Just a simple vanilla blog site from a physician

Have been getting on the treadmill due to the ice and snow preventing me from running outside (run exclusively in 5 Finger barefoot shoes) and playing golf (hey, it’s a 4-6.5 mile walk with 30 lbs of clubs).  In order to make the work constructive I’ve been launching online Continuing Medical Education programs from Medscape and AAFP’s Learning Link and getting about an hour’s worth of CME with each session.

Effect of eating extra 50 calories and watching TV

Small decisions matter

Have gone through Pain Management, Diabetes, Obesity and several other series.  What’s astonishing about all of these series is that in every case exercise has been shown to be as effective, if not more, than medications.  A few slides stand out but one of them today illustrated the impact of small decisions.

The good news about these slides is that the corollary should be true: It takes only small, daily decisions to lose weight and improve lifestyle, not major changes.

So what’s the best way to do this?  A number of people have suggested using any of the myriad of web or smart phone applications that track calories and energy expenditures.  I’ve found them to be quite good but it’s usually a pain to look up and add everything.  There are some, like Fooducate, that only require one to  take a picture of a food label to do to provide the information.  But the irony of these programs is they usually work best on the most unhealthy food products and the worst on natural, unprocessed foods that have no labels.  As much as I’d like to see an application that recognizes foods (slice of apple let’s say) without any further input I don’t think we’re going to see that soon in a mobile application.

But maybe we don’t need to wait.  There may be other solutions.

What if you could just take a picture of what you’re about to eat, zip it to your nutritionist, nurse practitioner or physician and have them either do the work for you or simply provide feedback? Would you do it? Would it provide value?   Most likely but there aren’t enough nutritionists or professionals that would tolerate getting bombarded all day long by food photos.

Nevertheless, I’ve been photographing everything I eat to see if it’s realistic to photograph everything eaten and now on the 3rd day of doing so.  For example, here’s what I had yesterday:

Here’s what I observed in my own behavior

  • It does become second nature … almost like reaching for the napkin or giving thanks.
  • A picture is a lot more objective than memory.
  • It is hard to see everything that is in the photograph so a extrapolating calories from a photograph is going to be problematic, especially for home cooked healthy meals.
  • Behavior modification, however, does occur.
    For example: just the thought of taking a picture has actually stopped me from reaching out and eating that extra handful of nuts, opening the candy jar or even having that extra drink. And I’m doing this just for myself and am not trying at all to lose weight!

This has prompted me into wondering if beneficial lifestyle changes could be as simple as taking pictures of what we eat?  Whip out your smart phones and take a picture of what you’re about to put in your mouth and let me know if you experience the same behavior changes.

So I get a page from my answering service about a patient of mine who I saw late this afternoon.  Turns out the treatment I gave her isn’t taking and she’s in excruciating pain. Logged into my EMR from home, pulled open her chart, reviewed the radiology image and the radiologist’s over-read.  Nothing.  No reason she should be feeling the way she is now.

After a brief discussion it’s obvious there’s nothing I can do over the phone so I ask her which emergency room she’s closest to.  It’s a hospital outside of our system but I tell her to go there as she can barely walk.

Call the ER and let them know she’s coming and ask them if they’d like my note from this afternoon.  Of course they would.  A couple of clicks later I’ve “printed” it to a secure PDF file and zipped it into an e-mail and off it goes.

Shows the importance of electronic access to information and also why we need a National Health Information Network (NHIN) so I wouldn’t have to take even these few steps.

Hello new world!

Just migrated my Spaces blog to WordPress in order take advantages of increased capabilities.

This all was part of the process up updating Windows Live Essentials in which the familiar Messenger becomes integrated with Facebook (but Twitter for some strange reason was left behind) and other social media.  This process has opened my eyes to a new world of computing and information management that has the potential to be as disruptive as the migration of music to the web that occurred over the last half decade.

First, the recent tools essentially integrate local instances of the application with web-based social media. This just streamlines the social communicating by eliminating the need to jump apps to participate in virtual communication. The distinction between e-mail, instant messaging and social media begin to blur and probably will evaporate.

Second, and probably more important, these tools have the potential to eliminate the need for local computing.  It now really doesn’t matter what you by for yourself and essentially the need to carry around a computer wherever you go.

MS Office now is really functional on the web with a stripped down but eminently functional version of Office 10 that enables me to keep relatively simple spreadsheets in sync using any device (hope pivot tables come soon).

 

Ubiquitous access in the making

 

What’s actually happening is that each of us who have a Windows Live account have a virtual Sharepoint services that we can use to manage our documents using any device that can connect to the web.

