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Misdiagnosis Could Have Paralyzed Young Screenwriter

My younger brother is an executive producer of the show “Nip/Tuck” and an executive producer of soon-to-air Fox show “Glee.“  Last year, he almost died.

It started when he woke up one day with numbness on one side of his body.

His doctor ordered an MRI. It found bad news: a tumor in his spinal cord, high up in his neck. He was referred to a neurosurgeon.

The plan was straightforward, but dangerous.  First, radiation.  Then, his spinal cord would be carefully cut open to remove the tumor. He was told he could end up paralyzed, or dead.  Concerned, he called me, and we started a case at Best Doctors.

One of our nurses took a history, and we collected his records.  Two internists spent hours reviewing them.  The records noted our family history of a kind of malformed blood vessel.  Our grandfather had hundreds of them in his brain when he died at 101, and our father has dozens of them in his.  I have one in my brain, too. This was in my brother’s charts, but none of his doctors had mentioned it.

An expert in these malformations told us a special imaging study should be done to rule this out as a cause of the problem.  Best Doctors gave that advice to my brother and his doctors.  They agreed.

The test showed this was precisely what he had.

Quickly, the plan changed. He still needed surgery — if the malformation bled, it could also paralyze or kill him.  But there would be no radiation, which might have caused the very bleeding we feared.  Even if that didn’t happen, the surgeons were prepared to operate on a tumor.  They would have been surprised to find a delicate malformation there instead.

In the end, his surgery went well.  He is having a good recovery and is busy with his new show.  But his case is a constant reminder of how important it is to have the right diagnosis, and how easy it is for things to go wrong.

Even in  Hollywood.

Is Health IT Being Rushed, Leading To Patient Errors?

Bolstered by the stimulus, there’s no doubt that there’s a significant push for doctors and hospitals to adopt digital medical records.

I’ve written before how we’re essentially throwing money at Windows 95 technology, but now, as an article from BusinessWeek points out, there’s a real danger in moving too fast.

Somewhat under-publicized were the incompatibilities with older systems in the Geisinger Health System, which after spending $35 million on software, noticed a spike medication errors that required another $2 million to fix.

Or what happened at the University of Pennsylvania, which found medication errors stemming from software designed to prevent mistakes.

Worse, there is no national database tracking the errors that are caused from electronic medical records. Because most of the programs are not open-source, confidentiality agreements meant to protect proprietary technology also serve to hide mistakes.

Ideally, these issues need to be resolved before throwing more money into bad technology. But, because of the intuitive notion that technology automatically improves health care, no one seems to be advocating a more cautious route which may, in actuality, better serve patients.

***

Better Health Editor’s Note: Please read this post for more in-depth coverage of how difficult it is to transfer health records electronically.

Physicians And The H1N1 Flu

Yesterday I visited the Centers for Disease Control in Atlanta and was taken inside the command center, where almost 100 staffers have been working around the clock to monitor and stem the current outbreak of flu.

I first spoke to Toby Crafton, the manager of the command center, who oversees the day-to-day operations. He and his team have been preparing for a possible pandemic of flu or another infectious illness for years. I also spoke to Michael Shaw, PhD, who heads up the virology labs that are studying the H1N1 virus causing the current outbreak. He’s spent a career learning the laboratory techniques that are so urgently needed right now. The third person I spoke to was Dr. Richard Besser, Acting Director of the CDC, who has been working at the agency for 13 years and is an extensively published expert in infectious diseases.

I mentioned that last week I had received an email notification from the New York City Department of Health (NYCDOH) about how I should be managing my patients with flu-like symptoms. The advice was actually not intuitively obvious to me. For example, the Department of Health said that for patients with mild illness, treatment with anti-viral meds like Tamiflu and Relenza was only recommended for patients who also had underlying conditions that increased their risk for complications due to influenza. Dr. Besser pointed out that it was especially important right now for physicians to stay up to date with the recommendations being made by public health officials. Doctors can contact their local department of health and sign up for the same type of email notification that I received.

This brings us to the main point of today’s blog post. Many of us – patients and physicians alike – have been thinking about the influenza virus for about a week. Public health officials like the teams at the CDC and the NYCDOH have been thinking about it for years. Physicians, me included, are used to practicing medicine based on “clinical judgment.” We understand that medicine is an art and not a science, that there are many different ways to approach a problem, that there’s often no clear “right” or “wrong.” We are also used to doing things “our way”, whatever that way is. But this is not a time for doing things “our way” if it’s at significant odds with strong recommendations being made by public health officials. There are recommendations that may seem logical – like prescribing medication for somebody with mild flu symptoms “just in case” that nevertheless go against the judgment of people who have trained for years to think about how to deal with an epidemic.

