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Saturday, March 30, 2013

Hello from Walnut Creek

LAS-SFO. I would never fly anyone but Virgin domestically were it possible.
Below, the AirTrain station which takes you straight to BART. Shot that one with my iPhone 4s
Above: The view to the west from the hill overlooking Cheryl's place in Walnut Creek.
Winery tucked in the hills. Paradise.

First, courtesy of Soliant Health.

The Dedicated Doctor


Commentary: The litigation and risk-management concerns meaningful use triggers
March 29, 2013 | James M. Hofert, Partner, Hinshaw & Culbertson LLP and Roy M. Bossen, Partner, Hinshaw & Culbertson LLP and Linnea L Schramm, Associate, Hinshaw & Culbertson LLP and Michael A. Dowell, Partner, Hinshaw & Culbertson LLP

New federal healthcare legislation and implementing regulations seek to exert control over aspects of patient care, from outlining the substantive information that healthcare providers should obtain from their patients to specification of treatment algorithms a physician should consider once a diagnosis is made.

Meaningful use standards require healthcare providers to affirmatively act to identify potential future health risks in patients seen for unrelated health conditions. New regulations also require continued patient follow-up after discharge from care to ensure compliance with care directives. The regulations reflect laudable goals but create significant potential risk for malpractice claims for unwary healthcare providers.

Thus far, great concern has been expressed as it relates to physician and institutional liability if information systems are hacked or if cloud-based products are illegally accessed. CHIME noted that there are significant program issues relating to system interfaces so as to allow communication of EHR between physicians and other institutions. Multiple industry associations have suggested that implementation of Stage 3 be delayed by up to two years to allow for evaluation of the impact of Stages 1 and 2 on the healthcare system.
The emphasis that has been placed on the adoption of information technology in the healthcare field in the last several years, meanwhile, generates potential legal and risk management concerns. As the requirements for acceptable EHR systems evolve, so do relevant common law standards of care. The rapidity with which healthcare institutions must develop and implement EHR systems to meet “meaningful use” criteria presents significant risk for malpractice claims.

Initial transition from paper to electronic record systems can create risk of: implementation errors (software issues); inadequate training issues; incorrect or inconsistent use; and individual mistakes in the creation of the electronic record. The use of both paper and electronic records may create documentation gaps leading to misdiagnosis and inappropriate treatment. Procedures must be developed for confronting problems in the implementation of electronic recordkeeping. Consistent standardized use of developing electronic systems is imperative.

Meaningful use requirements relating to the need to document and treat a patient’s future health risks creates a gray area as to what, if any, responsibility institutions and physicians have in evaluating patients for potential health issues unrelated to the reason for hospital admission and/or treatment. Regulatory requirements relating to coordination of post-hospital care creates obligations to provide services in a reasonable manner, including follow-up where provider/patient communication potentially becomes a significant problem.

The use of electronic communication systems to diagnose and treat patients remotely creates a potential malpractice risk. There is a clear risk of misdiagnosis associated with remote treatment. There is also litigation risk in relation to the failure to properly follow-up...
Reading things like this inevitably takes me "Back Down in the Weeds'."

Individual variation is perceived as normal when occurring in faces and physiques. In physiology and pathology, variation is equally normal and pervasive. Yet, it is often perceived as abnormal, or is not perceived at all. The reason is that medical knowledge about physiology and pathology is usually expressed as rough generalizations about large populations. Knowledge expressed in that form is more easily recalled and processed by the unaided mind than detailed data about unique individual variations. As a result, these more detailed data are less likely to be incorporated in the body of medical knowledge (that is, less likely to be published or otherwise made generally available). Even when thus incorporated in medical knowledge, detailed information about unique individual cases is less likely to be taken into account by practitioners, because their unaided minds cannot quickly comb through the medical literature. In the Addison’s disease case, for example, none of the multiple practitioners who commented on their patient’s deeply pigmented nevi were aware of an article on a Addison’s disease patient in Denmark with nevi of similar appearance (see note 10 above). (It is unknown how frequently Addison’s disease manifests itself with this form of hyperpigmentation, in part because medical records do not reliably record such data, in part because records are not maintained in a structured electronic form accessible to researchers, and in part because Addison’s disease sometimes occurs without ever being diagnosed.)

