges that “at Mayo, we do see a number of quite wealthy people—but that was true in New York too.” Indeed, high-income patients typically flock to prestigious medical centers like Johns Hopkins, UCLA, Mass General and New York-Presbyterian.

So when officials at a medical center like UCLA try to argue that Medicare’s bill are higher when patients are treated in L.A. because the hospital is treating a different “population” of patients suffering from and “more complex” and “more severe illnesses,” this doesn’t quite ring true. Certainly, it is hard to believe that the difference is large enough to explain bills that are 80 percent higher.

As Dartmouth’s Dr. Elliott S. Fisher, a co-author of the study comparing Medicare spending at five academic medical centers, points out: “We are comparing patients with identical outcomes — all were dead in two years. So it’s unlikely that differences in the severity of illness account for the variations we saw.”

It also is important to keep in mind that, “contrary to popular assumptions, it’s the volume of services, not the price per service, that accounts for most of the variation in Medicare spending” observes Dr. Jack Wennberg, the founder of what is now known simply as “the Dartmouth research.” And as more than two decades of Dartmouth research have shown, it is the supply of hospital beds and doctors that drives volume—not patient demand. When more resources are available, as they are at UCLA, patients spend more time in the hospital and undergo more procedures. Yet outcomes are no better; often they are worse.

“UCLA knows it has a problem,” Wennberg confided in an interview last year. “But what are they going to do—close down beds and fire doctors? They need that stream of revenue that comes from the beds and doctors to service their debt.” So Medicare spends more at UCLA—and some patients are over-treated.

But Not All Mayo Clinics Are Created Equal

Mayo offers lessons for reformers. Still, it’s not easy to replicate the success Mayo enjoys in Minnesota. Not even Mayo can do it.

Over the years, the Mayo Foundation system has grown beyond its original Rochester, Minnesota site, establishing group practices in Phoenix, Arizona; Jacksonville, Florida; Eau Claire and La Crosse, Wisconsin as well as in several other communities in Minnesota and Iowa. But when Dartmouth’s researchers examined how these spin-offs use their resources, they found “surprising” variations.

“Indeed,” the report observes, “the spectrum of approaches to caring for patients with severe chronic illness ranges from a low resource input, low-intensity end-of- life pattern favoring primary care to high resource input, high-intensity end-of-life care relying on medical specialists. In short, we find no evidence that providers in these systems use a distinctly Mayo Clinic strategy for allocating resources and managing chronic illness.”

It is worth noting, however, that at the four Mayo practices that Dartmouth’s researchers studied, the quality of care turned out to be either “very high” (LaCrosse and Phoenix) or “above the national average” (Jacksonville and Eau Claire.)

The variation suggests that it may not be the Mayo “system” that lifts Mayo’s flagship Minnesota hospital above the tide. Rather, some observers suggest, it may be the highly egalitarians and collaborative “culture,” which puts patients ahead of everything and everyone else, that makes the Mayo Clinic in Rochester, Minnesota so special.

These are values that can be traced directly back to William Mayo and Charles Mayo, who, together with their father, William Worrall Mayo, founded Minnesota’s Mayo Clinic in 1903. The Clinic was one of the first examples of group practice in the United States. As Doctor William Mayo explained in 1905: “The best interest of the patient is the only interest to be considered, and in order that the sick may have the benefit of advancing knowledge, union of forces is necessary…it has become necessary to develop medicine as a cooperative science.”

The Mayos also made it clear that patients’ interests were not well served if doctors competed with each other. Late in life William emphasized that in addition to making a commitment to the patient, doctors must make a commitment to each other: “Continuing interest by every member of the staff in the professional progress of every other member,” would be essential to sustaining the organization’s future.

More than one hundred years later, building a health care system that adheres to such a collective vision of its mission may be difficult. Perhaps it can only be done in Minnesota.

Nevertheless, the 2008 Dartmouth Atlas does provide sufficient data to support the thesis that integrated delivery systems are likely to provide the most efficient high-quality care. And the report makes it clear that Mayo is not the only integrated system that stands as a benchmark for excellent collaborative care. Both Intermountain Healthcare (IHC) in Utah and the Sutter system hospitals in Sacramento are singled out for praise.

So the structure of the system is important. But so is the soul. On that point, I would argue that we should pay attention to the “firewall” between the doctors and the money at Mayo. Ideally, in any medical center, the money and the businesspeople should be on one side of that wall; the doctors and the patients on the other side. Clearly, someone has to make sure that the hospital can stay afloat financially. But too often, money gets in the way of medicine.

In the end, Mayo offers proof that when a like-minded group of doctors practice medicine to the very best of their ability—without worrying about the revenues they are bringing in for the hospital, the fees they are accumulating for themselves, or even whether the patient can pay—patients satisfaction is higher, physicians are happier, and the medical bills are lower. Isn’t this what we want?

I will be attending NEJM Horizons Conference to push the boundaries of traditional medical publishing, suggestions welcomed

noreply@blogger.com (Ves Dimov, M.D.) — Wed, 22 Oct 2008 10:14:53 PDT

This weekend, the New England Journal of Medicine "will bring together a group of visionary medical students and trainees to help NEJM push the boundaries of traditional medical publishing. They are looking for creative minds to join the editors for a weekend to explore what's possible."

In July, the Editor for Medical Education of the New England Journal of Medicine (NEJM) asked me to inform my readers (2,200 daily RSS subscribers plus 1,600 visitors) that the journal is seeking applications from interested residents and students to join them in Boston from October 24-26th, 2008 to discuss the future information needs of physicians and physicians in training. I was intrigued enough to apply and was honored to be invited to participate in the NEJM Horizons Conference along with 20 of the brightest people from around the world (which automatically makes me a misfit).

The organizers of the NEJM Horizons Conference used a Ning-based social network to get the participants to know each other and foster collaboration before the meeting. Some of my posts to the network are shown below. One of my other projects, the Annual Perioperative Medicine Summit started using Facebook for a similar purpose this year.

Suggestions for NEJM.com posted at the conference social network

Just a few ideas:

- Add comment sections to the online articles
- Start an editor(s) blog
- Start a Twitter micro-blog
- Add a social network similar to Sermo
- Allow for embeddable articles/images/videos similar to the newly-launched embeddable Google Books
- Have the editor make the weekly podcast, similar to JAMA, Annals of Int Med and The Lancet
- Add tag clouds to NEJM articles
- Add Text-to-Speech and convert to MP3 to NEJM articles

NEJM is a Journal (Only) No More

Text-to-Speech for Mobile RSS Reader and Cell Phone

This is an application I would like to have:

A mobile text-to-speech reader which:
- reads selected (full-length) feeds from my mobile RSS reader (cell phone)
- reads articles (NEJM, NYT, WSJ, etc.) from my cell phone

I could use the time to exercise or just walk in the park.

Talking about blogs would be great too. I see it as a 2-way process:

1. Input through RSS.
2. Output through blogging and micro-blogging (Twitter).

After I announced my participation in the NEJM Horizons Conference on Twitter, Scanman (a radiologist from India) and Sandnsurf (an ER physician from Australia) had some suggestions, shown below:

Twitter Discussion (oldest post at the bottom, newest at the top)


	AllergyNotes @scanman Will Twitter live from the NEJM Horizons Conference when I find time, no NDA. Thanks for the suggestions. http://tinyurl.com/67t89z 1 minute ago from web in reply to scanman

