HealthInsight REC retreat

It's been a good week (notwithstanding that I'm gonna pay for it come Monday via my left-in-the-lurch EP caseload). Hectic, but far better than I'd expected. Extremely frank, constructive, and congenial. I work with a lot of very smart and accomplished people. Sometimes I feel very old and slow on the uptake.

I was greeted with an effusive and genuine hug and kind words by my original blog nemesis ("exceeding your Scope"), our former bi-state REC Executive Director (she has since ascended to SVP of Corporate Strategy). That was especially nice. Sharron and I go all the way back to UTK, where we both had (albeit at different times) the same Correlation and Regression professor. I still have my textbook, a treasure ("A Handbook for Linear Regression," Mary Sue Younger, PhD, 1979).

Lots to report -- retreat stuff that I can properly speak of, that is (some things we discussed are considered proprietary), along with the never-ending HIT topical updates. The gathering was both a lessons-learned and asset inventory reflection, and a forward-looking "sustainability" brainstorming effort (see update below).

But, first, a random photo essay.

The new SLC office suite is very nice

They had a weekend of heavy snow before we arrived. Beautiful (but cold).

We commenced in the HealthInsight Boardroom.

The view eastward from Wyatt's office. Nice.

Stephanie!

Nevada REC Manager extraordinaire Erick Maddox

Maggie, of the SLC office.

Our HealtHIE Nevada table. I hear we're doing a booth. Make it a good one.

Final morning session. I had a Mount Everest headache that lasted 'til late today.

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Socializing. I have to say, the SLC crew stepped up this time. Though, I think I now need to fast for a week.

First night, some great chow and conversation at The Bayou.

Eating again. Brazilian chow. Carnivore to the Max.

Left to right: Keith, Kym, Erick (sitting in snow), Catelyn, Gina, Stephanie, Eileen, and Wyatt.

Wyatt hosted us on a tour of Temple Square. Their interactive ancient Jerusalem model city in the Visitors' Center is very cool.

A huge gallery of very nice artwork.

The Temple Reflecting Pool.

In the Rotunda in the Temple Square Visitors' Center.

Above: The Family Tree Center at Temple Square.

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Wednesday night outing to Park City. OK, this place is wild.

Above: Uhhh... Irony-Free Zone alert. Oh, never mind.

LOL, Stephanie!

Fatali.com, amazing work

8x10 film camera, wow.

Park City reminds me very much of Gatlinburg, TN (I used to live in South Knoxville, and spent much time in the Smokies).

BTW:

Don't expect any sympathy from the endocrinologists.

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REC URGENCY

REC "Sustainability" may well be a moot issue.

The Fiscal Cliff and Meaningful Use: Be Very Afraid
By Joseph Goedert
NOV 16, 2012 8:11pm ET

During the congressional tax/budget debate coming very soon, someone in the Republican Party is going to demand another $20 billion or so cut from an entitlement program or another government program that is near and dear to the Democratic Party. Someone in the Republican Party will mention that boondoggle health information technology initiative in the hated stimulus bill, and someone in the Democratic Party will decide that’s where another $20 billion in savings can come from. Whatever federal funds are left to support electronic health records meaningful use, health I.T. workforce training, health information exchanges, best practices dissemination, regional extension centers and anything else in the HITECH Act will be gone.

Don’t believe all the talk of how health I.T. has bi-partisan support. Nothing but the most sacred cows will be considered sacred in the upcoming budget battle. Since health I.T. doesn’t pass the sacred test, the spigot is in danger of running dry unless the nation’s physicians and hospitals rise up en masse and scare the hell out of their congressional representatives and senators...

Don’t count on consumers to take the field for meaningful use and anything else reform-related. Half of consumers bought the malarkey that health reform was socialized medicine, if not communist medicine, and either way it would kill Grandma. And consumers simply don’t have the pull that providers, insurers and companies do. The elections are over, so consumer (i.e., voter) influence just dissipated and won’t manifest again until the mid-term elections...