In short, the unaided mind naturally turns to population-based medical knowledge. Yet that knowledge falls far short of what is needed for the care of unique individuals. The more individualized knowledge that patients need is either unknown or not accessible. This shortfall is most critical at the outset of care. As the case study observes, clinicians usually begin diagnostic investigation by considering first population-based knowledge of what diagnose are “most common.” (Thus the aphorism among physicians—”when you hear hoof beats, think horses, not zebras.”) Yet, this approach is fraught with risk, because it may divert attention from the diagnostic possibilities most applicable to the individual patient. In the case study, for example, Addison’s disease, a rare condition, “did not make the list [of diagnoses to consider] until it was nearly too late to save the child’s life.” Whether a disease is common or rare depends on the context. (Thus the aphorism among physicians might become, in central Africa, “when you hear hoof beats, think zebras, not horses.”). In the general population, Addison’s disease is indeed rare. But in the tiny subpopulation of patients with a combination of findings like fatigue, hypotension, weight loss, abnormal pigmentation, dehydration, nausea, and abdominal pain, Addison’s disease is common (perhaps almost universal). People with this pattern of findings are not identified as a subpopulation in the medical literature and thus do not fit into the usual “evidence-based” mode of analysis.

As applied to individuals, knowledge about large populations is useless, indeed misleading, until other, more individually applicable knowledge is first taken into account. Yet, this other, individualized knowledge is not made readily accessible. Even more disturbing is the health care establishment’s response to this dilemma. Physicians are increasingly expected to apply knowledge derived from large population studies and clinical trials. Referred to as “evidence-based medicine,” a better label for this approach would be “evidence-missed medicine,” because it systematically excludes the individualized knowledge and data essential to patient care. Yet, “so-called evidence-based medicine is rapidly becoming the canon in many hospitals,” Dr. Jerome Groopman observes. “Treatments outside the statistically proven are considered taboo until a sufficient body of data can be collected from clinical trials.”

Evidence-based medicine is rightly intended to prevent physicians from following arbitrary local practices and unsupported personal judgments. But that goal can only be achieved by meticulous accounting for individualized information. Absence of that basic standard of care explains the delayed diagnosis in the Addison’s disease case and much of the health care system’s dysfunction. [Medicine in Denial, pp. 23-25]
Ponder the aggregate ramifications of all the the foregoing. The difficulties attending other fields pale in comparison.


Few manpower specialists have noted the cohort effect likely to manifest itself shortly. A continued economic recovery and, more importantly, a recovery in retirement plan and medical real estate asset values will lead as many as 100,000 physicians of all stripes to leave practice in the next few years. We will be replacing a generation of workaholic, 70-hour-a-week baby boom physicians with Gen Y physicians with a revealed preference for 35-hour work weeks. During this same period, we’ll be adding 1.5-1.7 million net new Medicare beneficiaries a year and enfranchising perhaps 25 million newly insured folks through health reform. “Train wreck” is the right descriptor of the emerging primary care supply situation...

Electronic health records. Green’s optimism about the potential productivity improvements from electronic health records might also be misplaced. Despite, or perhaps because of, the pressure from meaningful use to automate office practices, physician offices added 162,000 workers from 2007 to 2011, even with a 10 percent shrinkage of visit volume. Many of these new hires were medical secretaries, physician assistants, and the like.

If there are productivity offsets for practicing physicians from automating medical records, they are hard to detect. Most physicians I’ve talked to about their EMR conversions are spending less time with patients and more time feeding their EMRs coding information and complying with new Medicare documentation requirements.   The result: richer coding and more dollars from fewer patients. Unless documentation requirements are reduced, it is not clear that the EMR will actually make it easier for physicians, or other clinicians for that matter, to see more patients...
Nice article.

April 1, 2013 at 5:45 pm
sara jennings, phd says:

Doctors have become window washers for the HIT vendors, insurance executives, and hospital CEOs. The intrusions and manipulation of medical care to enable the building of their fortunes and greed is despicable. The CPOE and CDS machines make life nasty for doctors and serve no meaningful beneficial purpose, except, perhaps, for a chimp.

More to come...

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