	AllergyNotes @scanman Sure. Planning to talk about RSS and mobile text-to-speech as application of choice. about 3 hours ago from web in reply to scanman
	AllergyNotes Selected to participate in the Annual ACAAI FIT Bowl competition. Have to submit 10 questions. Any suggestions? http://tinyurl.com/6y7ac9 about 3 hours ago from web
	scanman @AllergyNotes Good luck & have fun at the conference. Tell the other participants to join the gang at twitter/friendfeed etc :) about 3 hours ago from twhirl in reply to AllergyNotes
	AllergyNotes @scanman NDA is pretty typical when you discuss new projects. I do not know if NEJM will use one. Lancet did not when I consulted for them. about 3 hours ago from web in reply to scanman
	AllergyNotes @scanman To give credit when credit is due, NEJM is the journal with the best Web 2.0 offerings, by far. about 3 hours ago from web in reply to scanman
	AllergyNotes @scanman Well, NEJM is using the Ning social network for the conference and that's a good start. about 3 hours ago from web in reply to scanman
	scanman @AllergyNotes Let's hope for the best. They may allow you to live tweet. But the prospect of asking their permission to do so rankles >.< about 3 hours ago from FriendFeed in reply to AllergyNotes
	scanman @AllergyNotes How the heck do they think they're going to innovate w a bunch of youngsters in a conference if they don't embrace new media? about 3 hours ago from FriendFeed in reply to AllergyNotes
	AllergyNotes Planning to update Twitter live from the ACAAI meeting in November, will be presenting AllergyCases.org there: http://allergycases.org/ about 3 hours ago from web
	scanman @AllergyNotes That's exactly what is SO WRONG about NEJM & the other suffy med journals. NDAs & copyright :( Boo about 3 hours ago from FriendFeed in reply to AllergyNotes
	AllergyNotes @scanman I would be happy to update Twitter from the NEJM conference after I make sure it's OK with NEJM and see the NDA, if there is one. about 3 hours ago from web in reply to scanman
	scanman We've got 2 votes already for @AllergyNotes as the representative of medtwits & live-tweeter at NEJM Horizons Conference http://is.gd/4wFK about 3 hours ago from twhirl
	sandnsurf @scanman @allergynotes AGREED looking forward to some great discussion. We have linked medical publishers in the medtwitts.... about 3 hours ago from web in reply to scanman
	scanman @AllergyNotes You HAVE TO live tweet from the NEJM Horizons Conference. I nominate u as the representative of the medtwits :) about 3 hours ago from twhirl in reply to AllergyNotes
	scanman Most traditional medical publishers send emails & give RSS feed of TOC and a few short snippets on podcasts & think they've reached the... about 3 hours ago from twhirl
	scanman @AllergyNotes Open source is the 1st thing that NEJM has to adopt if they hope 'to push the boundaries of traditional medical publishing' about 3 hours ago from twhirl in reply to AllergyNotes
	scanman @AllergyNotes Wow! Congrats. Don't be too modest. You'd fit right in. Teach the old codgers about Web 2.0 ;) about 4 hours ago from TwitterFox in reply to AllergyNotes
	AllergyNotes Periop Medicine summit is starting to use Facebook for the same purpose. Do you see a trend? http://periopmedicine.org/ about 4 hours ago from web
	AllergyNotes NEJM Horizons Conference https://secure.nejm.org/hor... about 4 hours ago from web

	AllergyNotes The organizers of the NEJM Horizons Conference used a Ning-based social network to get to know and foster collaboration before the meeting. about 4 hours ago from web
	AllergyNotes Getting ready to attend NEJM Horizons Conference with 20 of the brightest people from around the world which automatically makes me a misfit about 4 hours ago from web

At the reception dinner, I will be seated next to Jeff Drazen, the Editor-in-Chief of NEJM, therefore, I would like to solicit any suggestions for NEJM you may have. Please submit them in the comments section below.

References:
NEJM Invites Students and Residents to IT Horizons Conference
NEJM is a Journal (Only) No More

Updated: 10/22/2008

The Four Rules of Work Design

Joshua Schwimmer, MD, FACP, FASN — Wed, 01 Oct 2008 13:00:00 PDT

Image via Wikipedia

Via Medscape (free registration required), The Four Rules of Work Design (as applied to medical practice):

Rule 1 Addresses How People Work: All activities must be highly specified as to content, sequence, timing and expected outcome.

Rule 2 Addresses How People Communicate: All communications must be highly specified and direct, with clear yes-no signals back and forth.

Rule 3 Addresses How Pathways Are Constructed: The pathway for every service or product must be predefined, highly specified, simple and direct - with no loops or forks.

Rule 4 Addresses How Improvements Are Made: All improvements must be made using data-driven scientific methods, as close to the work as possible, by the people who do the actual work and under the guidance of a teacher or coach.

On Caring for Difficult Patients

Joshua Schwimmer, MD, FACP, FASN — Wed, 01 Oct 2008 11:27:37 PDT

Dr. Tony Miksanek discusses caring for three "difficult patients" on Medscape (free registration required).

Americans Who Have Insurance —But Still No Access To Care, Part I

Maggie Mahar — Tue, 02 Sep 2008 17:31:18 PDT

A friend who lives in Boston complained, not long ago, about not being able to find a physician. In Boston? “Come on,” I said. “This is like claiming you couldn’t find a liquor store.”

“They’re all oncologists and cardiologists,” he grumbled. “Last week I cut my hand badly enough that it needed stitches. I have good insurance. But I couldn’t get an appointment with my family doctor—or any of my friends’ doctors. I didn’t want to spend hours in the ER. So I wound up going to my sister’s house. She sewed it up at her kitchen table.”

His experience is not as unusual as it sounds. Some 56 million Americans do not have a regular source of care according to the National Association of Community Health Centers (NACHC) -- even though many of them do have insurance. The problem is a shortage of primary care physicians (PCPs) in many parts of the country, particularly, but not exclusively, in poorer communities.

Even Docs Have to Call In Favors

Not long ago, Bob Wachter, Professor and Associate Chairman of the Department of Medicine at the University of California, San Francisco (UCSF) , and author of Wachter’s World warned his readers: “The Long-Awaited Crisis in Primary Care: It’s Heeere.”

Indeed, if you try get an appointment at UCSF’s general medicine practice, you will find that it is “closed” –even if you are an UCSF physician. They just aren’t taking any new patients. “Turns out we’re not alone,” Wachter adds. “Mass General also is not accepting any new primary care patients.”

He calls attention to “to two very powerful NPR reports on the topic – the first, a WBUR special by healthcare journalist Rachel Gotbaum called ‘The Doctor Can’t See You Now,’ is the best reporting on this looming disaster I’ve heard .

Wachter summarizes highlights: “Getting a ‘regular doctor’ (a PCP) at Mass General now takes the combination of cajoling, pleading, and knowing somebody generally referred to as ‘working the system.’ In other words, the process of finding a primary care doc is now like getting a great table in a trendy restaurant.

“The report also makes clear that providing more ‘access’ through expanded insurance coverage won’t do the trick,” Wachter explains. “Massachusetts, you’ll recall, markedly expanded its coverage a couple of years ago (in legislation proposed by that ex-liberal, Mitt Romney). Scott Jasbon, a 47 year-old contractor/bartender, thought he was all set when he enrolled in one of Massachusetts’ subsidized health plans. He was wrong.

“‘I received a card with my doctor's name on it and I was told that was my primary care physician,' Jasbon recalls. “’I called the office. They told me that they no longer took the insurance. So then I went through every list of doctors in Sandwich, in the book, called each doctor, and each doctor told me the new plan that I received, they, no one took the insurance… I knew that there was something wrong with me, and I was explaining to each doctor actually as I called them, "I'm having problems urinating." Hot flushes, I was hot all the time. I knew something was wrong, and I couldn't get anybody to take care of me.’”

“Jasbon ended up in an ED [emergency department ], where he was diagnosed with diabetes and hypertension. The ED staff helpfully suggested that he should think about getting a PCP. . .”

Readers commenting on Wachter’s post confirmed the story. One wrote: “I’m a physician and we moved to a new city a couple of years ago. I had to twist arms and call in favors to get myself and my wife PCPs--and we have ‘good’ insurance and no significant health problems (yet).”

At the Center of Healthcare Reform: A Medical Home for Every American

In the meantime, health care reformers talk about how, once we have national health insurance, we will create “medical homes” where primary care physicians will, at last, be rewarded for taking the time to co-ordinate patient care.

In a recent issue of the New England Journal of Medicine, for instance, a panel on “The Health of the Nation: Coverage for All Americans,” focused on the need for a “patient-centered home” that would be accountable for overseeing patient care.

The panel began by discussing the difficulties primary care physicians face today. Dr. Arthur Caplan, a professor of bioethics at the University of Pennsylvania, summed up the PCP’s lament: “I don’t have time to talk to anybody . . . . I don’t get reimbursed enough. I’m swamped by paperwork. I don’t have time for anything. And I answer to a bunch of— non-MD folks who are telling me what to do half the time. . . ..”

By contrast, in the brave new world of universal coverage, the panel members agreed, primary care doctors should be rewarded for talking to their patients, “making sure that patients are getting appropriate counseling” and that “they're up to date with their preventive care.” While specialists may see only a single body part, the PCP will have “the big picture.”

Commonwealth Fund president Karen Davis explained how physicians would be compensated: “in addition to fee for service [the practice would receive] a monthly . . . fee for being a medical home. It's a blended system of payment, which has worked very well in Denmark, where people have well-established relationships with primary care and compensation for primary care is on a par [with] or even higher than compensation for specialty care.

Former U.S. Senator Dr. Bill Frist then zeroed in on electronic medical records, describing them as key to helping the primary care doctor keep track of the specialists his patient is seeing, what those doctors are prescribing, and what they are recommending.

Davis agreed: When it comes to healthcare information technology, she noted, “we are way behind. One fourth of American primary care physicians have electronic systems. The Netherlands, New Zealand, Denmark, UK. . . ninety percent of physicians have totally electronic offices. . . What’s different in those countries? The government was willing to set standards on what is an acceptable system. . ..

And “in Denmark,” Davis added, “they found once they got this up and running, they were saving 50 minutes a day. Because it was so much easier to get the information they needed, to order a prescription or authorize a refill of a prescription. It really pays off. . . . But it needs leadership. National leadership...”