 

Same look and feel as Office 10

 

This is causing me to rethink cloud based computing.  I attempted to use Google Apps but they behaved too much like web-based applications and also required me to learn and manage different front ends to manipulate the data.  Microsoft’s cloud-based Office, on the other hand, looks and acts identically to Office 10 applications on my PCs and, I’m assuming will mirror the Office 11 apps soon to be available on my Macs.

With regard to spreadsheets, the only feature really missing that I use frequently is pivot tables and once that’s there then it begins to raise the question whether I need to perpetually upgrade to the latest version of Office on all of the 4 machines I use regularly (2 Win7 devices, an iMac and MacPro).

To be sure locally installed programs do have many more features, can be used when not connected to the web, run faster and are not constrained by space or size that would require space upgrades on web sites.  But from a rigorous fiscal perspective it probably makes sense to migrate all of my data to the web and be done with worrying about or putting a lot of expense into locally owned applications.

So what will the world in the near future look like?  My guess is that we will all eventually subscribe to storage and applications in the cloud and be free from having to purchase, haul and struggle with local computers.  Virtually everything will be connected to everything and all we need to do is walk up to any device anywhere in the world, identify ourselves and have immediate access to our own computing resources with unlimited power and storage.

Cool.

An article, Cost of Doing Nothing by Reed Ablelson in this morning’s New York Times, illustrates clearly why no matter what happens in Congress over the next few weeks our Health Care will never be the same. Our current system is simply unsustainable and incremental changes have done nothing to curb the escalation in health care costs. It is apparent that large changes are coming. The question is not if but when and by whom? 

I was struck by how much blame each of us carries in this dilemma. Most physicians in this country are payed by what they do, not what they produce. As a result we are all under pressure to bring in enough income to pay our nurses and staff. Estimates vary but most primary care physicians (of which I am one) need to post at least $400,000 – $600,000 a year in order to make ends meet (staff, malpractice, lease, equipment, supplies, etc.) and even then profit margins are very slim.
In large multispecialty groups where salaries are often calculated by Relative Value Units (RVUs), physicians need to crank out 5-6,000 units just to break even. What’s insidious is that a physician will tally up more RVU’s for procedures than brain work. So it’s much simpler to do something to a patient than work with the patient … a lot simpler and a lot more profitable.

This has led to serious shortages of primary care physicians and an abundance of specialty physicians partially due to the high cost of medical school, the need for repayment of student loans and prestige that comes with disciplines with high revenue potential.
We physicians have lobbied heavily to keep our costs from dropping, forcing Congress to delay each year the implementation of the Sustainable Growth Rate formula that was voted into law in 1992. These small, yearly decreases in payment have gradually accumulated to where a massive 21% cut in Medicare payments is scheduled to go into effect this coming Monday, March 1, 2010 (was to have taken effect January 1 but Congressional action forestalled it until February 28 and will be in effect barring further action by Congress). The AMA is confident that emergent legislation will prevent these cuts from taking effect and forestall them yet another year and CMS is holding payments for 10 days to allow action to take place. Physicians have seen real reimbursement declines in the face of increasing costs everywhere else so the net effect of inaction might be to further reduce the access of patients to physicians.

Eventually, the system will collapse and the results will be catastrophic not only for physicians, their offices and staff but for Medicare patients who may not be able to get in to see a physician at any costs because doors will be shut to them as it is to many Medicaid patients around the country.
Physicians can still afford to do this because there are enough privately insured patients to generate the revenue needed to keep their doors open for now. At some point this house of cards crumbles.

We patients are also to blame. In the last 20 years we’ve seen an ever increasing cost of health care diverted towards chronic diseases that are in large measure preventable. Obesity, diabetes, high blood pressure, coronary artery disease and many forms of cancer can be directly linked to lifestyle choices.
In addition we choose ignore “natural” ways of preventing diseases through immunizations and dietary changes.
When we hurt our backs we refuse to go to physical therapy and instead insist on medications, MRI’s and even surgery when the evidence points to better results with simple physical therapy.
We patients insist on antibiotics when we feel bad even though repeated studies have shown for many of these conditions we will get better faster without them.
It is infinitely cheaper to stop smoking and avoid lung and heart disease than to pay for cigarettes, medicine and procedures. Yet we complain about the cost and effort involved in smoking cessation programs (even though they are less expensive than the monthly cost of a pack-a-day cigarette habit).

