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Advancing Medical Progress With Case Studies While Maintaining HIPAA Compliance

It was an interesting tweet that referenced a soon-to-be-published case report from the Annals of Emergency Medicine (via @EmergencyDocs) that piqued my interest:

Thrilling case study: emergency doc cracked chest to save 42 y/o woman in cardiac tamponade after ablation therapy.

Details about the case are quite specific and the case report heralds from a town in Minnesota. It describes, in very specific detail, the management of a patient who presented to the emergency room in shock from cardiac tamponade after a catheter ablation procedure for right ventricular outflow tract tachycardia.

Is this unique case report HIPAA compliant?

I would say, according to our current definition of HIPAA’s “personal health information,” such a case report is Read more »

*This blog post was originally published at Dr. Wes*

Research Provides Further Justification For Women To Avoid Smoking

Women who smoke begin menopause a year earlier than nonsmokers, researchers concluded, adding that earlier menopause is associated with osteoporosis and heart disease.

Researchers conducted a meta-analysis of the available data about smoking and menopause, finding 11 studies comprising about 50,000 women, using age 50 as a threshold for early or late age at natural menopause (ANM). Results appeared in Menopause.

In five studies, participants were classified as Read more »

*This blog post was originally published at ACP Internist*

Interesting Neuro Case Requires ER Doc To Recall Forgotten Med School Knowledge

Yesterday, I presented the case of a woman with double vision and ptosis and challenged you all to a game of “spot the lesion.” To be honest, I found this stuff impenetrable as a medical student and it was only by sheer force of will that I was able to commit it to memory for exactly long enough to pass a test on it before immediately purging it from my memory. I did this several times for various board exams and such, but it never really “stuck.” Hated neuro beyond words, I did.

As mind-numbing as I found it all in the abstract, I get excited about these cases in application. I may not remember where exactly the internal capsule is or what it does, but when I see someone with an interesting neuro deficit due to a lesion there, all of a sudden it makes so much more sense, and is, dare I say it, cool. I know, kinda sad.

This case is as classic (and cool) as you will ever see. It’s a complete palsy of the Oculomotor Nerve (CN 3 for those keeping score at home).

So how do you approach figuring that out? Read more »

*This blog post was originally published at Movin' Meat*

Case Report: A Craniopharyngioma In The Prepontine Cistern

We report a pathologically proved craniopharyngioma in the prepontine cistern. A 50-year-old woman presented with swallowing difficulty for 1 month. She underwent brain MR and CT imaging.

T1-weighted, T2-weighted, and contrast-enhanced T1-weighted images showed a large peripheral enhancing cystic mass in the prepontine cistern. Inside the lesion, high signal intensity (SI) on T1 and low SI on T2-weighted imaging were noted (Fig 1). The CT scan showed features similar to those on the MR images, except for the addition of a peripheral small calcification in the cystic lesion. We could not find any connection between the mass in the prepontine cistern and the sellar or parasellar area. The mass was partially surgically removed, and histopathologic examination revealed craniopharyngioma in the prepontine cistern.

  • Figure 1
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  • Fig 1. A 50-year-old woman with a craniopharyngioma in the prepontine cistern. A, Sagittal T1-weighted image shows a cystic mass in the prepontine cistern. B, Contrast-enhanced T1-weighted sagittal image shows a peripheral enhancing cystic mass in the prepontine cistern. Read more »

*This blog post was originally published at AJNR Blog*

Patient Participation In EMRs Can Improve Efficiency

Our office has been on Electronic Medical Records (EMR) for nearly thirteen years.  We see a high volume of patients, keep our overhead down, and are able to be quite successful financially.  All of the “EMR is impossible” and “EMR makes things worse” stuff you read around the web are disproved quickly with a step into our office.  We implemented EMR successfully in a private practice setting without help from an economic stimulus, a hospital system, or a magic wand.

Not that it was easy; we went through many years of struggle to get to where we are today.  We struggled mainly because we were exploring unknown territory.  We had very few other successful EMR implementations to learn from.  We used slow computers and programming developed in the pre-Internet era.  We made huge mistakes and struggled at times to make our monthly budget.

But we did it, and practices implementing now can learn from my and others’ success.  Probably the main lesson we learned is to put office function ahead of implementation.  Since we are a business, we must stay profitable while implementing.  Since we are practicing medicine, we must never compromise quality in the process.  This meant that we implemented over time, focusing on parts that would either improve our process or at least not bring us down.