Others on the panel jumped into the conversation . . . . Until finally, Dr. Steven Schroeder a professor of health and health care at UCSF, interrupted:

“I think there is an elephant in the living room that we’re not talking about. All these comments presume the persistence of a vibrant primary care system.

“But,” Schroeder observed, “if [as we discussed earlier, doctors are] telling their sons and daughters and nephews not to go into medicine, those that [do] go into medicine know for sure they don’t want to go into primary care. . . . They want to go on what they call now the road to happiness. So this means they want to go into Radiology, Ophthalmology, Anesthesia, Dermatology . . . It’s an old-fashioned road. And why do they want to do that? They want to do that because they’re coming out with huge debts. Because unless we fix the payment system, they’re not gonna get the kind of income that they’d like.”

But the problem isn’t just the relatively low pay that primary care doctors receive. Students are also “more attracted to shift work, so they don’t have to worry about patients after they leave,” Schroeder added. “They want that eight-to-five job. And then finally, they don’t like all the hassles that we’ve been hearing about” in primary care.

“So the electronic medical record by itself isn’t gonna fix that,” Schroeder warned. “And unless we do more fundamental surgery on making primary care a more compelling field...in the future in primary care may will be practiced by [people] other than doctors. And maybe,” Schroeder allowed, “this isn’t a bad thing...”

The discussion swirled forward, as panel discussions do, without really facing up to the implications of Schroeder’s comment. But he was asking exactly the right question about the promise of “a medical home for every American.” Who, exactly, is going to be at home?

Once again, making sure that everyone has health insurance is not synonymous with ensuring that everyone has health care.

A Dearth of Doctors

Because the pay is low, the pace is hectic and the hours are long, fewer and fewer medical students are becoming family doctors or internists. Over the past decade, medical schools have witnessed a 22 percent drop in the share of graduates who choose to become “generalists” rather than specialists. A 2008 NACHC study estimates that to provide services to medically disenfranchised Americans who don’t have a regular source of care, we would need up to 60,000 more primary care professionals.

Instead, the pool is shrinking. Fed up with a broken system, older PCPs are retiring early. And younger PCPs are switching specialties. Wachter points to an “ABIM study [which] found that 10 years after initial board certification, approximately 21% of general internists were no longer in the practice of general medicine [vs. 5% of subspecialists leaving their field].

“The dwindling number of PCPs who remain in practice are being far more discriminating about the patients – and insurance payments – they will accept,” Wachter adds. “With Medicare reimbursement tightening . . . and Medicaid reimbursement near Starbucks barista levels . . . the result is primary care ‘access’ that sounds good in a press conference but is not real.

“You might ask, won’t the existing PCPs need to accept even these low insurance payments? After all, they need to see some patients to generate an income. Well, as it turns out, no,” writes Wachter, answering his own question. “The remaining PCPs are in such demand . . . that they can afford to limit their practice to patients with better paying commercial insurance.”

In the NEJM panel discussion Schroeder suggested that “someone other than doctors” may wind up doing the job. I’m assuming that he’s referring to nurse practitioners. And certainly, nurse-practitioners, working with primary care doctors, pediatricians or geriatricians could screen patients, take care of the least complicated cases, and give the doctor the 30 or 40 minute he needs to talk to—and listen to—patients with more difficult problems.

But as Niko’s post below reveals, we also face a serious shortage of nurses. Indeed, the same 2008 NACHC study says that, in order to staff medical homes, we would need up to 44,500 additional nurses.

Boosting the pay for physicians and nurses willing to co-ordinate patient seeing might draw more young professionals into primary care. But expanding the pool of primary care doctors and nurse is rather like drilling for oil. Even if we raised their fees tomorrow, it would still take many years for students to move through the pipeline, and into the workforce.

Moreover, it is important to keep in mind that it is not just the low salaries that med students find daunting. “Some primary care educators used to say that the problem was that students didn’t have opportunities to see the real practice of primary care docs – if they did, they’d recognize the subtle satisfactions and be more inclined to enter the field,” Wachter notes. “But an upcoming paper by UCSF’s Karen Hauer and others demonstrates that such exposure actually discourages trainees from choosing primary care. Primary care docs are frustrated and demoralized, and most of them are honest enough to share their angst with their students. In other words, It’s The Practice, Stupid.

The Lack of PCPs Creates Holes in the System

In the meantime, as Kevin M.D. pointed out not long ago, the lack of primary care physicians helps explain the number of hospital re-admissions.

Kevin began by pointing to an op-ed in the Boston Globe which urged Medicare to stop paying for patients who are rehospitalized within 30 days after leaving the hospital. “These readmissions are often avoidable,” the op-ed’s author wrote. “And if Congress focuses on reducing the need for rehospitalization in areas where the practice is most common, Medicare could save many billions of dollars.

Kevin took issue: “Not surprisingly, op-eds like these are written by non-physician policy makers, and further puts doctors in increasingly difficult situations. Physicians are pressured by hospitals to discharge patients and keep the turnover high, which increases revenue for the hospital. Now they're taking it from the other end, with this proposal not to pay for readmissions. It would be nice if someone advocated the proper support system be put in place first before acting on these ideas.

“The major reason for readmissions is inappropriate follow-up, which can be directly traced to a lack of primary care access. Solve the primary care shortage, and readmissions will go down.”

This makes sense. Granted, part of the problem is that some hospitals don’t take enough time explaining medications to patients—and making it clear what follow-up treatment they will need. But for proper follow-up, patients do need that “medical home”—a primary care physician who knows that his patient was in the hospital, and why, and what the instructions are for follow-up care. The primary care doctor should have the patient’s hospital records, a list of medications that he is supposed to take, the dosages, and recommendations for physical therapy or other treatments.

But if the patient does not have a primary care doctor, who is going to pick up the slack? The hospital can’t follow him home.

The lack of PCPs also is putting added stress on emergency care. Patients who cannot get an appointment with a primary care doctor are crowding ERS. From 1996 to 2006 Emergency room visits jumped more than 32 percent from 90.3 million according to the National Center for Health Statistics, a division of the Centers for Disease Control and Prevention. And this is not because more Americans lack insurance.

To the contrary, the study found the proportion of emergency visits by the uninsured had not changed substantially between 1992 and 2005, although the number of overall visits went up 28 percent. The survey found that people in the highest income bracket - in excess of 400 percent of the federal poverty level -- accounted for an increasing portion of emergency room visits, while the lowest income brackets remained virtually unchanged.

So much for the theory that illegal immigrants are responsible for the excruciatingly long waits in the nation’s ERs.

Who Suffers

“The state of primary care is not only sad, it is incredibly stupid,” Wachter concludes. “ Mountains of research have demonstrated that primary care-based care is less expensive – without access to primary care doctors, patients get their basic care in emergency rooms, or from subspecialists, or not at all. In any case, care is fragmented, technology over-intensive, and wickedly expensive.”

Yet, “the forces of inertia getting in the way of solving the primary care crisis are so strong that only a very powerful implosion will create the political wherewithal to overcome them. Specialists don’t want to forgo income, medical students will continue to vote with their feet, existing primary care docs have resigned themselves to more of the same and are hunkering down for retirement, and many patients are perfectly happy bypassing primary care docs to get their care from hordes of subspecialists. The patients who take the biggest hit, of course, are poor and middle class folks with chronic diseases – even those with insurance – who can’t find a PCP and can’t afford a VIP doctor, and who therefore live in perpetual fear of the next crisis.”

In Part II of this post, I’ll explore how specialists might become part of the solution. As Dartmouth researchers argue in "Tracking the Care of Patients with Severe Chronic Illnesses: Dartmouth Atlas of HealthCare 2008": “training more primary care physicians alone won’t solve the problem of . . ..the lack of co-ordination in our fragmented health care system.” If we want to contain costs while lifting quality, specialists, too, will need to begin thinking in terms of the “big picture.”

100+ Tips for Being On Call in the Hospital

Joshua Schwimmer, MD, FACP, FASN — Sun, 19 Oct 2008 08:05:35 PDT

Several weekends ago, while seeing nearly fifty patients in the hospital, I asked readers of this blog and my followers on Twitter a question: "What advice do you have for physicians on call?"

The question hit a nerve, and the result was over a hundred tips from a dozen different physicians. Some are directed at residents, others at attending physicians. Some tips apply to the daytime, some apply to 3 o'clock in the morning. Some tips are unrealistic. Some are thought experiments. Some tips might make your day go quicker, and some will purposefully slow you down. Some tips might improve the care of your patients, some might make you more mindful, and some might help you reconnect with the reasons you became a doctor in the first place.

There’s bound to be something here you'll find useful.

Thanks to everyone who generously contributed their advice, including Doctor Anonymous, Theresa Chan (Rural Doctoring), Jen McCabe Gorman, A. Mangla, Mark Johnson, Nephron129, Huck, and several anonymous physicians.

Addendum: For the most recent version of this page to which you can add your own advice, visit The Efficient MD Wiki.