He's right. Read all of it (linked in the title). The Money quote, for me:

Here’s what you face in the fiscal cliff fight: The industry--and those critical funding programs--are up against Democrats who don’t want to face reality, and Republicans who don’t know what reality is and don’t care to learn.  Think the election changed anything on the House and Senate floors? Think again. Democrats don’t have any more power than they did before, but may think they have a mandate--which they don’t necessarily have--and won’t make the compromises necessary to get the fiscal house in order. With few exceptions, Republicans are in denial of their Electoral College wipeout and are doubling down on their hatred of all things President Obama. They can’t wait to get their hands on reform-related spending when the fiscal cliff negotiations gear up.

We shall see. Within 5 weeks or less, I would say. Unlike five years ago, when we at HealthInsight got screwed by CMS (10% of staff -- me included -- were laid off with one day's notice after the feds pulled back a bunch of QIO funding and our DOQ-IT program was essentially spiked), this time I have a contingency exit plan. I will not be blindsided again.

A bit of black humor on Rendered Redundant Day

I would expect a lot of REC folks' resume updating to be ensuing nationally (for those who've not already begun).

apropos, see

Subcommittee Examines Federal Efforts to Promote Health Information Technology Witnesses detail progress and challenges in developing and implementing interoperable technical standards
NOV 14, 2012

Washington, D.C. – The Subcommittee on Technology and Innovation today [11/14] held a hearing to examine progress on the development and implementation of interoperable technical standards and conformance testing procedures for health information technology (HIT).

“Effective utilization of information technology in the medical field has the potential to fundamentally change healthcare in our country,” said Subcommittee Chairman Ben Quayle (R-AZ).  “Application of health IT could lower health care costs by reducing duplicative and unnecessary tests and procedures.  It could also lead to more effective care by helping to reduce medical errors and could help to improve public health outcomes by aiding in clinical decision making.”

However, Quayle raised concerns about the lack of progress made towards greater interoperability of health IT systems.  Quayle stated that, “without interoperability, many of the potential benefits of health IT could go unrealized.”

The hearing reviewed the activities of the Office of the National Coordinator for Health Information Technology (ONC) and the National Institute of Standards and Technology (NIST) in promoting interoperability through the development of technical standards for HIT, and examined the implementation of the Health Information Technology for Economic and Clinical Health (HITECH) Act...

Read the Chairman's opening statement here (pdf).

Below: The timing of this was no coincidence.

CMS Reports $8.35 Billion in MU Payments to Date; 400 Hospitals Registered in October
Thursday, November 8, 2012

Following a surge in the number of hospitals signing up for the program in October, the Centers for Medicare & Medicaid Services has paid more than $8.35 billion through its “meaningful use” programs to date, the agency reported Nov. 7.

In response to the end of the federal fiscal year on Sept. 30, 400 hospitals registered for an estimated $340 million in Medicaid and Medicare payments in October, Rob Anthony, a specialist in CMS’s Office of eHealth Standards and Services, said during a Health Information Technology Policy Committee hearing...

CMS made $645 million in meaningful use payments in October alone, according to draft estimates released Nov. 7.

Emphasis mine (last sentence). Hmmm..., sooner-than-normal ad hoc update? Let's take a speculative stab at the intended audience here.

$645 million in one month? As I've noted previously, that's approximately the entire 62-REC four year funding allocation.

One thing emphasized during our retreat was that we could expect to be micromanaged to get our REC EP clients who've yet to register with the CMS Meaningful Use portal -- irrespective of their readiness to Attest -- to get off the dime and sign up before the year is out.

Presumably so ONC can bandy the "look-at-the-MU-demand" numbers in front of the Hill and the Administration. All while they continue to remain deafeningly silent on the issue of continued REC funding so that we can serve EP and EH Stage 2 needs.