And it’s worse when we’re healthy! We often choose not to purchase health insurance, which only drives up the cost of health insurance for everyone. If only sick people purchased health insurance it would be more costly than medical care (providers of health insurance have the cost of medical care, their own business and profits to shareholders to address). Insurance only works when a critical mass of enrollees never utilize their insurance.
And then there’s politics. The cost of being a politician by its vary nature will prevent the politician from making the hard choices. It’s simply much easier and less costly for supporters to pull funds from anyone making a hard decision since most hard decisions adversely affect a critical mass of supporters in the short term.

So what are we to do? Well, for one we need to act because no one else is going to.

For my own part I have resolved to be a role model for my patients. I am trying very hard to make the decisions I ask my patients to do. My diet has changed as have my exercise habits. In addition I have started listening more to my patients (it does adversely affect my income potential for the organization for whom I work). I make sure that each hour an appointment slot is left open for same-day appointments. I have encouraged patients to log into our web portal for routine things that can be treated without a face-to-face visit. I’m using this web portal to communicate directly with patients instead of having protecting myself from them using the phone triage, nurses and other barriers. This lowers the number of staff needed to meet their needs and, yes, has the potential to increase my own work. We’ve stopped taking samples in our offices and are working with patients to chose generic medications wherever possible.

There are many other things that we’re going to try over the next year to continue to provide more value for a unit of cost and all of you are encouraged to suggest ideas.

As patients it is usually less expensive to do the right things. First, change our lifestyles to maximize our genetic potential. We do need to stop smoking. We do need to move rather than sit. There’s no reason we shouldn’t all be at our ideal body weight and should constantly strive to maintain that weight.

We do need to be proactive and strengthen ourselves to grow old rather than sit back and let it happen. We do need to leverage our own immune systems and get vaccinated (which is really the best natural approach to preventing diseases) not only for ourselves but for those around us. It is much less costly to get vaccinated than to get sick, no matter how minor that illness is. The complications from vaccinations are infinitely smaller than the complications from any of the diseases.

When we do get sick it is our responsibility to learn about our illness and help the physicians make decisions. It’s my experience that most bad decisions are made from lack of information than from malpractice. It is our responsibility to know what over-the-counter medications, vitamins, herbal supplements and our past medical histories. Make sure the physicians making decisions are aware of this. If the recommendation is something other than medicine we need to follow that advice (physical therapy and counseling are effective and even if they are not “covered” by most plans are the things that will cost you less in the long term). If medicine is prescribed we need to know the medicine and take them as directed along with redoubling our efforts to make the changes necessary in our lives to decrease the need for those medications.

We all need to purchase insurance. Purchase only catastrophic if nothing else so that we don’t wreck our lives, the lives of our loved ones or undermine public budgets when major illness or injury strike.

We all need to wear seat belts, stop driving under the influence of mind-altering drugs, alcohol or texting. We need to wear helmets on bicycles, motorcycles and other vehicles without roll-over protection.

We need to care for others and not be responsible for hurting others.

Finally, we need to begin rewarding those politicians who make hard decisions. We need to counter the fringes and participate in elections. Neither the left or the right are going to be able to solve our problems. The center will and we need to begin rewarding those who work with others and not those who are obstructionists.

The bad news? It’s always easier to do nothing and be a victim than it is to do something positive and avoid being a victim. But that’s what we need to do if we went to lower the cost of health care and become part of the solution, not the problem.

There’s
a certain irony in that the more specialized a practice gets the more
technology there is available to help the physician. A retinal subspecialist is
a good example where they have in office orbital CT scanners and a host of
other extremely expensive tools available for the physician’s use at the time
of the visit.  On the other side of equation the primary care physician
who has to deal with the entire body and mind is often left with only a paper
chart, a stethoscope and devices that haven’t changed much in 100 years to
study the patient, derive a diagnosis and treat the patient.  The stark
reality is that this is completely backward!  The physicians needing the
most technology are those who are asked to treat the most conditions.

What’s
silly is that by the time a patient is seen by the subspecialist the diagnoses
have already been made (usually by other physicians higher up in the tree) so
the need for extremely expensive equipment is superfluous and supports
subsequent specialized treatments.

It’s
my opinion that if technology was available at the front lines many diseases
would be diagnosed, caught and treated long before they require subspecialised
therapy or treatment.

We’re
all familiar with the Tricorder was suddenly available only the
subspecalists would be given them and the physicians who would derive the most
benefit would be prohibited from using them either by
cost or reimbursement.

There
are many devices such as a dermatoscope, tonopen, digital o
phthalmoscope, otoscope, not to mention digital scales are
available but outside the reach of most primary care physicians.  Yet, if
each exam room was equipped with these digital devices AND connected to their
electronic medical records many diseases that now are missed could be diagnosed
earlier, more accurately and treated at a much lower cost than they are now.