--

Drink more water. Does staying well hydrated affect your performance? In the rush to see patients, it’s easy to forget the simple things, like drinking water. Try drinking at regular intervals — say, every three hours. Set a timer to go off every three hours, and drink at least eight ounces of water. You might discover that this improves your mental acuity and performance.

Get outside at least once a day. Vow to get out for at least five or ten minutes every day (weather permitting, of course). Staying in the hospital too long can make anyone claustrophobic. Look at the horizon. Breathe the outside air. Get a fresh perspective.

Make a game of remembering names. Attempt to memorize as many of your patients’ names as you can. You may be one of those people born with the skill of instantly remembering names. Most of us aren’t so lucky, and we have to work hard at it. It’s a skill worth improving. Try memorizing the names of all the patients you see. One method is to say the persons name aloud to them (“Hello, Mr. Jones.”), Repeat the name three times to yourself, then focus on an unusual feature of the patient and connect this feature to the person's name.

Walk more quickly. Try walking 25% faster than you otherwise would. Observe the effect on the rapidity of your thinking.

Take the stairs instead of the elevator. If you need to walk up or down two flights, ditch the elevator and use the stairs. Extra credit: buy a pedometer and aim for 10,000 steps during the day.

Nap. If you feel sluggish in the middle of the afternoon, experiment with taking a 15 minute nap. (This is long enough to refresh you without causing you to fall into a deep sleep.)

Time yourself. Set a specific time to spend with each patient: say, 5 - 15 minutes with a follow up patient, and 30 minutes with a new patient. (Use a watch with a vibrating alarm, like the Dakota Vibe.)

Use a tally counter. Keep this in your pocket and record the notes you’ve written, or the times you’ve done something correct, or the small tasks you’ve accomplished. Aim for 100.

Connect with other people who are on call with you. There’s a certain friendly familiarity that comes with being one of the few people working in the hospital. Also, you may need them for consults, and they may need you.

Pay attention to your breathing. While walking in the hospital, quiet your mind and focus on the breath. Try to maintain your focus and concentrate only on the breath.

Refine one part of your physical exam. For ten patients in a row, pay particular attention to how you perform one part of the physical exam. Do a complete cardiac exam, or pulmonary exam. Do it the same for each patient. Analyze your technique.

Track down the coffee. Better yet: Find out who makes the coffee. Make friends with them. Quickly. Same with charge nurses. (Jen McCabe Gorman)

Maintain eye contact. Make a conscious attempt to keep your eyes focused on the eyes of your patients. Don’t look away. Occasionally switch from eye to eye. Maintaining eye contact tells your patients that you are paying attention to them. It’s easy to forget this and look at our list, or at the part of the body we’re performing the physical exam on — anywhere but the eyes.

Ask questions. Find out patients' backgrounds. Dr. Faith Fitzgerald has a story that she tells about a group of residents who purposefully presented to her “the most boring person on their team,” an utterly unremarkable old woman. After some questioning, Dr. Fitzgerald discovered that this woman was actually one of the last survivors of the Titanic. Everyone has a story. It’s easy to lose site of patients’ humanity when you’re rushing through the hospital on call. For at least a few of the patients you see, ask a question. Try to find out something about them. What have they worked as? Where do they live? What is interesting about them? Ask one question of each patient, like “Where have you worked in your life? Where have you lived?”

Do everything when you can. Eat when you can, sleep when you can, pee when you can. (Rural Doctoring)

Eat a Cliff Bar. Doctors notoriously are too involved with taking care of others to take care of themselves. We ignore our own bodies. We may be hungry or thirsty, but are rushing too quickly to pay attention. Midway through the morning, when you may feel yourself losing steam and are maybe slightly hungry, try having a snack. Something small, like a Cliff Bar. See if that gives you an extra boost of energy.

Get to the hospital ridiculously early. Wake up at 4 or 5 AM. Getting in early has advantages — it’s easier to concentrate and accomplish tasks if there are fewer people around. However, typically morning labs are not available until late in the morning or early in the afternoon, so this strategy may require you to check labs again. (If you haven’t slept much, getting in early works best when combined with a nap.)

Reevaluate your gear. Your day will be much more pleasant if you have the right equipment. Ever use a pen that didn’t write smoothly and felt awkward in your hand? Ever use a stethoscope with poor acoustics? These little things may not seem like much, but if you’re examining a lot of patients and if you’re required to write a lot of notes (assuming you’re not using an EMR), little things matter. Having the right gear can make the difference between being frustrated and relaxed at the end of the day.

Lie down whenever you can — even if only for a minute because it might turn into an hour. (Rural Doctoring)

Count stairs. Sometimes you'll be too damn tired to pay attention; wakes you up. (Jen McCabe Gorman)

Consciously write less. Make ever word count. Be sure to include the pertinent parts of the history, the pertinent positives and negatives, but be aware of the subtext to your notes — you are trying to establish in the reader’s mind your argument for a specific diagnosis or plan. For more on this idea, see Developing Clinical Problem Skills by Harold Barrows.

Consciously write more. As an experiment, imagine the worst possible outcome or potential diagnoses for some of your patient. How have you excluded these diagnoses? Take some extra time to convince the reader that your discarded diagnoses are not the correct ones and that further tests are not needed.

Don’t get distracted. "Being on Call can be overwhelming especially if you have to see over twenty patients. I usually get my list of patients in the morning and then geographically I make a 'plan of attack,' and then I go full steam ahead. Try not to chat with people although it can be tempting. Staying focused on the patients and their issues rather than what you want to do when you leave the hospital really makes my speed remain fairly contstant. There is nothing so novel here that you haven't heard before — make yourt plan of attack, stick to it, focus on the work without getting distracted." (A. Mangla)

Change your pen. If you’re used to a ball point pen, switch to a roller ball. If you’re used to a roller ball, try an inexpensive fountain pen or gel pen. It’s amazing what the difference of a pen can make in your mood and your writing. (If you write most of your notes electronically, obviously this advice doesn’t apply.)

Learn to recognize when people are sick. For residents: “If you think a patient has a chance of ‘crumping,’ ‘lay eyes’ on the patient early in the night so when you’re called at 2 AM you have a reference to compare to.” (Mark Johnson)

Say one encouraging thing to everyone (if possible). “You’re doing better.” “Your kidney function is improving.” “Everything looks stable.” It’s often difficult for patient’s to tell whether they’re improving or not. Even simple words of encouragement can lift someone’s spirit.

Respect the nurses. “Respectful interactions with RNs is key to survival. Rudeness results in bodies found in ditches.” (Rural Doctoring)

Don’t wear a watch. Does not looking at the clock make you faster?

Take a deep breath. If you become short tempered with patients or their families because of stress, catch yourself. Relax. Sit down.

When encountering complex differential diagnoses, use a mnemonic. For example, VINDICATUM: Vascular, Inflammatory, Neoplastic, Drug, Iatrogenic, Congenital, Autoimmune, Trauma, Unknown/Idiopathic, & Metabolic. For new patients with uncertain diagnoses, use this mnemonic.

Choose your rounding time carefully. “Certain period of the day are more conducive to rounding. 8AM is notoriously hard because the nurses are signing out and there is no workspace available. Family visiting hours, usually from 10 am until the early afternoon, can be tough too if you have a lot of patients to see. If you only have a few patients to see, this is probably the best time as you can take the time to explain things to the family and patient together. Like another person has written, avoid socializing.” (Anonymous)

Make sure your pager is on. Don’t laugh. (Doctor Anonymous)

For each patient, ask: how am I getting them closer to discharge? What’s the plan? How am I getting them to their goal of being well and out of the hospital? (Or failing that, how am I making them more comfortable, etc.)

Review ACLS. For residents: “Scan the CPR/ACLS protocols for about 90 seconds each AM while walking into the hospital in AM to refresh.” (Mark Johnson)

Normalize your patients. At some point during their hospital stay, most patients should be normalized. In the rush to manage more complex problems, this is easily overlooked. Normalization means turning a "patient" into a "normal person." This is accomplished by removing intravenous lines and catheters, stopping unnecessary medications, not drawing labs daily, getting people out of bed, and planning for discharge. A patient who is otherwise doing well may stay in the hospital for weeks (or even die) because of a complication like line sepsis, urinary tract infection from a catheter, or deep venous thrombosis. Sometimes, these complications may be prevented by early and aggressive normalization.

Take a stairway or elevator you’ve never used before. Many hospitals that I’ve worked at have multiple elevators and stairways, many of which I’ve never used. Experiment with using them.

Consciously relax. Doctors are often at their most stressed when on call. Ever few minutes, relax your facial muscles. Let your shoulders drop. Before seeing each patient, relax yourself.

Wake up early post call. For residents: “Set your alarm in AM for plenty of time to wake up & get a fresh cup of coffee (even if it means less sleep) prior to AM rounds.” (Mark Johnson)

Always give patient and their families the benefit of the doubt in any interactions. Presume that if they’re acting upset, or hostile, they have a reason. It may always not seem like a good reason to you, but presume it’s there. Try to see the reason. It’s surprising how often hostility melts away with a small amount of human kindness and empathy.