But, hey, our "REC lobby" is all over it inside the Beltway and across the ether: twitter.com/ARCHealthIT

"Our website is currently under development.
We hope to have it up sometime in the near future."

Yeah, I know I said I was gonna lay off. But, really? In three days we'll be five months out from their debut press release.

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BUSINESS AS USUAL AT ONC?

Call for public comments this month will kick off Stage 3 timetable
November 16, 2012 | Diana Manos

EHR visionaries: Start crystalizing your thoughts on meaningful use Stage 3.

Leaders of the HIT Policy Committee, which advises the Office of the National Coordinator for Health IT (ONC) on technology infrastructure, have indicated that ONC expects to call for public comment on a draft of Stage 3 meaningful use requirements this month.

At an HIT Policy Committee meeting on Oct. 3, the meaningful use workgroup presented preliminary recommendations for Stage 3 to the committee. Final Stage 3 meaningful use requirements are expected to become effective in 2016...

The HIT Policy Committee has presented the following timeline for the development of Stage 3, which includes a November release of a request for comment (RFC):

• Dec. 21, 2012 – RFC deadline.
• January 2013 – ONC to synthesize the RFC comments for HIT Policy committee workgroups to review.
• February 2013 – The workgroups will reconcile RFC comments.
• March 2013 – The workgroups will present a revised draft of Stage 3 requirements to ONC.
• April 2013 – ONC is expected to approve final Stage 3 recommendations.
• May 2013 – ONC will transmit final Stage 3 recommendations to HHS...

Should be an interesting conclusion to year 2012.

I've been digging around of late in the "seven waves" of Draft NIST standards for 2014 Stage 2 CEHRT. This very last one is, well, to sum up, a beaut...

Test Procedure for §170.314(g)(4) Quality management system (pdf)

“We have adopted a certification criterion that accounts for the fact that we did not publish the quality management document as we had proposed. The certification criterion we have adopted is more general and provides more flexibility. The certification criterion expresses that for each capability an EHR technology includes and for which that capability's certification is sought, the use of a QMS in the development, testing, implementation and maintenance of that capability must be identified. Unlike our proposal, any QMS may be used to meet this certification criterion and even an indication that no QMS was used for particular capabilities for which certification is requested is permitted.”

§170.314(g)(4) Quality management system. For each capability that an EHR technology includes and for which that capability’s certification is sought, the use of a Quality Management System (QMS) in the development, testing, implementation and maintenance of that capability must be identified. 

• (i) If a single QMS was used for applicable capabilities, it would only need to be identified once.
• (ii) If different QMS were applied to specific capabilities, each QMS applied would need to be identified. This would include the application of a QMS to some capabilities and none to others.
• (iii) If no QMS was applied to all applicable capabilities such a response is acceptable to satisfy this certification criterion."

Gotta love (iii). Emphasis mine. Are you guys kidding? A Clinic Monkey Moment, for sure.

Maybe I'm just wasting my time.

ERRATA

Changing topics. Below, yikes. I can relate.

End of the Line in the ICU
by Kristen McConnell

Last year I graduated from nursing school and began working in a specialized intensive care unit in a large academic hospital. During an orientation class a nurse who has worked on the unit for six years gave a presentation on the various kinds of strokes. Noting the difference between supratentorial and infratentorial strokes—the former being more survivable and the latter having a more severe effect on the body’s basic functions such as breathing—she said that if she were going to have a stroke, she knew which type she would prefer: “I would want to have an infratentorial stroke. Because I don’t even want to make it to the hospital.”

She wasn’t kidding, and after a couple months of work, I understood why. I also understood the nurses who voice their advocacy of natural death—and their fear of ending up like some of our patients—in regular discussions of plans for DNR tattoos. For example: “I am going to tattoo DO NOT RESUSCITATE across my chest. No, across my face, because they won’t take my gown off. I am going to tattoo DO NOT INTUBATE above my lip.”

