March 8th, 2007 by Dr. Val Jones in Opinion
Tags: Hospitals, International, Personal
2 Comments »
A Turkish friend of mine told me that he had saved for several years to bring his grandmother to America for a visit. His pre-teen son had met her only twice in his life (via trips to Istanbul) but they corresponded frequently and had a very close bond. My friend said he wanted to surprise his son by having his grandma at home when he came back from school on his 14th birthday. The only hesitation, my friend said, was that his mom didn’t speak any English and he was worried that she might get lost during an airplane transfer or in the airport. He worried that she would be afraid and alone.
Being in a foreign country where you don’t speak the language can be a frightening experience. When I was a teenager, I flew to Zaragoza, Spain to visit a friend of my mother’s. I felt excited at take off from the US, but as the plane approached the unfamiliar red soil of our destination, a sense of uneasiness settled in. The flight attendants started messaging in Spanish, and as we touched down I knew that I wasn’t home anymore. All I knew how to say was “hola.”
As I made my way through the airport, all the signs were in Spanish, I knew I needed to get a cab, but I wasn’t sure where to wait – and the Spaniards didn’t seem to respect queues. Once I fought my way to the front of a gaggle of natives, I realized that the cab driver needed to ask me clarifying questions about my friend’s address. I responded in English, to which he repeated his question with increased volume. I felt really stupid and quite helpless.
My experience was kind of similar to the feeling that patients have when they are thrust into a medical situation with a sudden, life threatening illness. Healthcare professionals can forget how foreign everything is to the patient, and go about their activities without explanation, or with jargon-rich “medicalese” that is virtually inscrutable to the person with the illness. When questioned, they repeat the jargon, raising their voice for emphasis and “clarity.”
Hospitals spend lots of money on translator services for foreign languages, but many healthcare professionals forget that medicine itself is a kind of unique language that requires translation. As the consumer driven healthcare movement takes wing, it will be more and more important to provide a kind of translator service for those who need to make educated decisions about their medical options. The accuracy of the translation can be a matter of life or death, and so healthcare consumers need to be very selective in where they get their information. Considering the source of your information has never been more important. Don’t let your health be lost in translation.
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
February 25th, 2007 by Dr. Val Jones in Opinion
Tags: Finance, Health Policy, News
1 Comment »
There is an old question still sparking debate in the blogosphere (see Kevin MD’s links): is health care a right or a privilege? I think it’s worthwhile to consider both sides of the argument, as one’s position on this issue actually provides the foundation for how one proposes to “fix” this broken health care system.
I have searched the Internet for some of the best quotes on the subject (and I’m sure I have missed most of them) to frame the debate. Today’s post is devoted to the “health care is NOT a right” position. My next post will provide quotes from the “health care IS a right” camp. I hope that you will provide your own views pro or con as comments.
Mr. Robinson wonders if (based on the US Constitution) one can classify health care as a “right:”
By definition, rights can not extend past the boundaries of one’s own person. One can not, for instance, exercise one’s right to free speech by demanding that one’s neighbor cease speaking, for by doing so, one would deny the neighbor’s right to free speech. Given that healthcare, for the most part, is the product of someone else’s knowledge, labor, capital, and equipment, it is not within the boundaries on one’s own person. Healthcare can not be a right because it makes demands on other people.
This analogy by Dr. Peikoff sheds some light on what would happen if healthcare were treated as “a right” by the government:
Take the simplest case: you are born with a moral right to hair care, let us say, provided by a loving government free of charge to all who want or need it. What would happen under such a moral theory?