Avoid socializing. Recognize that being on call is a time that you need to get work done and socializing is not your goal.

Consciously socialize. Recognize that being on call is a time when you can deepen your relationships with other doctors.

Group your tasks. Similar tasks should be performed together. Rather than examining patients, checking labs, and writing notes, try doing each of these tasks at once — for example, examine all patients on the floor, check all labs for all patients, then write as many notes as you can. If you use this technique, be sure to ensure accuracy by writing small notes to yourself on an index card or on a note template so you don’t neglect to write down significant physical findings.

Triage. While it may be tempting to start at the top of the hospital and work your way down, or go from one floor to the other, it’s a better idea to see patients who are sick or require decisions early. That way, you’re less likely to discover that someone is unexpectedly sick at the end of the day. Of course, it’s better to see a few patients at each nurses station — it’s inefficient to constantly criss-cross your way through the hospital floors, returning to places you’ve already been. There’s a balance between seeing patients efficiently and seeing the most critical patients first.

Experiment with breaks. Take a five minute break every one to two hours. Athletes understand that for sustained peak performance you must take breaks. If you keep going at top speed for the whole day, you’ll burn out.

On an index card or PDA, write down everything you don't know. One of the best ways to learn more and learn efficiently is to keep a list of things you don’t know. Whenever you encounter a clinical question that you don’t know the answer to, write it down on an index card or PDA. (Assuming you don’t need to know the answer right then — if you do, by all means, look it up.) At the end of the day, devote some time to looking up the answer to every clinical question you have using a resource like UpToDate.

Have a printout of every patient you are covering in your pocket. "Keep to do list with check boxes next to each items. Write down tasks to be done at a particular time. For example, check labs on Mr. X, Mrs. Y, and Z at 2200. Keep commonly used numbers on the sheet or handy in your pocket (other residents, cardiology fellow, common hospital floor numbers.)" (Mark Johnson)

When “cross-covering” a patient, write down everything you do. (Mark Johnson)

Reevaluate your templates. Being on call is a stress test of the system.

Bring your favorite foods from home. “I bring 2 bottles of water and 2 sodas each weekend call. I like to bring ~6 sandwich bags of sliced cheese, crackers, nuts, carrots, dry cereal to snack on throughout the night, also a few chocolates makes the night.” (Mark Johnson)

If you’re staying overnight, stuff a call bag. One resident’s call bag includes a medical book, non-medical book, travel-sized deoderant, toothbrush, toilet paper, fresh pair of scrubs, undershirt, and underwear for the AM. (Mark Johnson)

Carefully choose your pocket resources. For residents, consider Massachussets General Hospital’s “Blue book,” Tarascon’s Internal Medicine/Critical Care, and Tarascon’s Pharmacopia. (MarkJohnson) I also liked On Call: Principles and Protocols.

Treat your call day just just like a regular work day. “I go through my same routine. I don't come in later, but rather at my usual time. I avoid nurse signout time (7am at our hospital) and I start with the most critically ill.” (Nephron129)

Write as you talk on the phone. You may often be put on hold or on a phone call which doesn’t require your full attention. Make productive use of this time. Write notes, check labs, or do other activities. The general principle is that there should be no downtime unless you want it.

Knock on the door (or the wall) before entering patients’ rooms. Even when you’re at your most harried, be polite. Patients will appreciate it, and when you do have time, being polite will be second nature.

Write standing. If you find that your energy is flagging, or that you your notes are overly lengthy, experiment with writing standing up.

Always keep a stack of business cards handy. Good advice generally, but especially while on call. You never know when a new patient or physician will ask for your card.

Find that zone of maximum benefit. Avoid defensive medicine, too much writing, and too much testing. The curves for you and for your patient are different.

Be kind. Say kind words to people who can't understand or hear you because they are unconscious. (Sometimes, they can hear you.)

Watch your body language. Face patients. Smile. Don’t rush. Don’t hunch your shoulders.

Have your fellow pre-round on everyone. Then come in at 8. (Huck)

Change up your routine. Start at a difference place in the hospital. Write with a different pen. Consciously alter large or small parts of your usual routine.

Some institutions film you. Be aware of how you appear. (Anonymous)

nephron129 said...

The best piece of advice for weekends on call came from one of my mentors. The people who are the most bitter are those who think that just because it's a weekend that somehow they can still make plans to attend some event in the early afternoon.
I try to avoid socializing but I also try to recognize when I've hit the wall and I need a break. I try to take 10-15 minutes to recharge in the late morning and then again in the early afternoon. It sounds silly but getting nourishment is important too. If you remember back to your intern days, you usually had a snack in your pocket or at least knew where the food was on the nursing units.
Just some thoughts.

Anonymous said...

MAKE SURE YOU KNOW WHERE THE PATIENTS ARE IN THE HOSPITAL:
WE HAVE A RATHER LARGE HOSPITAL. IT'S IRRITATING, AND TIME-WASTING, TO GO TO THE ICU TO SEE MRS X, ONLY TO FIND THAT SHE'S JUST BEEN TRANSFERRED TO THE REGULAR NURSING UNIT -- USUALLY THE ONE YOU WERE JUST AT -- WHICH IS THE EQUIVALENT OF 2 BLOCKS AWAY. SOMETIMES, EVEN THE PHYSICIAN SIGNING OUT TO ME MAY NOT KNOW THAT HIS/HER PT HAS BEEN OR WILL BE TRANSFERRED.

WE ALSO HAVE A TERRIBLE HOSPITAL EMR WHICH ITSELF MAKES IT HARD TO FIND PATIENTS, SO WE HAVE TO BE SURE THAT SIGN-OUTS AND CONSULTS GIVE US PATIENT'S EXACT FULL NAME. EG IF I WERE TOLD (ON THE PHONE) TO SEE A HARRISON BROWN, BUT HE'S REALLY HARRISON BROWNE, THIS EMR SYSTEM WOULD SIMPLY TELL US NO HARRISON BROWN IN SYSTEM -- OR WOULD GIVE US INFO ON WRONG PT.

FINALLY, MAKE SURE THE PT STAYS IN THE ROOM WHEN YOU'RE ON YOUR WAY. TELL NURSES TO VERIFY HE'S IN HIS ROOM AND KEEP HIM THERE. I'VE SOMETIMES GONE TO SEE A CONSULT (IN THE A.M.) FOUND, UPON ARRIVAL, THAT PT WAS DOWN AT MRI AND WOULDN'T BE BACK FOR AN HOUR, AND HAVE THEN HAD TO COME BACK LATER IN DAY (OR EVENING) TO DO WHAT I INTENDED TO DO AT 8 A.M. KEEP PT IN ROOM; THEY CAN DO THE MRI OR WHATEVER AFTER YOUR EVAL, UNLESS IT'S REALLY URGENT.

Huck said...

"Check in with your significant other EVERY call-night, set aside a time to talk, or at least text saying when you will call. They are lonely, and you get so busy that you can easily forgot.

Things I would like to implement
- "Jott" notes to myself to keep todo list on iphone
- Carry the hospital's cell phone (I found it took bulky, and phones are about everywhere)
- however if you do a lot of "page & run" its great to be able to page to cell phone, the uber-busy neurosurgeon residents are great @ this"

Theresa Chan (Rural Doctoring) said...

Physical survival on call

* Before call, determine food strategy. Some hospitals have horrendous food, residents almost always know where to call for delivery, etc. but bring food if you want alternatives/healthier stuff to eat.
* Sleep when you can:
o Even if you only have 5 minutes, it might turn into 20 minutes or an hour
o Don't be picky about where you nap--call room might be far away from where the action is. Nothing wrong with napping on a loveseat, 2 rolling chairs, the floor...
o Don't sleep on top of your pager if it is on vibrate mode, you probably won't feel it.
* Caffeine is helpful up to a point but drinking plenty of water or Gatorade is better for the long haul. You won't feel as seedy/sick after you get off call.
* Choose good shoes. Your feet will ache after being up for 24+ hours. Running shoes are good for some, clogs for others. Make sure they have good support and shock absorption. Some people wear TED hose.
* Bring a toothbrush. You will feel more human after freshening up.
* Bring Artifical Tears. Eyes feel weary and dry in the hospital at 0300.
* Apply deodorant before call. Please.

Call Team Strategies

* Before calling the attending/cardiologist/nephrologist, etc., page the rest of your team to see if they have to speak to the same person. Saves redundant beeps and attendings will be less grumpy as a result.