Another nurse says that instead of DNR, she’s going to be DNA, Do Not Admit. We know that such plainly stated wishes would never be honored. Medical personnel are bound by legal documents and orders, and the DNR tattoo is mostly a very dark joke. But the oldest nurse on my unit has instructed her children never to call 911 for her, and readily discusses her suicide pact with her husband. You will not find a group less in favor of automatically aggressive, invasive medical care than intensive care nurses, because we see the pointless suffering it often causes in patients and families. Intensive care is at best a temporary detour during which a patient’s instability is monitored, analyzed, and corrected, but it is at worst a high tech torture chamber, a taste of hell during a person’s last days on earth.

I cared for a woman in her 90s whose family had considered making her a DNR, but decided against it. After a relatively minor stroke that left her awake but not lucid, Helen* went into kidney failure and started on continuous hemodialysis. Because she kept pulling out her IV lines and the feeding tube we had dropped into her nose and down to her stomach, we put boxing glove-like pillow mitts on her hands. When I approached with her medicine, Helen batted at me with her boxing gloves, saying, “NO. STOP.” She frowned, shook her head and then her fist at me. Her wishes were pretty clear, but technically she was “confused,” because when asked her name, the date, and her location, she failed to answer. During the next shift, Helen’s heart stopped beating. But despite talking with the doctors about her advanced age and the poor state of her health, her family had nonetheless decided that we should “do everything we can” for her, and so Helen died in a frenzy of nurses pumping her with vasopressors and doing chest compressions, probably cracking several ribs.

That was a situation in which a patient’s family made a decision that probably caused Helen to suffer and did not help her. But there are circumstances where it is the healthcare team that chooses to push on with intensive interventions. And there are circumstances where bureaucracy, miscommunication, and the relatively low priority, among very busy physicians, of making decisions about how far to pursue medical care cause patients to linger in the ICU weeks past the point when any medical professional thought meaningful recovery was possible.

Consider another example, of a patient with advanced cancer, in this case an elderly woman with a well-informed husband who knew his wife was dying and that she didn’t want to end her life with an extended ICU stay. After her last tumor resection this woman developed an infection, and during a meeting with her husband the attending physician explained that the main problem we were immediately dealing with was the infection, which was bad and could well be something she would not recover from. The patient’s husband explained that he knew that his wife didn’t want to be there and that her underlying diagnosis plainly meant that her life was going to end, that they both understood this and didn’t want to painfully draw things out. Then he asked if he had any decisions to make—in effect being as blunt as he could without simply insisting that they withdraw care then and there.

The doctor said no. She said that the patient needed to complete the course of antibiotics to see if the infection could be cured, after which they could approach the question of whether to continue with intensive medical care. I imagine the doctor saw some distinction between letting the patient die of her primary, terminal diagnosis and letting her die of a complication. So the husband’s efforts to stick up for his wife went unheard, and she stayed in the ICU, comatose, for about two more weeks—quite the opposite of her stated wish—before everyone agreed to let her go.

On the other side of the spectrum are the poor forgotten patients, the ones who linger because nobody will speak up for them and the medical team is not legally allowed to decide to do anything short of maintaining life, day after day. One man with a severe stroke languished over a month while his family members dodged the responsibility of visiting, witnessing his condition, and making a decision about his care. Every morning the health care team rounded on him and we discussed the various states of decay of his body—he had severe diarrhea, frank blood in his urine, and ventilator associated pneumonia—and then moved on to discuss the efforts being made to contact his family and impress upon them the need for action. The ICU had nothing to offer him, and someone needed to choose: he would either have a tracheostomy and permanent surgically placed feeding tube in order to be moved to a ventilator dependent nursing home, or have his care withdrawn.

Similarly, we had a homeless woman with a severe brain injury. CT scans of her brain showed an undifferentiated mass of swollen tissue—this is very bad. We were draining cerebrospinal fluid out of her head because the swelling had obstructed the flow of this fluid, causing hydrocephalus and increased pressure within her brain. Her pupils did not react to light, and she had no corneal reflexes—that is, when you touched her eyeball, she didn’t flinch. What kept her from being brain dead was the fact that her ventilator was set to “pressure support,” meaning that she initiated breaths, and she still had a cough reflex.