Haircuts are free, like the air we breathe, so some people show up every day for an expensive new styling, the government pays out more and more, barbers revel in their huge new incomes, and the profession starts to grow ravenously, bald men start to come in droves for free hair implantations, a school of fancy, specialized eyebrow pluckers develops — it’s all free, the government pays. The dishonest barbers are having a field day, of course — but so are the honest ones; they are working and spending like mad, trying to give every customer his heart’s desire, which is a millionaire’s worth of special hair care and services — the government starts to scream, the budget is out of control. Suddenly directives erupt: we must limit the number of barbers, we must limit the time spent on haircuts, we must limit the permissible type of hair styles; bureaucrats begin to split hairs about how many hairs a barber should be allowed to split. A new computerized office of records filled with inspectors and red tape shoots up; some barbers, it seems, are still getting too rich, they must be getting more than their fair share of the national hair, so barbers have to start applying for Certificates of Need in order to buy razors, while peer review boards are established to assess every stylist’s work, both the dishonest and the overly honest alike, to make sure that no one is too bad or too good or too busy or too unbusy. Etc. In the end, there are lines of wretched customers waiting for their chance to be routinely scalped by bored, hog-tied haircutters some of whom remember dreamily the old days when somehow everything was so much better.
This attorney wonders where the “rights” begin and end in the health care environment:
If we speak of a right to healthcare, we need to ask: What kind of healthcare? Perfectly healthy people seek healthcare simply to confirm that they are healthy. Some people seek treatments—vaccines, nutritional and hormonal supplements, surgery to eliminate genetic cancer risks—as preventive measures in order to preserve their health. Some people seek healthcare for conditions that others would not, such as minor colds, common balding, or sports performance enhancement. Few of us would be willing to recognize, or finance, a “right” to whatever kind of healthcare a person might think desirable.
A physician gives an example of what can happen when consumers demand their “rights” to health care:
“Doctor, this guy states he has a bleeding brain tumor and wants a CT scan of his head,” the emergency department registration clerk announced as I entered his room. He looked me in the eye and intoned, ” I want a CT scan of my brain. I have a bleeding brain tumor.” “Do you have a headache, neck stiffness, loss of strength?” “No,” he responded. I proceeded to examine and finding no neurological deficit I inquired why he thought a CT scan was needed. He informed me that a relative had suggested that the numbness he felt in his scalp might have been a sign of a tumor. He was furious when I told him a CT scan was unnecessary and indignantly took my name to make a complaint to the administrator. I had denied him his right.
A patient continues the refrain:
What’s so special about health care? Why not rights to higher education, job training, clothing, computers, child care, cars, etc.? There are a lot of things that will improve a society if everyone had them. This doesn’t mean that we should establish positive rights to provide all these things for those who can’t afford them. We need to keep incentives in place (and perhaps provide education) to encourage people to spend and save their money wisely and to nurture a solid work ethic. Encouraging people to help themselves seems to be a solution for the long-term, not trying to get everyone else to buy the necessities for them.
Do you think that health care is a right?
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
February 23rd, 2007 by Dr. Val Jones in Opinion
Tags: Family Medicine, Internal Medicine, News, Research, Technology
2 Comments »
I’ve been thinking a lot lately about the plight of family physicians – reimbursal for their services continues to decline, overhead steadily increases, and pressure to see a minimum of 30 patients a day can drive them to near despair. Family physicians want to provide quality care for their patients, but are exhausted by volume demands and paperwork.
If you missed this article about the primary care crisis in America in the New England Journal of Medicine, it’s an excellent read. Here are some excerpts:
Excessive demands contribute to long waiting times and inadequate quality of care for patients. A growing proportion of patients report that they cannot schedule timely appointments with their physician. Emergency departments are overflowing with patients who do not have access to primary care. The majority of patients with diabetes, hypertension, and other chronic conditions do not receive adequate clinical care, partly because half of all patients leave their office visits without having understood what the physician said.
These problems are exacerbated by the system of physician payment. Thirty minutes spent performing a diagnostic, surgical, or imaging procedure often pays three times as much as a 30-minute visit with a patient with diabetes, heart failure, headache, and depression…
These factors add up to an unsurprising result: fewer U.S. medical students are choosing careers in primary care. Between 1997 and 2005, the number of U.S. graduates entering family practice residencies dropped by 50 percent…
Who might support a national policy to rescue primary care? Employers and insurers, public and private, may reap a return on investment by fostering a more effective primary care sector that will reduce health care costs… Whoever takes up the cause of primary care, one thing is clear: action is needed to calm the brewing storm before the levees break.