Cross-cover

* Have signouts on you, whether electronically or on paper. Make sure signouts are complete when you receive them.
* If there are labs to check on signout, make sure you check them. Also make sure the resident signing out tells you what to do with abnormals.
* If you're cruising around the wards/units, you might as well check in with the charge nurse to see if there are any questions/PRNs needed so you don't get beeped as soon as you leave. Similarly, if you get called to one ward, ask "Does anybody else need to speak to me?" before you get off the phone.
* Expect the most floor calls as soon as a new admission gets to the ward.
* Have strategies for the most common calls: fever, low/high bp, agitation
* Be nice to RNs when they call, but be clear about the info you need for specific questions, so they will learn to have that info ready when they call in the future. For example: if they are calling about hypertension, ask: has it been this high before? what meds is the patient on? HR?

Admissions

* In ER, write down vitals, labs, meds, allergies and look at ECGs/XR before you see the patient if possible
* Get the old chart. (Hopefully you have EMR and this won't be a big deal.)
* Don't automatically accept the ER attending's diagnosis
* History-taking: Get the big picture, then zoom in on details
* At first you may feel you need to write your H&P before you write orders, but take time to develop a running idea of the orders you need as you interview the patient. It will actually save you time in the future.
* Don't forget PRNs. Think about the poor schmo you're going to sign out to after call is over.

When you don't know the answer/what to do

* Talk to your senior resident
* Look stuff up in your favorite resource. Find one broad resource and stick to it. (I use UpToDate).
* Go look at the patient again
* If the issue is whether to do the LP/paracentesis/thoracentesis in the middle of the night, you're better off doing the procedure and getting the data then trying to justify not doing it the next day. When it come to paracentesis/thoracentesis, you can do a small-volume diagnostic tap at least [I can write up some instructions one day, or maybe your program already teaches residents how to do these.]

Prioritizing

* When on call, you're going to have multiple nurses, attendings, patients pulling your attention in 1,000,000 different directions. Get used to it. It doesn't get better after residency.
* Process requests/questions by urgency:
o Patient status deteriorating?
o Order or study needs to be done now or else you'll lose the opportunity to get essential data?
o Cranky attending on the phone and you need to speak to him/her?
* If none of the above are true, and if the situation will not create an irreversible calamity, it is far better for you to finish what you're doing right now, assuming it can be finished in 15-30 minutes or less, than it is for you to be pulled away and leave a task unfinished. What you want to avoid is having a dozen loose ends all around the hospital.
* Group tasks: if you're checking labs on the computer, take a second to run your list and check all the outstanding labs at once. Ditto radiology. Ditto dictations--once you're on the phone, get 'em all done.
* I cannot emphasize this enough: Dictate the same day you see the patient. It is painful at first but your life will get much better if you can get in the habit early.

Want to contribute your own advice? Please leave a comment.

Image Credit: Fractal Hospital, Flickr

Maybe People Don’t Want Prescription Drugs from Canada

Jacob Goldstein — Fri, 26 Sep 2008 08:42:00 PDT

A program in Boston that allowed current and retired city employees to buy prescription drugs from Canada is shutting down due to lack of interest, the Boston Globe reports. The program never had more than a few dozen takers.

One key reason: Since prescription drug coverage was added to Medicare at the beginning of 2006, fewer retirees have needed to look north for cheaper drugs. (Though if the Medicare drug premiums keep rising, maybe interest will rise again.)

That’s led to declining interest among cities and states in setting up similar programs, the Globe says.

Recent safety problems stemming from drugs and food products manufactured overseas may also have made people less eager to get their drugs shipped to them from a foreign country. (Yes, we realize that many drugs sold in the U.S. are manufactured at least in part overseas.)

Earlier this month, advisers to Obama and McCain — who have both supported allowing people to buy drugs from Canada — said the were re-evaluating their positions in light of the safety problems, Reuters reported.

Map via Wikimedia Commons

Medical records and Facebook

Kevin — Thu, 11 Sep 2008 10:36:51 PDT

Provocative piece by hospitalist el jefe Bob Wachter. He laments how archaic most electronic records are, and I agree:

You’d think that medicine's conversion from paper to electronic records would solve many of these problems, but – to date – all it has done is create new-fangled electronic silos. In most EMRs, including the GE system we’re using at UCSF, the notes are really just electronic incarnations of what previously lived on dead trees – no more likely to facilitate collaboration than the paper records they replace.

In many cases, they spew out template-driven notes that are long on noise and contain very little useful information. Very little power of the electronic medium is being harnessed.

On the other hand, Web 2.0 sites, like Facebook, provide intuitive tools that enhance collaboration and social communication:

How great would it be if, through the medical record, I could interact with multiple specialists who have seen my patient – in real time, just like my kids are interacting with far-flung friends on Facebook. And if nurses could leave me a note which I could answer online without having to respond to a page. And if the daily plan for a patient – developed collaboratively – could be shared among all the caregivers, with notes appended when a patient’s clinical ship seemed to be blowing off course.

One problem is that much of health information technology is staffed and programmed by has-beens. There is very little innovation, with most of forward-thinking ideas confined to sites like Google, Facebook, and MySpace.

It would be nice if an electronic record was designed with the singular focus being the end-user experience. They should make physician's lives immeasurably easier, and significantly decrease the time spent charting and tracking patients.

There are very few record systems that meet even this minimal standard.

An EMR like Facebook? We can only wish.

Emergency care

Kevin — Sat, 13 Sep 2008 11:06:33 PDT

Emergency department overcrowding is nothing new, and is often pointed to as a symbol of healthcare's dysfunction.

In Boston, it has been decreed that emergency departments are no longer able to go on diversion. Apparently when EDs close, it causes more problems than it solves. Makes sense on one level, as patients are shuttled to hospitals who have no records of them.

This is a mere band-aid solution, since the underlying mechanism of overcrowding isn't addressed.

Over at Slate, there is a nice article describing the allure of emergency care. One reason is that primary care physicians have little incentive not to suggest the ED for their patients:

Assume a patient calls his doctor about a new symptom. Ideally, after listening on the phone and deciding that it's probably nothing serious, the doctor arranges an office visit for the next day, offers reassurance, and averts an unnecessary late-night E.R. visit. But doctors don't get reimbursed for that call. And what if they tell a patient to wait and something bad happens? Then malpractice lawyers have a field day.

Another reason is the convenience of emergency care. You can conceivably receive STAT blood tests, imaging scans, and specialist consultation in one (albeit long) visit.

Even with a high co-pay, it's still a bargain for the patient:

In the E.R., a single $100 co-pay may feel like a relative bargain compared with the alternative: fees for multiple trips to the doctor and testing centers, hours on the phone arranging the whole process, and days of missed work.

The solutions are obvious to regular readers here, and it deals with re-aligning the financial incentives:

We also should restructure the payment system for primary-care doctors so they won't go belly up if their schedules aren't 100 percent booked, given how little they're paid per patient. They should get paid for those after-hours calls.

Primary care physicians need to find ways to optimize their schedules for same-day, urgent care appointments. Some do, many don't. Converting all office schedules to a hybrid open-access/fixed-appointment format should be a minimum step to help relieve the emergency department burden.

Palliative Care and Hospitals' Bottom Line

Niko Karvounis — Fri, 12 Sep 2008 08:33:24 PDT

If there are such things as universal truths, then one of them is almost certainly this: nobody likes to be in pain (okay, maybe masochists). This simple assumption is the key principle behind palliative care, which focuses on reducing the severity of pain and managing symptoms of patients with advanced illness—instead of relentlessly concentrating on trying to cure a condition. As many have put it before, palliative care is about caring, not curing—helping patients feel better, sometimes through medication and sometimes through communication and personal support.

Palliative care seems like a practice that would be somewhat at odds with American-style medicine, which centers on maxing out detection efforts and treatment interventions. The reasons for this tendency are two-fold: in our warped reimbursement system, doctors get paid more to do more procedures, and our medical culture is very much focused on ‘beating’ sickness instead of treating people.

Yet palliative care has been on the upswing in American medicine over the past few years. According to the American Hospital Association, as of 2005, 30 percent of U.S. hospitals and 70 percent of hospitals with more than 250 beds had a palliative care program—an increase of 96 percent from 2000. What’s behind this surge?

One hopes that hospitals are increasingly recognizing the value of palliative care to patients. Palliative care is not just about hospice care—that is, care for the dying—though it’s a big part of helping sick patients pass on in comfort. It’s also, as Dr. Diane Meier, the Director of the Center to Advance Palliative Care and member of The Century Foundation’s Medicare Working Group, has noted, an important part of helping all people with advanced illness have a higher quality of life. If we ignore palliative care, we end up with patients who might be getting ‘treatment,’ but who are miserable and in pain during the process. “Forcing a choice between cure and comfort until the end-of-life predictably results in preventable suffering during all other stages of a serious illness,” Meier pointed out in a 2007 commentary for Medscape.

But it would be foolish to ignore the elephant in the room when it comes health care: money. In the newest Archives of Internal Medicine, Meier and a collection of co-authors from the Palliative Care Leadership Center offer another possible explanation as to why palliative care is catching on: it saves hospitals money.