The first day I took care of her, when she’d already been there over a week, I was told that there was a plan to seek a court-appointed guardian to make her health-care decisions. Any friend or relative could have become her decision maker, but this woman was alone. A few days later—why did it take that long?—the social worker presented the patient in court and a lawyer became her official guardian. This lawyer was unwilling to withdraw care. Further, he was unwilling to make the patient a NO CODE. If her vital signs became unstable and she started to die, we would have to use vasopressors, chest compressions, and defibrillation to keep her heart beating and keep her alive.

After this, she remained in the ICU for over a week, and the medical team began itching for ways to get her off of the unit, because she began to be seen as a living corpse taking up a critical care bed and its associated resources—things that could save a different very ill person. Eventually, their only objective was to wean her off of the ventilator and move her out of the ICU, so that her continued care would be someone else’s issue to deal with.

These four patients had different injuries and different circumstances. What was common to them was that they all suffered the bodily harm and indignity of being physically invaded in every sense, robbed of their integrity entirely, and pinched and poked continuously during the last days and weeks of their lives. Since nobody at the time thought they were going to get better, the people doing this to them—myself and other nurses—had an overarching question: Why?

All of us love the opportunity to help save a life. That happens in intensive care, and it is exciting and miraculous. But in the instances I’ve described, and many, many others, nobody involved is under the delusion that a life is being saved. This is where we become cynical, and where many nurses choose not to reflect on the painful purgatories trapping our patients. Rather, they express their opinions succinctly in wry conversations about DNR tattoos, and they master—or bluff—an exquisite segregation of the mental and physical work of caring for these patients from their own emotional energy. They do this in order to be able to continue working. They get over the absurdity of certain circumstances, and they manage not to care.

I’ve not accomplished this. The absurdity weighs me down, and so I want to describe it to you. Medical science can do incredible things. But you would not believe the type of life these life-sustaining treatments often allow.

People who are at the end of their life and are being kept alive artificially have a way of shutting down. Fighting this process is not a peaceful act. Most of the patients I’ve described were on ventilators, with plastic tubes pushed into their mouths and down their tracheas in order to provide respiratory support. The tubes are taped to their faces, and patients who can move at all are usually both tied down by their arms and sedated when on a ventilator, because it is so physically uncomfortable that patients will use their last ounce of strength to pull the tube out of their mouth. These patients were already comatose due to their injuries, but other critically ill patients who were previously awake and responsive become unable to speak while on a ventilator. Once intubated, patients are unable to clear their respiratory secretions—phlegm—and so we stick smaller rubber tubes connected to suction into the breathing tube, down their trachea and towards the entrance to the lungs themselves, in order to vacuum the secretions out of their lungs. You can imagine that this too is uncomfortable.

Patients obviously can’t eat, so they will have had a feeding tube pushed up their nose or through their mouth and their esophagus, down into their stomach. This often takes a few tries, requiring us to pull up the bloody tube, re-lube it, and push it back in at a different angle. If a patient is ill long enough, these instruments will be replaced with a tracheostomy in the neck rather than a tube down the mouth and a feeding tube going directly into the stomach rather than down through the nose. These are for patients who aren’t expected to be able to eat or breathe independently in the long term.