On
the pure information front, I find the time cost of logging into multiple
systems (our own EMR and those of nearby hospitals, reference labs not
interfaced without our system, imaging
centers, online reference sources such
as UpToDate,
ePocrates,
MDConsult
an
d a host of other tools that I wind up using in the exam room prevents me
from exploiting them in the typical 10-15 minute appointment. Even though
we’ve equipped the PCs in each exam room with 21” swivel monitors we find
there’s a lot of visit time that could be saved if the all of the information
needed at the time of the visit didn’t need to be navigated to.

When
not seeing patients I usually grab all of the computers to which I have access,
splay them up in front of me (including one of the units from the nearest exam
room).  Productivity increases
dramatically.  Most information
resources are at my fingertips in parallel rather than serially if restric
ted
to a single machine or reduced screen real estate.  This is exactly why traders in most brokerage houses sit
behind multiple displays in order to work.  Time is money and faster, better (well, maybe) are made if
one doesn’t have to
waste time navigating to that information.

So
what am I saying?  

I
am confident that if we would put the most technology possible into the hands
of front line physicians who have to address the broadest spectrum of patient
concerns we might be surprised at how much more efficient, productive and cost
effective healthcare would be.

So
one day I see myself practicing in a room with all of the tools at my and my
patient’s fingertips.  Any
questions could be quickly answered, the record would not have to be populated
with vague text but actual images of the pathology observed, sophisticated
imaging and testing could be accomplished at the point of care before the
patient left the room. The patient and I would have a very good understanding
of the next steps rather than waiting for all the ordered tests to come back as
the patient is sent across town f
or them, paying higher and higher prices the
closer we get to the definitive diagnosis.

And
then I
wake up only to have had a wet dream.  I have to return to the small,  cramped, jail-cell exam room with the
one computer and a variety of relatively low-cost analog devices and try to
answer difficult questi
ons. Often having to disappoint the patient by sending
them on to another person or facility to eventually get to their answers.

Why I Like Taxes

The
first Christmas blizzard ever in Kansas City reminded me why my wife
and I chose to live in Overland Park, a suburb of Kansas City on the
Kansas Side of the state line Taxes.  We chose it because property
taxes were significantly higher than just across the border in
Missouri. Huh? Doesn’t seem to make sense, you say. Apparently we’re
not alone because we’re surrounded by neighbors who frequently get
reminded of the benefits of living where taxes are higher and reaping
the benefits of those shared expenses.

The blizzard? Right.  Three
hours into the blizzard we saw city snow plows clearing our
neighborhood streets.  And they came back several times in a 24 hour
period.  None of us had problems getting out when we needed to.  Today
we went to Church, 2 days after the snow.  The minute we crossed the
state line we found ourselves maneuvering snow-packed streets littered
with cars stuck in their driveways and communities locked in.  Almost
all of those who were at the early service lived on the Kansas Side
while many on the Missouri side who lived only a few blocks from Church
were homebound. Snow plows may never make it to their side streets
before the snow melts.

In our neighborhood most of us were out
shoveling not only our driveways but our sidewalks.  Those with snow
blowers went from house to house without being asked wishing their
neighbors a Merry Christmas.  Even teen age school children put aside
their Play Stations and cell phones to help. Why?  I think a large part
of it was that the streets were plowed and therefore the mobility
barrier was only our driveways.  That wouldn’t be the same if the
streets were filled with 10 inches of snow.  What good does it do to
get out and shovel your driveway when you still can’t go anywhere?


So what does this have to do with taxes?  When people see their money
going to local services like snow plows, good schools and civic
government a stronger sense of community and pride exist.  Ironically
the more selfish people are in the short term the more isolated and
costly it becomes for them to live as a community.  Communities are
made of those who are fortunate and those who are less fortunate.
 Those who reach out and help each other socially, fiscally,
spiritually and neighborly are those who are healthier and live better.

I was struck by an Randall Stross editorial by in the NY Times this morning titled,

"Sorry, Shoppers, but Why Can’t Amazon Collect More Tax?.
 The article describes the elaborate efforts Mr. Bezos has gone to keep
from paying taxes to the states in which they provide services.  This
gives Amazon a competitive advantage at the expense of teachers, civic
services, public roads and a whole host of other tax-based services on
which Amazon itself relies.  Similar corporate measures are costing
states up to $350 billion a year and we’re all suffering for it.  Mr.
Stross concludes “Amazon’s in-house counsel should help the company
meet its civic obligations — and toss “entity isolation” in the trash
can. Amazon’s employees are too scattered, its customer base and its
sales too large and the states’ fiscal crisis too grave for it to
continue to play tax-avoidance games.”