Meier and co. looked at more than 5,000 palliative care patients and 20,551 patients who only received “usual care” (i.e. care focused on curing rather than caring) across eight hospitals. After controlling for age, gender, condition, and even insurance coverage within the sample group, the research team found that, for patients discharged alive, “palliative care consultation was associated with adjusted net savings in total costs of $2,642 per admission compared with usual care.” For patients who died in the hospital, “palliative care consultation was associated with adjusted net savings in total costs of $6,896 per admission and $549 per day.” In other words: “hospital palliative care consultation teams are associated with significant hospital cost savings.”

This is important stuff, because any and all savings make a difference to hospitals. The authors point out that hospitals have a median operating margin—that is, the profit made on patient care—of just 2 percent, which breaks down to about $27-$40 per day. That’s not a lot. So why does palliative care save money? Simple: “discontinuing costly non-beneficial interventions among seriously ill patients reduces hospital costs.” In other words, consultation from palliative care teams appears to make patients and doctors think twice about undergoing costly, unproven treatments intended to “prolong life and avert death at all costs.”

It’s hard to over-estimate the importance of any sort of consultation that influences this decision-making process surrounding issues of what kind, and how much, intensive or invasive care seriously ill patients receive, particularly for end-of-life care. As the famous annual Dartmouth Atlas research project has shown again and again, spending more time and money on severely ill patients doesn’t necessarily make them healthier. In fact, regions of the U.S. that spend more on Medicare patients over the course of their last two years of life have slightly worse mortality outcomes.

Unfortunately, it’s generally difficult to get physicians to rethink the do-everything-you-can-because-you-can-do-it logic that results in bombarding patients with painful, and sometimes inhumane, care. In May, Maggie reported on a harrowing story that Meier recounted to an audience of medical students about a man who was literally tied to his bed so that doctors could install a feeding tube he didn’t want in order to ‘save’ him. A 1995 JAMA study confirms that such stubbornness amongst doctors isn’t as rare as you might hope. This study looked at 9,105 patients over two years who had life-threatening illnesses, and split the sample roughly evenly into two groups. Patients in the first group had access to a specifically trained nurse to have “multiple contacts with the patient, family, physician, and hospital staff to elicit preferences, improve understanding of outcomes, encourage attention to pain control, and facilitate advance care planning and patient-physician communication.” In other words, these patients had a special go-between representing their preferences and palliative care priorities to doctors. The second group did not, and received usual care.

Unfortunately, the JAMA found that the addition of a specialized nurse didn’t make much of a difference. Patients in the first group “continue[ed] to receive low-yield, burdensome, and high-cost tests and treatments including prolonged ICU stays—a probable result of highly ingrained physician and hospital practice patterns and prevailing hospital culture.” Sadly, according to the JAMA authors, it seems that “enhancing opportunities for more patient-physician communication, although advocated as the major method for improving patient outcomes, may be inadequate to change established practices.”

It’s tough to convince doctors that they should be prioritizing palliative care—at least when it’s only a nurse and a patient discussing things. But it seems that full-on palliative care consultation—intervention by an interdisciplinary consultation team that can include any range of medical experts from fields like oncology, internal medicine, psychiatry, and other disciplines as needed—does make a difference. Maybe doctors will only listen to other doctors, or maybe there’s strength in numbers; whatever the reason, it seems that “palliative care consultation fundamentally shifts the course of care off the usual hospital pathway and in doing so, significantly reduces costs.” It looks like a lot fewer patients want to be poked, prodded, cut open, or irradiated than the medical establishment usually assumes—they just need a critical mass of experts valuing their comfort in order for these preferences to be made reality.

As palliative care becomes more common in the U.S., it will undoubtedly face many of the same difficulties that surround so many other health care issues, such as compensation and equity. As Meier told Maggie earlier this year, reimbursement for palliative care consultations is abysmally low: “When a three-person palliative care team made up of a doctor, a nurse and a psychologist spends 90 minutes in a meeting with a family, Medicare would probably pay $130 to $140—for all three people.” Just as concerning is the fact that hospice care, which is a large part of palliative care, is also unevenly distributed in the U.S.: though African-Americans make up 13 percent of the total U.S. population, the Robert Wood Johnson Foundation reports that they make up only 8 percent of hospice patients—while whites make up 83 percent of patients who receive end-of-life hospice care.

Still, whatever challenges may lie ahead for efforts to better integrate palliative care with American health care, evidence that it saves money—and helps to divert doctors from a medical methodology that has proven to be much more expensive than its benefits warrant—is an important start.

Sapping VistA’s Soul

Niko Karvounis — Mon, 09 Jun 2008 07:42:44 PDT

In the past I’ve spoken highly of VistA, the Veteran’s Administration computerized health records system—and with good reason. VistA has a lot going for it. In 2006, it won an “Innovations in American Government Award” from Harvard. Studies show that use of VistA has improved VA productivity by 6 percent a year since national implementation was achieved in 1999. In a time of sky rocketing health care costs, VA care has become 32 percent less expensive than it was in 1996 in part thanks to VistA. The computerized system also has helped the VA reach an amazing prescription accuracy rate of over 99.997 percent. And last—but certainly not least—VistA is a flexible program that allows for much independent tinkering in the name of improvement, both by techies outside of the VA and those within the administration.

Given all these pluses, you’d think that the government would be happily throwing its weight behind VistA and ensuring that the system is firmly institutionalized for the long-term. But in fact, just the opposite is happening. VistA is under attack; and it’s the federal government that’s leading the assault.

According to Dana Blankenhorn, a writer at ZDNet (a much-trafficked techie website), VistA is dying “of starvation and neglect.” It’s demise comes in part from an unlikely source: the Department of Defense (DoD). In 2005, the DoD introduced it’s own computerized health records system, called AHLTA. The system was developed by Integic, a private firm that was acquired by defense giant Northrop Grumman a mere nine months before AHLTA’s formal roll-out.

So why would the DoD contract out the development of a health records system instead of co-opting VistA, which can be reworked for different contexts? It’s not because of it’s too difficult, that’s for sure. Blankenhorn quotes Phillip Longman, a senior fellow at the New America Foundation and an outspoken champion of the VA noting that the government “could wire Walter Reed or Bethesda (the two biggest military hospitals) for VistA in an afternoon. Technically there’s no big problem....”

Yet still, the DoD created an entirely new system—one which has only limited interoperability with VistA. Longman, the author of The Best Care Anywhere: Why VA Health Care is Better Than Yours, explains just how bad things are: “I just gave 11 [speeches] to front line VA employees in the last few weeks, and I heard over and over again their frustration over not being able to get to the people at the [DoD] making the hand-offs [of patients between departments]. Not only can’t the computers talk to each other, they can’t get the Army doctor in Germany on the phone to answer a simple question.”

This may seem silly but not outright harmful to VistA’s prospects—until you consider the fact that the DoD and the VA need to be able to work closely in order to coordinate solider care. When you introduce a new computer system, you also introduce the need for them to interface. Suddenly the issue isn’t expanding VistA, but merging it with AHLTA. The homogenization of a once-great open source platform becomes inevitable.

Indeed, the government is already working to fuse the two systems together—with help from the private sector, of course. This past September, the government hired the consulting firm Booz Allen Hamilton to “determine the feasibility of having a common electronic medical record system [across VistA and AHLTA] and what it would look like.” In November, Booz Allen and Garnter, a tech consulting firm, began helping the Army analyze industry suggestions on how to merge the two systems after the military issued a formal Request for Information to the private sector.

Of course, none of this would be necessary had the DoD used VistA as the basis for its technology rather than creating a new system from scratch—let alone one whose code and data is proprietary, and thus not easily reconcilable with other systems. (For-profit companies such as Grumman like to keep a tight grip on their products). But it seems that dishing out contracts has become more important than common sense. Last year the DoD awarded Northrop Grumman a $10.3 million contract to help deploy a common data pool for both VistA and AHLTA. (Northrop is a favorite of the federal government: the defense giant received a whopping $16 billion in federal government contracts in fiscal year 2007, behind only two other military-industrial giants, Lockheed Martin and Boeing).

What’s going on here? Why is the DoD strangling VistA? Why is the government wasting time and taxpayer dollars on contracts while ignoring the potential of a proven, high-quality IT system like VistA? Longman has some ideas. For one, he says, “there are DoD people who have built their careers on AHLTA and want people to switch to their system.” Further, he notes, “the recent political appointees to the VA…are people with DoD backgrounds. And the DoD culture is ‘procure everything’ – they don’t make anything themselves, they procure it. When they get to the VA they don’t appreciate the open source culture.”

Longman way well be right, but the DoD’s stance on IT is actually part of a broader paradigm shift that’s eroding VistA. The DoD wants what techies call a centralized IT system—that is, one with consolidated channels of authority and technological infrastructure. Traditionally the VA has a decentralized IT system, with 130 regional data centers and multiple IT teams working in local capacities in hospitals and administrations. Think of the distinction this way: the DoD wants one big IT department, and the VA historically relies on lots of little ones.

