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Monday, July 1, 2013

Summer reading list

My world of late has been principally about the myriad mechanics of the delivery of medical/health care information to the right place at the right time -- hardware, software, data, and policies. But, the effectual nuances of medicine extend beyond far those relatively mundane considerations. to wit:

A highly recommended read.
Beyond physical aspects of a patient that can stymie doctors’ empathy, there are also personality characteristics to which doctors react with less empathy than they should— patients who are hostile or manipulative, patients who are painfully shy and reveal nothing of themselves, patients who seem entitled and arrogant. Right after residency, I took a summer job in a family practice in Long Island, covering Friday and Saturday office hours for a physician I’ll call Dr. Palmer. I was in a middle-class town that in summers swelled to twice its size with wealthy Manhattanites whose beach houses lined the crystalline shores.

Needless to say, the setting was quite different from my training at Bellevue. It wasn’t just a matter of switching from an uninsured, largely immigrant population to an affluent, stable population, most of whom spoke English. It was a veritable culture shock— medically— to go from a world of critically ill hospitalized patients to a calm outpatient suburban setting of basically healthy people. My final month in residency had been spent in the ICU dealing with septic shock, severe hemorrhages, and multisystem organ failure. Now my patients came for a miscellanea of sore throats, rashes, and sprained ankles— ailments too pedestrian to even make it onto the medical radar during residency. But I quickly became a master at tick removal and identification of Lyme disease.

One day, a healthy-looking woman in her early forties came for an appointment. Cynthia Landon asked me to prescribe fen-phen (fenfluramine-phentermine), a weight-loss pill that was being heavily marketed at the time. 

The whole idea of weight-loss pills had always rubbed me the wrong way; it seemed like a Band-Aid approach to a problem that usually resulted from a lifetime of eating patterns and inactivity, so already my hackles were up.

From my vantage point across the desk, I thought she certainly seemed to be within a normal weight range. “Why do you want to take weight-loss pills?” I asked her, somewhat incredulously.

She grasped a handful of her stomach and said ruefully, “I’ve been trying to get rid of these extra pounds after having kids.”

I leaned closer to see what she was gripping, and it looked like a regular amount of stomach to me. After three years of round-the-clock AIDS, cancer, congestive heart failure, and cirrhosis, it was hard to get worked up over a couple of middle-aged pounds. I mean, really . . . “

Your weight looks pretty reasonable to me,” I said in what I thought was a pleasant, objective voice. It was a compliment, actually, because frankly she looked fine for her age. “Plus these pills don’t do much. Whatever pound or two they take off will come right back as soon as you stop. It’s not a permanent solution. And every medication has side effects to consider. Have you tried—”

But before I could get to any discussion about diet and exercise, Ms. Landon cut me off. “Dr. Palmer prescribes fen-phen for me,” she said curtly. “I need a prescription from you, not a lecture.”

I was taken aback by the sharp edge in her voice. I was even more taken aback that Dr. Palmer prescribed those pills for someone who wasn’t obese. But I was a temp here. These weren’t my patients; they were Dr. Palmer’s, and my job was to continue his usual care in his absence. This week he and his family were on vacation, and I was trying my best to act as a worthy substitute. But now I was getting annoyed.

“Every medication is a serious proposition,” I said. “You can’t just—”

“Dr. Palmer is my doctor,” she said angrily. “My insurance covers the medication, and this is what I need.”

Suddenly I began to feel unsure of myself. Dr. Palmer had decades of experience with outpatient medicine. All I had was three years in the hospital; what did I know about office-based medicine? Maybe this was what outpatient doctors did? Maybe fen-phen was appropriate for mild middle-age weight gain, and I was just being naïve? And if this was what the patient had been taking, who was I to stop it? Would that be “abandoning” a patient in the midst of her care?

But it didn’t sit right with me. So I finally said, “Maybe it’s best that you make an appointment with Dr. Palmer to talk about it with him.”

“He’s away this week,” she snapped back at me, “and the secretary told me that he’s completely booked the week he comes back."