These patients often develop diarrhea, sometimes simply because of the liquid food they receive—cans of smelly, nutritionally balanced tan colored slush—and sometimes because they’ve acquired a very hardy and aggressive bacteria, C. difficile, that is widespread in hospitals and causes profuse, foul stool. If they have diarrhea several times a day and their skin is exposed to it, the skin begins to break down, and so we place a rectal tube in their bottom, held in place beyond the rectum with a small water filled balloon. The diarrhea drains into a clear bag that hangs on the side of the bed. Sometimes when a patient is very sick, as in the case of the man whose family avoided him for over a month after his stroke landed him on my unit, they lose their rectal tone and the tube falls out. This is how I found myself up to my elbows in diarrhea with another nurse, struggling to clean the crevasses of his body and tape an ostomy bag around his bottom, the last hope to contain the flow of stool so that the patient wouldn’t sit in a continuous puddle of it while permission for his death was pending.

Breathing tubes, feeding tubes, and rectal tubes are only part of it. The patients of course have urinary catheters and IVs, often larger IVs that are placed centrally—threaded straight toward the heart to allow us to push drugs in concentrations that would damage smaller veins. Healthier hospitalized patients complain sometimes about their IVs and frequently about their urinary catheters—a rubber tube up your urethra isn’t pleasant. If the patients I’m describing could talk, though, I think the urinary catheter would be the least of their complaints.

In addition to the invasion of tubes, ICU patients live in a world of bright lights and loud alarms, continuous stimulation. People pry open their eyes and shine flashlights into them, then pry open their mouths.

We treat most patients with small shots of heparin in their subcutaneous flesh, in order to prevent blood clots. This makes them bruise easily, and patients who’ve been with us for a while are often peppered with tiny bruises from the shots. Then there are the bigger bruises caused by painful stimulus given by doctors and nurses who are monitoring the arousability of the patient, the depth of their coma. If he doesn’t wake up when you shout, or when you shake him, what about when you pinch and twist his trapezius muscle, or grind your knuckles against his sternum for a while?

It’s been said that dying is easy, and it’s living that’s painful. Not so in the world of intensive care. Patients who have a hope of recovering from their injury, genuinely surviving it, may be fighting to live. For them the torturous days as an ICU patient are required in order to surmount their injury. And there are always cases where nobody knows what the outcome may be, where the right thing to do is maintain physical function and give the body time to heal. Many patients will survive with deficits, will not return to their former selves but will be able to leave the hospital, go to rehab, begin the hard work of adjusting to another kind of life. But time and again we care for patients who are fighting to die, and having a very hard time of it, because in the ICU there are only two ways to die: with permission, too often not granted or granted too late, or in the last-ditch fury of a full code blue.

We are not helping these people by providing intensive care. Instead, we are turning their bodies into grotesque containers, and reducing their lives to a set of numbers monitoring input and output, lab values, and vital signs, which we tweak to keep within normal ranges by adjusting our treatments, during the weeks and days immediately preceding their death. This is the opposite of what should be prioritized when a person is known to be nearing the end of their life without the hope of getting well.

I want this to change. People who choose to do the work of caring for the gravely ill must concentrate on monitoring and responding to changes in their vital signs, administering their medications, examining all of their physical systems, coordinating their various tests and procedures, bathing them and cleaning up their bodily messes, dressing their wounds, keeping them comfortable, and communicating with their families. I don’t think that we should also have to deal with feeling that our work is morally questionable and at times, reprehensible.

Americans have a lot of work to do in developing a more sensible, fairer, and less wasteful healthcare system. That work needs to include taking a hard look at the conditions of patients whose lives may end in intensive care, both at the level of the entire health care system and at the level of the individual—our wishes for ourselves and our family members whose health is failing or has already failed. Our goal is to help these people, and assuming that prolonging their lives for the longest time possible is the only way to do this is a foolish and harmful mistake.

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MORE FROM NYC:

NOVEMBER 15, 2012, 11:44 AM
When the Patient Is ‘Noncompliant’
By DANIELLE OFRI, M.D.

"A 63-year-old man with hypertension, elevated cholesterol and diabetes," the intern recited as he presented the case to me in clinic. He read the list of seven medications the patient was prescribed. "But he's noncompliant," the intern added.

"Noncompliant" is doctor-shorthand for patients who don't take their medications or follow medical recommendations. It's one of those quasi-English-quasi-medical terms, loaded with implications and stereotypes.