A recent article in the Wall Street Journal sent ripples through the blogosphere. It was about how a few family physicians found a way to drastically reduce overhead – by being a solo practitioner and using technology to replace office staff and automate billing as much as possible.
Drs. Charlie Smith and Joe Scherger are family physicians here at Revolution Health who are leading the charge towards high tech solutions for family physicians. Charlie explains his philosophy in his recent blog post:
Having practiced primary care for over 30 years, I’m convinced the model of receiving in office care for every problem is not working well. I really like the ideas espoused by Don Berwick in changing the model of care in the doctor’s office to that of seeing patients in groups, treating them by phone or by e mail, rather than in the office. Using phone calls or e mails to sort through the patient issues, the doctor can decide to see the ones who really need to come into the office and the others can be taken care of without an office visit. This is a MUCH more efficient method, allows you to take care of many more people that need care, and gets people the care when they need it, rather than forcing them to wait until they can fit into a slot in your office.
The ideal way to partner with your doctor to use the health care system in the most effective way possible is to call or e mail him whenever possible, use the internet to research all of your health conditions, and only go into the office when you require in office care, such as exams, procedures, lab tests or x rays. Become an e patient!
I personally believe that Revolution Health can substantially improve the life of family physicians through innovative technologies designed to automate their practices as much as possible (thus reducing overhead and time spent on paperwork), as well as educating patients about the management of their diseases and conditions, (thus improving outcomes and increasing pay for performance bonuses), and triaging low acuity issues through online physician emailing services and retail clinics (thus helping patients receive the care they need without excessive use of office time).
Who will take up the cause of primary care (asks the NEJM)? Revolution Health will. Let’s work together to improve the quality of life for physicians and patients alike.
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
February 18th, 2007 by Dr. Val Jones in Opinion
Tags: Hospitals, News, Parenting, Technology
5 Comments »
In a happy coincidence, my favorite blog fodder feeder sent me a link to an article about Kaiser Permanente’s electronic medical record woes a day prior to Dr. Feld’s latest post on the subject of EMRs. Dr. Feld’s thoughts on the matter will certainly help to round out this discussion.
I’ve always been fascinated by technologies that are ahead of the curve. I blame this on my parents (take note – parents can be blamed for good things). Growing up in rural Canada our family was ahead of the tech curve – we had a satellite dish before there was scrambling, we had the very first Apple computers at home, and we built our own yogurt factory complete with an advanced digitally automated temperature gauge system, before the rest of the industry had moved beyond millimeters of mercury.
In college I was the first kid with a laptop in class, and in med school I was one of the first with a PDA. I took a portable printer with me to Europe in the late 80’s to go along with my Wordstar word processing program. I thought I was pretty cool, I guess! Stirrup pants, granny boots, permed hair and pink lip gloss. Those were the days.
Cliff Bassett recently asked me why I was working at a new company (Revolution Health) that was so cutting edge rather than remaining in clinical practice. I had never thought about why I did it before – but now I see that it was part of my pioneering pattern. There’s nothing more fun than being ahead of the curve… but it can be aggravating as well.
Technologies are awkward for their first adopters – they aren’t streamlined, they can actually take more time rather than saving it, and they can make communications with others (who don’t use it yet) more difficult. But a few of us do it anyway – we jump in head first, believing by faith that the enterprise itself is worthwhile and that once we get to version 3.0 we’ll be sitting pretty.
But what do we do when we’re at version 1.0? Normally, we just tear our hair out and send lots of “bug alert” messages to developers. But when the technology affects someone’s health, the bugs are a lot more sinister. The recent article about Kaiser Permanente’s digital growing pains is disturbing indeed:
Kaiser Permanente’s $4-billion effort to computerize the medical records of its 8.6 million members has encountered repeated technical problems, leading to potentially dangerous incidents such as patients listed in the wrong beds, according to Kaiser documents and current and former employees… Other problems have included malfunctioning bedside scanners meant to ensure that patients receive the correct medication, according to Kaiser staff.