I could feel the pressure like a barometric surge. This patient clearly wasn’t going to back down. Well, damn it, neither was I. If she thinks she can railroad me just because I’m the new doc in town . . . 

Then I glanced up at the clock and thought about the full waiting room outside. I didn’t want to spend all morning fighting this out; there was too much else to do. I could just give her the prescription and be done with it. How much harm could thirty pills do? I probably wasn’t ever going to see her again. What would it matter in the long run? But then I would have been manipulated by this patient. That alone was getting me steamed.

“I’m sorry,” I finally said, my voice now as curt as hers. “But in my professional opinion, fen-phen would not be medically indicated in this situation.”

Ms. Landon glared at me for one long hard moment, then pursed her lips and stood up. She grabbed her handbag and exited the room without a word or glance. I felt shaken, but also proud that I’d resisted her pressure and stood my ground.

Summer was just waning when an article appeared in the New England Journal of Medicine showing that fen-phen might cause valvular heart disease. Shortly thereafter, the medication was pulled from the market. I felt vindicated, even smug. I told you so, I imagined saying to Ms. Landon.

But as I think about this episode years later, I realize that I let my own anger at being manipulated dominate the interaction. My sense of feeling threatened made it hard to be empathic toward Cynthia Landon. I wasn’t able to step past my own issues— both my lack of confidence as a new doctor, and my personal bias against the medication itself— and try to understand her issues. Perhaps she had an eating disorder that had drastically altered her perception of her weight. Perhaps there were other underlying issues at play, emotional issues more complex than a few extra pounds post-kids.

But we never got that far. I wasn’t able to be particularly empathic with her not just because I was angry but also because she seemed so entitled. She apparently felt that she could just march right in and demand whatever she wanted. She struck me, at the moment, as spoiled and vain. All I could think of was how many patients at Bellevue were truly sick and really needed medical care. Her selfish use of the medical system for her petty, superficial issues— not to mention the drug companies’ exploitation of this— disgusted me.

But maybe none of that was true. Maybe underneath the seemingly superficial concerns were serious issues that were crying out for attention. Maybe I’d just screwed up and missed a biggie. Depression. Suicidality. Domestic violence. Bulimia. Drug addiction. Alcoholism. Any of these serious (and potentially fatal) conditions could have been lurking beneath a simple request for diet pills. Even wealthy, insured people with extravagant beach homes get sick. Even annoying, selfish, and entitled people need care. But my empathy was stymied that day by the emotions that ignited between us, and I wasn’t able to explore beneath the surface.
My only consolation was that perhaps I’d spared her from the side effects of fen-phen. A few years later, I learned that I might have even spared her from the side effects of Dr. Palmer. A DWI conviction revealed a serious alcohol problem. Complaints were filed by several patients, and his practice came under investigation. Ultimately, his medical license was suspended because his medical practice “did not meet an acceptable standard of care.”

Danielle Ofri, What Doctors Feel: How Emotions Affect the Practice of Medicine (pp. 11-16). Beacon Press. Kindle Edition.
More on this fine book shortly. One eloquent physician. BTW: recall her citation of Victoria Sweet's equally worthy book "God's Hotel," noted in my May 12th, 2012 post.

The Darkest Year of Medical School?

Dr. Ofri, writing for
...After two years of the predictable life of lectures, textbooks, and exams, [med school] students are plunged into the world of actual clinical medicine, where patients and their illnesses rarely go by the book.

It is the moment these students have been waiting for. One would think that the third year of medical school would be a crowning achievement—the donning of the white coat, the grasping of the golden ring after many years of striving. And in some ways it is. The learning curve is voraciously steep as students soak up clinical knowledge at an impressive rate.

However, there is a darker side of this transition to clinical medicine. Many of the qualities that students entered medical school with—altruism, empathy, generosity of spirit, love of learning, high ethical standards—are eroded by the end of medical training. Newly minted doctors can begin their careers jaded, self-doubting, even embittered (not to mention six figures in debt).