A centralized system provides more information security—after all, when you have a more standardized technology it’s easier for central management to protect the data, because it’s housed in fewer places. A desire for this sort of consolidation lends itself to procuring commercial software, because it’s easier to buy a self-contained, out-of-the-box solution in order to ensure uniformity.

But ready-made, one-size-fits-all centralization lacks integration. You get a single type of platform, but it only performs limited functions. Unlike VistA, which contains modules with different functions (prescription drug ordering, electronic patient records, etc.) that nonetheless can communicate with each other, the commercial model lets vendors selling one small, specialized part of the IT chain. As more of these niche programs are purchased, the space for innovation grows smaller and smaller. It’s IT by way of assembly line.

VistA, of course, is famous for being open source software that is adapted by various IT teams and used for many different purposes. Unfortunately, the VA is moving away from this model—and not just because of the DoD. In November, the VA signed a contract with the Cerner corporation to replace its VistA laboratory software with Cerner’s proprietary platform. A specialized subset of the VA’s IT needs is now in corporate hands. The VA will no longer be able to tinker with lab software to produce home-grown improvements.

Admittedly, the VistA lab module was born in the 1980s—it needs to be updated. But do you really need to throw the baby out with the bathwater? As Scott Shreeve, founder of Medsphere, a company that adapts VistA for private hospital use, noted online, the fact that VistA’s old lab software is “widely distributed and [still] functional in today’s computing environment”—even if it’s not cutting-edge—is actually a testament to the program’s quality. Surely there’s something to work with here?

Nonetheless, Cerner has got its foot in the door. (It’s worth noting that, the DoD contracted with Cerner before the VA did.) Shreeve has called the Cerner grab “the first amputation in a long and steady surgical removal of VistA from the VA. Piece by piece, subsystem by subsystem, the VA appears to be taking" specialized software programs and string them together at the expense of “the beautiful and inherent advantages of a single, integrated software solution…” The future of the VA, it seems, is “a patchwork of [industry] solutions.” Shreeve continues: “Cerner now is positioned to wipe out VistA Radiology, VistA Pharmacy, Vista Registration, and ultimately the entire VistA clinical suite. Not only is Joe Public going to lose his several billion dollar investment in the largest and most successful implementation [of electronic health records] to date, but he is going to be paying even more in the future for all those Cerner licenses.”

This switch-over, notes Roger Maduro, an IT and open-source wizard who edits a VistA Newsletter, is “the first major departure from the VA's successful development methodology for VistA. Over the past 30 years VistA has been developed in-house at the VA using its own development methodology.” But now the VA is turning to buying technology instead of developing it on its own. Its reasons are the same as the DoD’s: centralization and security. But at what cost?

As Government Health IT, a trade publication, noted in February, the VA’s “historically decentralized management and IT structures have created one of the most successful health care systems in the world.” VistA has been remarkably flexible and responsive thanks to its decentralization, and “centralizing the IT infrastructure could compromise VistA’s strengths by constraining creativity and introducing proprietary software into an open system.” The free exchange of ideas is effectively quashed.

Fred Trotter, an open-source medical software programmer and an IT consultant, spoke to Government Health IT about how the VA’s old open system used to work: “historically, each hospital hired programmers to solve that hospital’s needs. Other hospitals then adapted those solutions to their own needs. [But] with the centralization process, all VistA programmers will be working for a central bureau. This could stop 30 years of innovation in which the best local innovations were taken national.”

It’s no exaggeration to say that we’re seeing the corporatization of the VA—not just in the sense of privatization, but also in the broader ethos of highly structured management systems. This means that the features that have made VistA such a success—flexibility, customizability, and openness—are in trouble. The balance between security and innovation is a very sensitive one, but in the past, we have figured out how to keep information secure. What’s harder is figuring out how to foster creativity. Centralized bureaucracy is rarely the answer.

Curiously, the government assault on VistA comes at a time when the system is making headway in private hospitals around the nation. Recently, for example, Shreeve’s Medsphere has implemented VistA in places such as Century City Doctors hospital in L.A., one of the largest physician-owned hospitals in the United States. Other medical centers that use VistA include the Lutheran Medical Center in Brooklyn, N.Y. , Memorial Hospital of Sweetwater County in Rock Springs, Wyo. , and facilities in the West Virginia Department of Health and Human Resources. The system is also in use at Midland Memorial Hospital in Midland, Texas, and at the U.S. Department of Health and Human Services' Indian Health Service. Clearly, this is a system that works in a lot of different contexts—so why is the government abandoning it?

Healthcare IT is an incredibly complex field, and it’s easy for the average citizen to tune it out. But when a program like VistA is being phased out, we should pay attention—and ask questions. In 2009, we expect to see changes at the VA. Health Beat will be keeping an eye on whether corporatization is hurting returning veterans.

Savings from Health-Care Computerization May Be Overstated

Anna Wilde Mathews — Wed, 21 May 2008 11:05:00 PDT

Whizbang computer systems are taken almost on faith as the solution to all sorts of ills in health care.

In Washington, just about everyone supports the notion of beefed-up health information technology, at least in the abstract. The pitch has been that innovations like electronic health records and e-prescribing will improve patient care and safety while also saving money through increased efficiency. How much will be saved? Could be around $77 billion a year in all, according to a widely cited projection from researchers at the RAND Corporation.

Hold on, says the Congressional Budget Office, whose green-eyeshade-wearing analysts take a shot at that rosy savings estimate, and a similar one from the Center for Information Technology Leadership.

The CBO says that “both studies appear to significantly overstate the savings for the health care system as a whole–and, by extension, for the federal budget” that health IT legislation could accomplish. You can find the CBO IT analysis here, along with CBO Director Peter Orszag’s summary of it.

This isn’t just some wonky economics debate. It is potentially a big challenge for those who want Congress to take major steps to encourage adoption of broad health IT. The CBO is Congress’s scorekeeper, telling lawmakers what their bills will cost the federal government. So what it says can have a big impact. Famously, the CBO’s 1994 estimate that the Clinton health plan would cost far more than the White House projected was widely seen as one of the things that sank it.

Customize Google Docs Forms

Ionut Alex Chitu — Sat, 03 May 2008 14:14:29 PDT

Adding forms as a way to include information in a Google Spreadsheet was one of the best decisions made by Google lately as it increased the adoption of the product. Unfortunately, Google doesn't offer options to customize the forms or validate the input. But just because Google hosts the forms for you doesn't mean you can't copy the code on your web pages and edit it.

After copying the code, you can edit the CSS rules to customize the form, remove the references to external files or the links to Google's terms of use. This article has a list of pretty forms customized only using CSS. If some of the fields need to have a certain format (for example: dates, email addresses etc.), you may include some JavaScript code that validates the input before submitting the form or after a certain field loses the focus. This JavaScript library includes the code for some common validations, so you can use it without too much programming effort. LiveValidation requires to write some code, but it validates the input as you type.

Here's a simple styled form that validates the first field using an annoying alert (you can submit the form only if JavaScript is enabled):

In what year did you first use Google?

What search engines did you use before Google?

And here's the code:
<style type="text/css" media="screen">.ss-form-container{width: 380px;background-color: #FFF;border: 1px solid #CCC;padding: 0.5em 1em;font-size: 0.9em;}.ss-q-title{font-weight: bold;padding-left:7px;display: block;}.ss-q-submit{color: #000;}.ss-form-entry{margin-bottom: 1.5em;} .ss-q-short, .ss-q-submit{background:#f7f7f7;border:solid gray 1px;margin:8px;padding:0px 3px; color:#666666; }</style><script type="text/javascript">function custommsg() {document.getElementById("form-message").style.display=""; document.getElementById("form-message").innerHTML="Thanks for your answers!"; document.getElementById("form-container").style.display="none";} function validate(f){var year =parseInt(f.elements[0].value);if (isNaN(year)|| year<1996 || year > (new Date()).getFullYear()){alert("Invalid year");return false; } return true;}</script> <div class="ss-form-container" style="display:none;" id="form-message"> </div> <div class="ss-form-container" id="form-container"><form action="" method="POST" target="fake-target" onsubmit="this.action='http://spreadsheets.google.com/formResponse?key=pLaE9tsVLp_1lGkqPo-vdfw'; if (validate(this)) {custommsg(); return true;} else return false;"><div class="ss-form-entry"><span class="ss-q-title">In what year did you first use Google?</span><input type="text" class="ss-q-short" name="single:0" /></div><div class="ss-form-entry"><span class="ss-q-title">What search engines did you use before Google?</span><input type="text" class="ss-q-short" name="single:1" /></div><p></p><input type="submit" class="ss-q-submit" value="Submit" /></form></div><iframe src="#" id="fake-target" name="fake-target" style="width:0px; height:0px; border:0px;"></iframe>

Validation only works when JavaScript is enabled in your browser. Note that if you edit the form using Google Docs, you need to change the code from your web page.

{ Thanks, A. }