Still, 90% of physicians use paper records, making it difficult to share information – and this is no doubt contributing to the IOM’s estimated 98,000 error related deaths/year. Dr. Feld explains the complexity of a fully functional electronic medical record:
However, a paperless chart is in reality worth little unless the information entered is usable in a relational data base format rather than word processing format. Only then, can patient care be enhanced…An effective Electronic Health Record must consist of five components
Electronic Medical Records
Personal health records (PHR)
Continuity of Care Record (CCR)
Electronic health record (EHR)
Financial Management Record (read more…)
So, the bottom line is that the EMR is in version 1.0 at Kaiser Permanente, and only a twinkle in our government’s eye. It is complicated to create, nearly impossible to coordinate, dangerous if implemented half-way, and yet utterly necessary for ultimate cost savings and patient safety.
What can we do between version 1.0 and 3.0? Prayer and vigilance come to mind… it will be up to the foot soldiers (the docs, nurses, and hospital staff) to keep patients safe while juggling paper and digital until digital can fly on its own.
How do you think we can minimize our digital growing pains?
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
February 17th, 2007 by Dr. Val Jones in Health Policy, Opinion
Tags: Cancer, Health Policy, Medicare, Politics
5 Comments »
Within the past few years the Centers for Medicare and Medicaid Services (CMS) chose to enforce a rule (casually known as the “75% rule”) that resulted in denial of services to many heart, lung, and cancer patients requiring rehabilitation therapies.
CMS was looking for a way to cut costs in rehabilitation facilities, and decided to create a rule whereby these facilities would lose their approval status if they admitted too many patients with certain conditions. The CMS arbitrarily decided that 75% of all patients admitted to inpatient rehabilitation facilities had to have one of 13 diagnoses, or else the rehab facility would not qualify for Medicare reimbursement. Many important diagnoses were not included in those 13, including cancer, heart and lung disease, and many types of orthopedic injuries.
What does this mean? It means that getting admitted to a rehabilitation facility is no longer based on need, but on diagnosis code. Because of the financial pressure exerted by CMS (Medicare is the primary payer for most facilities) these rehab centers cannot afford to be delisted. So they turn away patients in need, for patients who have the “right” diagnosis.
What has this rule done?
- Limited clinical decision making by doctors – a physician is no longer able to recommend patients for acute inpatient rehabilitation purely based on their need for it.
- Decreased choice for consumers – people recovering from heart attacks, cancer or COPD (to name a few) will generally not be offered the opportunity to be rehabilitated in an acute, inpatient setting.
- Reduced quality of care – rehabilitation facilities specializing in oncology or cardiopulmonary rehab will need to divest themselves of aggregated expertise. Since these centers would no longer qualify for Medicare funding, they can’t afford to remain centers of excellence in these fields of medicine. Instead, they will need to turn their attention to the 13 diagnoses that qualify for inpatient rehabilitation.
- Puts lives in danger – patients who are not admitted to acute rehab will be forced to recover in nursing homes (also known as “sub acute facilities”) that do not have the level of expertise to take care of them safely.
The 75% rule is one example of the kinds of decisions that a government sponsored universal healthcare system will make. When one payer (government or non-government) develops a monopoly, their decisions can single-handedly limit consumer choice, prevent physicians from exercising clinical judgment, and decrease quality and safety of care. What will Americans say when the decision to fund organ transplants for people over 65, for example, is denied across the board?
When medicine is no longer applied in a personalized (case by case) manner, and population-wide rules are in effect, we will face ethical dilemmas far surpassing those we already have. A system that serves the needs of many still fails the needs of some – and when we lose the flexibility to “bend the rules” for the exceptions we will lose the best of what American medicine has to offer.
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