What if you’re a physician who strongly disagrees with a suggestion of public officials? Then challenge that recommendation publicly. Bring the discussion to light; maybe you’re right. While this is no time to go rogue, doctors have an obligation to think carefully and independently and to challenge recommendations that seem illogical. But don’t silently do things your own way.


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Can Mobile Technology Improve Patient Compliance And Health Outcomes?

I recently interviewed the CEO (Bill Reed) and SVP (Stuart Segal) of AllOne Health at the World Health Care Congress. Their enthusiasm for mobile technology rivals Better Health’s own Dr. Alan Dappen. Will mobile technology get people more engaged in healthy behaviors and assist with disease management? I hope so.

Dr. Val: What is “All One Health?”

Reed: All One Health provides a bundle of customized offerings to small employers – including insurance and health and wellness programs. We provide the same kinds of benefits that large insurers offer to large employers except we spend a lot of time analyzing the specific needs of small companies before initiating a health program for them. Some small companies have employees with diabetes-related challenges, and others might be more concerned about asthma. We also use predictive modeling (health risk assessments) to help the companies customize preventive health strategies for their employees.

Engagement and compliance are very important in bringing about substantive changes in healthcare – and good health can be incentivized by employers. All One Mobile is our means for connecting patients (or employees) with health coaches and nurses, which we believe is critical for affecting lifestyle changes.

Dr. Val: What does your “menu of services” look like from the employee’s perspective?

Reed: Each employee begins the relationship with a health risk assessment (HRA). That HRA recommends programs for the employee based on their risk factors, and prioritizes the top three things for them to work on. There are performance trackers linked to employer incentives for health improvements and the programs are available via the phone so that employees don’t have to be in front of their PC to interact with their health coaches. We have proactive outbound calling with an opt out feature. We believe that the mobile phone is critical for encouraging consistent participation in health programs. Our services center on phone-based reminders and personal relationships with coaches.

In the near future we’ll include blue tooth technology to have patients upload data from their home monitoring devices for their coaches to review. This is a more proactive approach to health management.

Dr. Val: And Stuart, tell me about the All One Mobile program for the Department of Defense (DOD).

Segal: The DOD was having difficulty with follow up care for military personnel returning from Iraq and Afghanistan with traumatic brain injuries (TBI). Once they returned to their communities, it was very hard to reach them. All One Mobile won a contract with the army to provide constant messaging services to soldiers with TBI because they need regular reminders to keep their rehabilitation on track. Army case managers can push out questionnaires to soldiers and depending on how they answer, the case manager might be triggered to give them a call while they have the phone in their hand. So the phone-based communication tool is the primary tracking device for soldiers who return to the US with TBI.

Dr. Val: What are the educational qualifications of your coaches?

Reed: Registered nurses, dieticians, and psychologists.

Dr. Val: And what if the patient needs to see a doctor?

The coaches are trained to refer patients to their doctor when it appears that they need it. We can also track their prescription patterns and send the patients a “gaps in care” letter to remind them to fill their prescriptions. Non-compliance with medications is a major problem that All One Health can address.

Dr. Val: How would a doctor use All One Mobile?

Segal: We’re currently working on making EMRs accessible via phones – so that no matter where a physician is, he or she can review patient records and track their progress remotely.

Dr. Val: Or better yet, when one doctor is taking call for her group, she can have access to patient records so that when she’s called in the middle of the night, she’ll be fully informed about the patient problem list and understand the context of the concerns much better.

Segal: Yes, and All One Mobile can be used in the Emergency Department setting – so that when patients are discharged home, they receive 30 days of our service. The hospital can send them their lab results (that were drawn in the ER) and easily contact patients to bring them back in if necessary. In addition the patients can take photos of their wounds, for example, and have the physicians see how they’re progressing.

Dr. Val: Any closing thoughts?

Reed: This kind of health communication is incredibly convenient. Patients don’t need to carry around a smart card, a thumb drive, or a paper record. They’re already carrying around what they need – their own cell phone. And almost everyone in the US, regardless of economic class or age, has a phone.

The Friday Funny: Butterfly Collections

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