Here, here. And the next time
it snows, storms or a crisis hits.  I’m glad I live in a community that
takes it’s taxes seriously.

The Situation

Saw one of my partner’s patients (new to me), a 71 year old woman with a history of hypertension, late in the afternoon with an 8 hour history of abdominal pain. She’d thrown up once but other than the epigastric pain was not that uncomfortable.  Vitals were stable, EKG normal and acute abdominal films were unremarkable.  Drew basic labs including pancreatic and liver enzymes and discussed with her the broad differential.   She elected to go home and wait for the labs to be resulted.  We batch our labs at the end of the day and since she was the next to last appointment of the day expediting the labs by ordering STAT would only add expense without improving the turn-around time.
Drove home, had a cocktail and enjoyed a meal with my family and then logged in to review that day’s labs (which by now were being resulted).  To my dismay her liver and pancreatic enzymes were in the thousands.  Called her cell phone to advise her to go to the emergency room right away.  The patient’s choices were many including the hospital with whom I share an EMR.  However, she was at her daughter’s home and there were two other hospitals very close by and she elected one of them rather than drive an hour to my own hospital.

Called the ER to discuss the case with the attending who said this was a “slam dunk” admission and transferred me to the Transfer Team so that the hospitalist could be notified. The hospitalist accepted the patient and asked if I could fax my visit note, recent labs, patient’s Face Sheet and summary to expedite care.  No problem, I quickly gathered that information together, assembled them into a document while the physician was on the phone and was about to click the SEND on our e-mail and paused …

The Problem

Was I doing HIPAA compliant?  Probably not.

Even though I had the patient’s verbal consent to do “whatever was required” to get her into the hospital I doubted whether that would pass not only our own internal compliance officers but any state and federal regulator’s judgement.

Our system does have a HIPAA compliant Medical Record Printing (MRP) function that gathers all of the HIPAA variables (who, what, to whom and why) but only allows us to FAX to those devices that have been tested and validated.  It doesn’t allow an end user to key in a new fax number.  The MRP function has 2 options:  Print and FAX.  And then only to defined printers and fax numbers.  There isn’t a way to generate a password protected PDF file that can be sent to where it’s needed.  Nor can it generate HTML documents that could be sent to a secure web server into which anybody downstream who is given the correct password could log in to retrieve it.

Our system also comes with a patient portal allowing patients to access and then do whatever they want with their own information including a function that lets them share the record with another physician who can then log in as a new user and view that record.  Over 80% of my patients are taking advantage of this but this was an elderly patient of my partner who is less aggressive in enrolling her patients.  This patient didn’t have an account and therefore the other option of sharing her record with the next physician wasn’t available to her.

This information would significantly speed up the admission and workup process on this patient and it was needed in a matter of minutes, not hours or days.  I had everything ready to go to the physician with one click of the SEND button.  Should I? Which is more important?  Compliance with old paper-based regulations or patient care?

Damn the torpedoes

I clicked the SEND button with only a little hesitation and felt good as the hospitalist thanked me profusely, complimented me on the thoroughness of the note which included the patient’s picture, all of the labs, radiologist’s preliminary interpretation and an image of the EKG.  She wanted to know why more referring physicians weren’t more accommodating and suddenly realized how important leveraging technology was.

Solution?

There have been years of discussion in Healthcare Information Technology circles about standardizing communications between Health Information Systems, numerous detailed proposals and countless arguments on how Patient identifiable Health Information (PHI) should be transferred from one system to another.  In the meantime these types of situations happen thousands of times each day.  The overwhelming majority of them are accomplished by Medical Records department personnel locating a paper chart, scanning and faxing the appropriate material to another provider’s fax machine and then taken to the requesting physician.  This process take time, often many hours transpire between the request and the fulfillment of that request and often involves many people and supplies.  The process is at the mercy of the resolution of the scanner and fax machines so many times the data in the hands of the requesting physician is barely legible. All this time there are low cost solutions using everyday tools that enable the transfer of this information directly between the two physicians who are involved in the care of the patient.

Surely we can come up with better regulations to let us care for the patient without having to worry whether some compliance officer or regulatory will spank us after the fact.

Any ideas would be welcome and passed on to our vendor and our compliance officers.  Uh, we’ll keep the regulators out of this one for the time being.