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Monday, January 16, 2012

Down in the Weeds'

OK, I have just finished an intense red-penned, yellow-highlighted, margin-noted initial cover-to-cover pass through "Medicine in Denial" (which I have heretofore cited in a number of recent prior posts).

One hardly knows where to begin. 267 pages of unmitigated butt-whup. It has to have its own post (note that I put a permanent link to the book on Amazon, over on the right; get a copy). Suffice it to say at the outset here that, if I ruled Health Care, this would be the first required text in med school. Maybe even before that.

Increasingly mindful of avoiding the pitfalls of "confirmation bias," I've held further observation and commentary until actually finishing all of it. It is one profound piece of work. I am extremely grateful to co-author Lincoln Weed for the post-pub proof copy. He admonished
"be aware that this is not a quick read."

Indeed. And, it has been worth every minute, every hour.
Building the infrastructure and changing the culture of medicine cannot be left to the medical profession alone. Leaders outside the profession, and especially the general public, need to understand the transformation that is possible. But writings like this book will not make that happen. A recurring pattern in the history of medicine is the persistence of ineffective or harmful practices, and resistance to needed innovations. What is needed to change that pattern is public understanding of why the status quo is bankrupt, a shared vision of an alternative, and an external compulsion to change...

...It does little good to subsidize the purchase of EHRs if their inputs are not guided and defined by knowledge coupling software compatible with the EHR design. It does little good to equip practitioners with knowledge coupling software if they are left free to exercise judgment on when to use the software or what data to collect. It does little good to design interoperable EHRs for exchanging patient data if the design does not also organize the data for coordinated care of multiple problems by multiple practitioners over time. It does little good for multiple EHR vendors to separately design such EHRs if variations reduce interoperability and ready comprehension by all. [pg 174]
This is an important book. It goes to the very core of the work I now do, work I believe in, but work that needs much more clarity of purpose.

Interview with Lawrence Weed, MD — The Father of the Problem-Oriented Medical Record Looks Ahead
A Final Question

LJ: Dr Weed, you have had an amazing career implementing a needed change in how patient data is handled through the POMR. Today, you outlined another major change that needs to be incorporated if the practice of medicine is to be improved. On the basis of your experience as an innovator, and knowing what you know today about medical education and the practice of medicine, are you optimistic such changes will be forthcoming?

LW: Based on what I know about all the vested interests in the present medical education system and in the present practice of medicine, I am not optimistic such changes will be forthcoming...



Well, that can't continue much longer. Click the graph for the link (PDF). The red text above is my text annotation (avg annual increase $1,127, linear R-sq 0.9979). Drop the numbers into Excel and extrapolate to the end of the decade.

Notwithstanding that the statistical +/- confidence limits around a linear projection will bow the further you go into the future, the implications should be clear (moreover, [1] the bowed CIs cut both ways, and, [2] nominal aggregate annual spending will not be as telling as "spending per service rendered," i.e., decreased "UTIL" -- self/household-rationing as a contributory function of increased cost).

NOTE: the Milliman report is silent as to whether their cost data are inflation adjusted.


So, today (18th) I saw a news item regarding a new HIT online workflow tutorial posted by the AMA.

Click the graphic above for the link. Not bad. I signed up and went all the way through it. Nicely done. They give docs CME credit for completing it, but others (clinic staff and interested people like me) get a "Certificate of Participation."

I found it well worth my time -- only took me about 90 minutes, and, it bookmarks where you left off if you have to do something else prior to completing the tutorial. Nice.

Nothing really that I didn't already know, and lacking some core stuff I'd have liked to seen included (e.g., task times-to-completion and error rates; see my "Workflow 4 Anyone" Powerpoint), but I came away from it with a sharpened attention to workflow issues pertaining to "pre-visit planning," which will be something to be more fully considered in our upcoming PCMH'ish CMS Innovations Grant should we get the award (see my prior post). Not to mention "Accountable Care" more broadly.

Sub-MD staff "Health Coaches" and all that.

Which segues neatly back into


“Physicians are right to condemn forms of control that involve exclusion of information and power over decision making. But physicians are in denial about the extent to which they themselves impose these forms of control on patients. Physicians are right to reject impoverished, cookbook medicine, but they are in denial of how impoverished is their own know-how. So too are they in denial when they view themselves as “highly skillful,” because their levels of skill would be far greater within a disciplined system of care. Physicians are right that “one cannot separate the decision from its context,” and they are right to reject uninformed controls by ‘outsiders.’“ But they are in denial of how much they themselves are uninformed outsiders to patients’ lives, outsiders whose exercise of control inevitably separates medical decision making from its context. And they are in denial of the need to submit to different forms of control over their own inputs to care—both decision making inputs and execution inputs.