Now we are at the position I thought might never come: survival is no longer in question, so we can dream.  We don’t have to act defensively, we can push the envelope.  We can afford to ask the question: “How can we build the best medical experience for our patients?”  We can imagine a destination and actually attempt to get there.

The ideal destination is one in which our patients’ care is improved by maximizing efficiency on our end.  Obviously I don’t want to make things harder for our practice, I want to make things easier.  But the goal of care is ultimately centered on the patient, not us.  So is there a way to accomplish both goals?  I think there is, and I think that our EMR is the tool that makes it possible.

Here are our goals in the process:

  • Simplify how things are done
  • Always have the right information available
  • Make communication clear and easy
  • Achieve the highest quality possible

I’m sure some think this is just idealism and can’t happen in reality.  I agree and disagree.  No system can be perfect, but the current healthcare system is so inefficient and ineffective that huge gains can be made.  The best way to show that is to get down to specifics.  Here is where our practice is heading:


The thing that takes the most time away from actual patient care is documentation.  Doctors are paid by the volume of documentation, not its quality.  Still, the main purpose of a record is to accurately know what is going on with the person facing you in the exam room.  Unfortunately, the patient is continually changing, so some information is only accurate for a short time.  Has the patient seen a specialist or been in the hospital?  Have the medications been changed, or just not taken?  Have they changed jobs, quit smoking, or gotten married?  Did their sister just get diagnosed with cancer?  The task of keeping this information up to date is extremely difficult.

Patients are the ones who know these things best, but they are only passive participants in the process.  To keep the record accurate, I must ask them all the right questions on a regular basis.  This cuts into time that should be devoted to care.  So why can’t the patients be allowed to maintain this part of the record?  Why shouldn’t they have access to parts of their record and the ability to correct errors?  Here is how we see this happening:

  • Certain parts of the record should be available for patients to review online.  Basic demographics, medications and allergies, family history, and lifestyle information is a good start.  If something new has happened, the patient can either update this information directly (like marital or smoking status) or notify the office of changes (like medication lists).
  • If the patient doesn’t update it online, then they can do so when they come into the office (while sitting in the waiting room).  Some people will undoubtedly not want to do this, but a significant percent will, decreasing the workload on the office while maximizing the quality of information.
  • Patients should be able to communicate important information to the office online.  If they go to the ER or see a specialist, if their blood pressure or sugars are high, they should be able to send that information directly to the physician.

Another area of potential gain is the gathering of information for a visit.  When a person comes to the office, they have to answer a series of questions related to the visit:

  • what are the symptoms the are having?
  • Are there any other symptoms?
  • How have they been since the last visit?

Gathering this information is essential, but it is one of the main causes of delays.  Here is how we want to employ technology to improve this process:

  • Put kiosks in our waiting room where patients can provide information, such as:
    • History of their present illness.  If they are sick, then what are the symptoms and how long have they gone on?
    • Review of systems.  What other things are going on in their health?
    • Medication and demographic review (if not done already online).
  • If patients fill out information online before coming to the office, the staff will bring them to see the doctor immediately (or at least as soon as possible).

Even 50% participation by patients in this process will have a huge impact on our office workflow.  The end result is a win-win: the patient is seen sooner, the information is more accurate, and the workload of the staff is reduced.  Will there be problems?  There always are; but the advent of ATM machines, airport kiosks, and online shopping are a few examples of process automation that have greatly improved the customer experience.  Why should medicine be different?

I am going to stop here, as I don’t want to lose you (if you haven’t already whacked the keyboard with your forehead).  Hopefully you can see that the use of technology applied smartly can help patients and medical offices at the same time.

And this is just the start.

**This post was published originally at Musings of a Distractible Mind blog.**

Latest Interviews

IDEA Labs: Medical Students Take The Lead In Healthcare Innovation

It’s no secret that doctors are disappointed with the way that the U.S. healthcare system is evolving. Most feel helpless about improving their work conditions or solving technical problems in patient care. Fortunately one young medical student was undeterred by the mountain of disappointment carried by his senior clinician mentors…

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How To Be A Successful Patient: Young Doctors Offer Some Advice

I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…

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Latest Book Reviews

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The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

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Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

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