As soon as a patient is described as noncompliant, it's as though a black mark is branded on the chart. "This one's trouble," flashes into most doctors' minds, even ones who don't want to think that way about their patients. And like the child in school who is tagged early on as a troublemaker, the label can stick around forever.

Despite efforts to change the term to the slightly more accurate "nonadherent," the word "noncompliant" remains firmly entrenched in the medical lexicon. No matter what it's called, however, it's an enormous problem. Experts estimate that some 50 percent of patients do not take their medicines as prescribed or follow doctors' recommendations.

When I address this issue with my patients, I - like most doctors -- typically ask the basic question, "Are you taking your medications?" and then write down "Yes" or "No." But a recent article in The Annals of Internal Medicine made me rethink that approach.

"It's an immense oversimplification" to reduce compliance to whether or not a patient swallows a pill, says the author, Dr. John Steiner, a researcher at Kaiser Permanente in Colorado.

To illustrate his point, he constructed a chart for a theoretical 67-year-old patient with diabetes, hypertension and high cholesterol and tabulated what it would take to be "adherent" with all medical recommendations.

Besides obtaining five prescriptions and getting to the pharmacy to fill them (and that's assuming no hassles with the insurance company, and that the patient actually has insurance), the patient would also be expected to cut down on salt and fat at each meal, exercise three or four times per week, make it to doctors' appointments, get blood tests before each appointment, check blood sugar, get flu shots - on top of remembering to take the morning pills and then the evening pills each and every day.

Added up, that's more than 3,000 behaviors to attend to, each year, to be truly adherent to all of the doctor's recommendations. Viewed in that light, one can see how difficult it is for a patient to remain fully compliant.

Even if they do succeed in some areas -- cutting out salt and taking their blood pressure pills, for example - they may still get chided by their doctors for not exercising, or for missing a colonoscopy appointment.

I once did a small experiment with a group of medical students. We wrote up prescriptions for a number of common medications-metformin, lasix, albuterol, lisinopril, ranitidine. I handed each student two prescriptions and two boxes of Tic Tacs, and instructed them to take the "medicines" for a week. When we met for our next session, I asked them how they did, and they all had abashed expressions on their faces. Not one was able to take every single pill as directed for seven days.

"Be compassionate," Dr. Steiner advises doctors. "Understand what a complicated balancing act it is for patients."

Doctors and patients need to work together to figure out what is reasonable and realistic, prioritizing which measures are most important. For one patient, taking the diabetes pills might be more crucial than trying to quit smoking. For another, treating the depression is more critical than treating the cholesterol. A water pill may be out of the question for a taxi driver on the road all day; a low-salt diet may be impossible for someone living in a homeless shelter.

"Improving adherence is a team sport," Dr. Steiner adds. Input from nurses, care managers, social workers and pharmacists is critical.

When I discuss the complicated nuances of adherence with my students, I often offer up the example of my grandmother. A thrifty, no-nonsense woman, she routinely sliced all her pills in half. Whatever the doctor prescribed for blood pressure, cholesterol and heart disease -- she took only half the dose. If I suggested she take the pills as instructed, she'd wave me off with, "What do those doctors know, anyway?"

She died suddenly in her home, at age 87, most likely of a massive heart attack. It was a painful loss for all of us. Had she taken her medicines at the appropriate doses, she might have survived the heart attack. But then maybe she would have died a slower and more painful death from some other ailment. Her biggest fear had always been ending up dependent in a nursing home, and by luck or design, she was able to avoid that. Perhaps there was some wisdom in her "noncompliance."

Danielle Ofri is an associate professor of medicine at New York University School of Medicine and editor in chief of the Bellevue Literary Review. Her most recent book is "Medicine in Translation: Journeys With My Patients."
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FOLLOWING THE REALLY BIG MONEY FIGHT TO COME

Basic Health Program
The Affordable Care Act offers states another option besides Medicaid and the exchanges for health coverage for low-income residents.