In researching my book What Doctors Feel: How Emotions Affect the Practice of Medicine, I discovered that the third year of medical school is when these high-minded traits begin to erode, an observation that won’t come as a surprise to anyone who’s been through traditional medical education.

For starters, the entry into the clinical world can be an intensely disorienting experience. Complications, drug interactions, patient idiosyncrasies, medical errors, insurance issues, and emergencies keep life frenetic. Everything—from the smell of infected bedsores and the insistent clanging of alarms to the foreign language of hospital lingo and the capriciousness of death—serves to create a disconcerting world. In the midst of this are the greenhorn medical students, acutely aware of their lack of practical skills to do anything of use.

And as soon as students have figured out the ins and outs of the electronic medical record system, the names of the social workers, and where the bathrooms are, they are shipped off to the next rotation—in a different place, with a different medical team, with different patients, with different expectations, and often an entirely new computer system to battle with.

Every four to eight weeks, the students are whisked through a new world: surgery, internal medicine, obstetrics-gynecology, psychiatry, neurology, pediatrics, and outpatient medicine. This ensures that students have a good grounding in the broad field of medicine, but it also ensures that any relationships formed—with patients, nurses, senior physicians, or mentors—are serially disrupted. It’s no wonder that so many students spend the year in a daze.

 Students are not just learning medicine during the third year of medical school; they are learning how to be doctors. Despite the carefully crafted official medical curriculum, it is the “hidden curriculum” that drives the take-home messages. The students astutely note how their superiors comport themselves, how they interact with patients, how they treat other staff members. The students are keen observers of how their supervisors dress—and how they may dress down those around them. They figure out which groups of patients can be the object of sarcasm or humor, and which cannot...
[A]s soon as students have figured out the ins and outs of the electronic medical record system, the names of the social workers, and where the bathrooms are, they are shipped off to the next rotation—in a different place, with a different medical team, with different patients, with different expectations, and often an entirely new computer system to battle with.



Lots of great stuff. These are just a few. The Kindle is hummin'.

My Cognitive Crack Pipe. The time drain bane that is Amazon's "1-Click Whispernet."

It goes on, screen after screen, lol.

JULY 2, 2013
Final HHS Health IT Safety Plan issued
The Joint Commission to expand capacity to investigate Health IT-related events

A plan to guide health information technology (IT) activities across the Department of Health and Human Services (HHS) to eliminate medical errors, protect patients, and improve the quality and efficiency of health care was issued today by HHS (PDF). The final Health IT Patient Safety Action and Surveillance Plan addresses the role of health IT within HHS’ commitment to patient safety. The Plan builds on recommendations from the 2011 Institute of Medicine report, titled Health IT and Patient Safety: Building Safer Systems for Better Care, and from public comments.

“When implemented and used properly, health IT is an important tool in finding and avoiding medical errors and protecting patients,” said National Coordinator for Health IT Farzad Mostashari, M.D. “This Plan will help us make sure that these new technologies are used to make health care safer.”

The Plan, implemented by the Office of National Coordinator for Health IT (ONC), outlines the responsibilities to be shared across HHS and details significant participation from the private sector. Through the Plan:

  • ONC will make it easier for clinicians to report health IT-related incidents and hazards through the use of certified electronic health record technology (CEHRT).
  • The Agency for Healthcare Research and Quality will encourage reporting to Patient Safety Organizations and will update its standardized reporting forms to enable ambulatory reporting of health IT events.
  • The Centers for Medicare & Medicaid Services (CMS) will encourage the use of the standardized reporting forms in hospital incident reporting systems, and train surveyors to identify safe and unsafe practices associated with health IT.
  • Working through a public-private process, ONC will develop priorities for improving the safety of health IT. ONC and CMS will consider adopting safety-related objectives, measures, and capabilities for CEHRTs through the Medicare and Medicaid EHR Incentive Programs and ONC’s standards and certification criteria.
  • To accompany the Plan’s surveillance of safety-related capabilities in CEHRT, ONC today issued guidance clarifying that ONC-Authorized Certification Bodies will be expected to verify whether safety-related capabilities work properly in live clinical settings in which they are implemented.
In addition to the Plan, today Dr. Mostashari announced ONC has contracted with The Joint Commission to better detect and proactively address potential health IT-related safety issues across a variety of health care settings. The Joint Commission will expand its capacity to investigate the role of health IT as a contributing cause of adverse events and will identify high priority areas for expected types of health IT-related events.
“It is widely believed that, when designed and used appropriately, health IT can help create an ecosystem of safer care...” — Institute of Medicine, Health IT and Patient Safety: Building Safer Systems for Better Care
Over a decade ago, the Institute of Medicine (IOM) report To Err is Human raised an alarm about the failure of health care to recognize and reduce the large number of avoidable medical errors harming patients.2 The ability of health information technology (health IT) to reduce medical errors is one of the reasons for the creation of the Office of the National Coordinator for Health Information Technology (ONC) under the Department of Health and Human Services (HHS) through the Health Information Technology for Economic and Clinical Health (HITECH) Act3—passed as part of the American Recovery and Reinvestment Act (Recovery Act) of 2009.4 In addition to creating ONC, the HITECH Act also provided economic incentives for eligible health care providers to adopt and meaningfully use certified EHR technology.

A key premise of these initiatives is that health IT, when fully integrated into health care delivery organizations, facilitates substantial improvements in health care quality and safety as compared to paper records. For instance:

  • Medication errors can be substantially reduced and clinical decisions can more easily be made based on evidence. Electronic health records (EHRs) eliminate prescription and other errors resulting from illegible handwriting, while capabilities such as clinical decisions support (CDS) and computerized provider order entry (CPOE) provide clinicians with best practice guidance and information on the allergies and medications of specific patients as part of the clinical decision-making process. CDS also supports delivery of care to patients based on clinical guidelines, including for preventative care, such as immunizations and routine screening tests.
  • Patient records can be stored centrally and easily accessed from multiple locations, making crucial health information available when and where needed as patients move within and between health care organizations. When a patient arrives at an emergency room, providers can begin treatment with electronic access to historical patient records.
  • Health IT can be used to more efficiently report, track, and aggregate patient data within and across organizations. This allows providers to more efficiently track and manage hospital-acquired illnesses. Disease outbreaks can be monitored, which allows for improved population health and identification of widespread threats to health, such as flu epidemics.
While health IT presents many new opportunities to improve patient care and safety, it can also create new potential hazards.5 For example, poor user interface design or unclear information displays can contribute to clinician errors.6 Health IT can only fulfill its enormous potential to improve patient safety if the risks associated with its use are identified, if there is a coordinated effort to mitigate those risks, and if it is used to make care safer...

This Health IT Patient Safety Action and Surveillance Plan (the “Health IT Safety Plan” or “Plan”) addresses the role of health IT within HHS’s commitment to patient safety. Building on the IOM committee’s recommendations, the Plan leverages existing authorities to strengthen patient safety efforts across government programs and the private sector—including patients, health care providers, technology companies, and health care safety oversight bodies. Importantly, the Plan outlines specific and tangible actions through which all stakeholders can fulfill their shared obligation to increase knowledge of the impact of health IT on patient safety, and maximize the safety of health IT and health IT-assisted care.

Successfully implementing this Plan will require a coordinated effort among multiple government agencies, private organizations, and individuals (e.g., clinicians, software engineers, health IT support staff, and usability experts). To coordinate this effort, ONC has established the Health IT Patient Safety Program (“Safety Program”) within the Office of the Chief Medical Officer with support from the Office of Policy and Planning. Through the Safety Program, ONC will collaborate with stakeholders to incorporate health IT and patient safety into their organizations, and will work closely with all actors to help them fulfill their responsibilities under this Plan. ONC will oversee the aggregation and analysis of data from the sources identified in this Plan, among others, in order to identify trends in patient safety and health IT, provide feedback to developers and providers, and inform policies and interventions to achieve this Plan’s objectives...
It'll be interesting to see how this news is received. The ankle biters will no doubt be out in force, notwithstanding everyone having had ample time to add their comments and recommendations (PDF).