Execution inputs were the primary focus of the Institute of Medicine’s To Err is Human. That report highlighted the need to protect patient safety by exercising tight control over execution of medical procedures. When we turn from execution to decision making, it is best to think in terms of not controlling but defining inputs, that is, making explicit the inputs that form the basis for decisions.

The basic inputs to decision making are (1) medical knowledge, (2) patient data and (3) the processing of that information. All three of those inputs are undefined and uncontrolled when they originate from the unaided minds of physicians. No one can know exactly what information physicians take into account, nor can we know how they take it into account, nor can we reliably improve the cognitive processes involved. All we know for certain is that medical decisions are enormously variable. The outcome is that patients have no assurance of reliable decision making…

In contrast, a system of defined inputs means first that the knowledge and data taken into account, and the processing of that information, are explicitly defined. Second, it means exercising some degree of control over the manner in which the defined elements are combined. Defining inputs to decisions in this way does not dictate those decisions any more than defining the elements of writing (an alphabet and standards of spelling and grammar) dictates the content of writing.

The need for tight definition and control over inputs goes without saying when the inputs are drugs and medical devices. An elaborate regulatory scheme controls entry into the marketplace and ongoing manufacture of drugs and devices. Yet, nothing comparable exists for the most important medical devices of all—the minds and hands of physicians. Graduate medical education, state law credentialing and board certification purport to regulate the entry of new physicians into the marketplace, while various ad hoc interventions (such as malpractice litigation and licensure board disciplinary proceedings) purport to regulate ongoing performance. Yet, no one trusts these forms of control. Epidemics of medical error, unnecessary care and irrational spending confirm that trust is not warranted. The reason is that existing regulation fails to define and control inputs to care comprehensively.

This means continually optimizing care at every step of decision making and execution. Optimizing care means not only enforcing high standards of care but also continuously incorporating feedback and new scientific advances. This continuous and comprehensive improvement entails a constant assault upon the status quo—upon the habits and roles and economic claims that take root from established practices…” [“Medicine in Denial” pp 44-45]

Click the above Dr. Richard Gitomer quote for the link to the location from where I appropriated the last two graphics. Emory University, Woodruff Health Sciences, "Cookbook Medicine."



Click the title above. This got cross-posted today on The Health Care Blog (wherein the always impolitic and sometimes reactively irascible BobbyG commented).
The good old days

In the good old days, I could pick up a chart from the rack outside the door, and in what seems life a few seconds, familiarize myself with with my patient’s history (because I kept a great paper chart if I do say so myself…) before opening the door to greet her. During the visit, I could sit with the chart in my lap, jotting down notes as we spoke, my focus on my patient and my thoughts rather than a user interface. Once the visit was over, a few brief jotted notes and some well-placed check marks on the encounter form summarized the visit, a few scribbles on a prescription pad or radiology order form clipped to the chart finished the orders (the rest taken verbally by my tech), a check off or two on the superbill and I was done.

Indeed. Well, I'm as romantic and nostalgic as anyone. When I was in grade school
(George Washington Elementary) in Morristown NJ in the 1950's, our family doc Dr. Renna, MD did Normal Rockwell-esqe house calls, replete with his iconic Little Black Bag.

I have no idea how he got paid or how good his charts were.

That was then, this is now.


This post is interesting (yet another cool blog).

...We need to affirm the necessity of having a transparent objective scientific standard for medicine. Otherwise, there is no standard of care. There would be no way of determining which treatments were legitimate and which were not. This question has many practical implications – which professions should be licensed, which treatments covered by insurance, which practices allowed under the scope of practice of each profession, what should be taught in medical, nursing, and other health-related curricula, and which practices constitute malpractice. Without a science-based standard, there are no answers to these questions...

...Further – we can’t have a double-standard. Within medicine there is a pretty clear consensus as to what the scientific standard is. It is slowly evolving, if anything becoming more stringent as we root out more and more subtle ways of subverting best scientific practice...
Indeed. But,
A core justification for the enormous time and expense of physician training, and for the legal monopoly and high compensation conferred on physicians, is their scientific training. Presumably that training enables physicians to apply medical science to patient needs with scientific rigor. Yet, one of the leading medical schools in the world here describes itself as failing to provide adequate experience in the elements of clinical medicine, failing to provide good learning conditions in either hospital and ambulatory settings, failing to provide uniformity of content, failing to enforce educational rigor, failing to reliably evaluate students’ core competency and failing to integrate basic science and clinical medicine. [Medicine in Denial, pg 199]

One gets the spins from all of this.

More shortly...

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