What's the issue?
The Affordable Care Act employs two main strategies for expanding health insurance coverage--first, by extending Medicaid to millions of additional low-income people, and second, by allowing better-off people to purchase private health insurance with federal subsidies through new state-based health insurance exchanges. But the law also provides for additional means of expanding coverage, including allowing states to run a so-called Basic Health Program beginning in 2014.

Under such a program, states could offer public health insurance to people whose incomes are too high to qualify for Medicaid but are also below 200 percent of the federal poverty level (in 2012, that means less than $46,100 for a family of four).

To help pay for this program, which would probably resemble Medicaid, states could draw on a portion of the federal dollars that would otherwise go to subsidizing the purchase of private insurance coverage for those people through exchanges.

Proponents of the Basic Health Program idea maintain that having such a plan would make coverage more affordable for low-income people and save money for some states. But others worry that the program could undermine the viability of the new state insurance exchanges and, rather than saving money, expose states to financial risk. Meanwhile, federal officials have not yet provided many details for states about how the program will be operated.

This policy brief explores the issues surrounding the Basic Health Program and outlines options for states...

Nicely done, in-depth piece.

Yet another bureaucratic nightmare is about to ensue. But, I suppose that's inevitable one way or another.
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INTERESTING

Every doctor makes mistakes. But, says physician Brian Goldman, medicine's culture of denial (and shame) keeps doctors from ever talking about those mistakes, or using them to learn and improve. Telling stories from his own long practice, he calls on doctors to start talking about being wrong.

...In a hospital system where medical knowledge is doubling every two or three years, we can't keep up with it. Sleep deprivation is absolutely pervasive. We can't get rid of it. We have our cognitive biases, so that I can take a perfect history on a patient with chest pain. Now take the same patient with chest pain, make them moist and garrulous and put a little bit of alcohol on their breath, and suddenly my history is laced with contempt. I don't take the same history. I'm not a robot; I don't do things the same way each time. And my patients aren't cars; they don't tell me their symptoms in the same way each time. Given all of that, mistakes are inevitable. So if you take the system, as I was taught, and weed out all the error-prone health professionals, well there won't be anybody left.

And you know that business about people not wanting to talk about their worst cases? On my show, on "White Coat, Black Art," I made it a habit of saying, "Here's my worst mistake," I would say to everybody from paramedics to the chief of cardiac surgery, "Here's my worst mistake," blah, blah, blah, blah, blah, "What about yours?" and I would point the microphone towards them. And their pupils would dilate, they would recoil, then they would look down and swallow hard and start to tell me their stories. They want to tell their stories. They want to share their stories. They want to be able to say, "Look, don't make the same mistake I did." What they need is an environment to be able to do that. What they need is a redefined medical culture. And it starts with one physician at a time.

The redefined physician is human, knows she's human, accepts it, isn't proud of making mistakes, but strives to learn one thing from what happened that she can teach to somebody else. She shares her experience with others. She's supportive when other people talk about their mistakes. And she points out other people's mistakes, not in a gotcha way,but in a loving, supportive way so that everybody can benefit. And she works in a culture of medicine that acknowledges that human beings run the system, and when human beings run the system, they will make mistakes from time to time. So the system is evolving to create backups that make it easier to detect those mistakes that humans inevitably make and also fosters in a loving, supportive way places where everybody who is observing in the health care system can actually point out things that could be potential mistakes and is rewarded for doing so, and especially people like me, when we do make mistakes, we're rewarded for coming clean.

My name is Brian Goldman. I am a redefined physician. I'm human. I make mistakes. I'm sorry about that, but I strive to learn one thing that I can pass on to other people. I still don't know what you think of me, but I can live with that.

And let me close with three words of my own: I do remember.

Nice work. Check out his radio show site as well:

www.cbc.ca/whitecoat

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More to come...