HHS Has Yet To Respond to GOP Senators' Meaningful Use Concerns
Tuesday, July 2, 2013

HHS has not yet responded to a letter and white paper -- released more than two months ago by six Republican senators -- outlining concerns regarding the federal government's electronic health record incentive program, according to a statement from the office of Sen. John Thune (R-S.D.), EHR Intelligence reports.

The senators had asked HHS to respond by June 16 (Murphy, EHR Intelligence, 7/1)...
The "REBOOT" Report. Not getting a lot of respect, it would appear. The Senate Finance Committee just held a hearing last week: "Health Care Quality: The Path Forward." No mention of this "Reboot" stuff that I can uncover. Neither Chairman Baucus nor Minority Ranking Member Hatch mentioned it in their opening statements.

From the Witness statements (referencing Health IT / Meaningful Use):
...Better capabilities in electronic record systems are also needed, to combine the data needed for meaningful quality measures and to enable the measures themselves. Electronic health record vendors are working to adapt their systems to the increasing importance of coordinated care for patients across different providers, and to achieve interoperability in practice and not just in theory across different EHR systems that may contribute to the care of a patient. In the meantime, a number of health care organizations and companies have developed technical products and support services to pull together data from multiple sources, including electronic clinical records and claims, for use in improving patient care. These efforts should be supported. For example, providers that are able to report electronically on outcome-oriented performance measures for their patients should qualify for “Meaningful Use” payments. The emphasis should be on whether data are actually flowing to enable better patient care, not on the specific features of an individual EHR system. CMS has taken some promising steps in this direction of aligning performance-based payment toward patient-level performance measures.

- Mark McClellan MD, PhD
...A multi-prong approach to measurement plus payment incentives demonstrated results over10 years: Two hundred physician groups in California associated with the Integrated Healthcare Association have participated in a pay-for-performance program over a number of years. In 2012, 47 of the physician groups received performance awards for meeting benchmark performance for meaningful use of health IT, patient experience, and clinical measures in key areas: cardiac, diabetes, musculoskeletal, respiratory, and prevention.

- Christine K. Cassel, MD, MACP
...We also recommend that Congress direct HHS and the Office of the National Coordinator for Health IT to prioritize the accelerated use of inter-operable electronic health records and clinical registries as sources of performance data. The EHR incentive program, known widely as “meaningful use,” has achieved remarkable levels of adoption of computerized health records across the nation’s hospitals and doctors’ offices. Yet information technology has rapidly evolved – to take advantage of the internet, cloud computing, and mobile devices – and our understanding of the serious consequences of fragmented care delivery has also evolved. Federal dollars are no longer needed to stimulate adoption of basic clinical computing technology, but federal funding is needed to support the public good of coordinating and measuring care delivered over an episode or a period of time. ONC and CMS should be charged with implementing a framework that will allow for evaluation of a patient’s care over time, including the appropriateness of care decisions, their outcomes, and the total resources consumed. This information framework should also permit Congress and the public to assess whether new models of care, such as episode payment, accountable care organizations, and even the new insurance marketplaces are contributing to improved health.

- David Lansky, Ph.D.
Witness Elizabeth McGlynn made no references to Meaningful Use. She did, ohwever, maked this observation: providers are moving away from paper-based systems; with the increased adoption of electronic health records, information technology has finally started to be a tool for change in health care. That means we have new opportunities for measures that are more meaningful to doctors, because they are derived from richer, clinical data rather than administrative claims. We can also develop measures that are more meaningful to patients, specifically measures designed to help patients make better, more informed choices about healthcare, based on reliable information about the quality of care.
Seems like Meaningful Use bashing isn't getting a lot of traction in the Senate thus far.

More to come...

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