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Latest Posts

A Doctor Seeks An Electronic Record For Her Health

Over the weekend I developed another bout of diverticulitis. Did the usual: fluids, antibiotics, rest, avoided going to the ER, cancelled travel plans.

One of my doctors asked a very simple question: is this happening more frequently? The answer, we both knew, was yes. But I don’t have a Personal Health Record (PHR) that in principle, through a few clicks, would give a time-frame graph of the bouts and severity of the episodes over the past several years.

The last time this happened, and the time before that, I thought I’d finally start a PHR. Like most compulsive patients, I keep records about my health. In the folder in my closet in a cheap old-fashioned filing box, the kind with a handled top that flips open, I’ve got an EKG from 15 years ago, an Read more »

*This blog post was originally published at Medical Lessons*

All Patients Are Empowered: And Other Myths About The E-Patient

Irrational exuberance was a term once used to describe the stock market before the last crash.  It also seems an apt description for much of the talk these days about empowered health consumers.

To be sure, patients today have unprecedented access to health information.  Patient decision-support tool can be found on just about every provider, payer and self-insured employer website.  Consumers can go to any number of websites to find quality data about hospitals, physicians and health plans.  Personal health records (PHRs) promise to make our personal health data portable for meaning that all our treating physicians will be “singing off the same song sheet.”

That’s what the industry experts tell us.  But what’s really going on?  Here I will describe what I see as the top 5 myths about empowered health consumers. Read more »

*This blog post was originally published at Mind The Gap*

Will Low Income Americans Use Personal Health Records?

The Society for Participatory Medicine was well represented last week at the 14th  ICSI/IHI Colloquium. (ICSI is the Institute for Clinical Systems Improvement, a small midwestern think tank that’s way too poorly known.) SPM members who presented:

  • Jane Sarasohn-Kahn of Health Populi gave the keynote for Day 2
  • Jessie Gruman, four time cancer patient and founding co-editor of our journal, gave an important breakout session, about which I’ll be writing soon. (Jessie is founder and president of the excellent Center For Advancing Health.)
  • Brian Ahier presented on the status of health IT, as Meaningful Use rolls out. (“You can’t measure the improvements that you gotta measure, unless you have computers keeping track of it.”)
  • I gave a half-day pre-conference workshop titled “Participatory Health: Reshaping Patient Care.” I’m told the workshop had 40-50% higher registration than usual: interest in participatory medicine is strong.

An unexpected bonus was that right outside the workshop door, a poster presentation addressed some questions people often ask about patient participation and online health records:

  • Will patients with problems actually use a PHR (personal health record)? (Many observers say PHRs are a non-starter, a pointless exercise.) Read more »

*This blog post was originally published at e-Patients.net*

Medical Information Shared Machine-To-Machine

Check out John Halamka’s post on some of the excellent work one of the workgroups convened by the feds is doing. Here’s the complete quote:

Imagine if every EHR could send data to every other EHR using a simple addressing mechanism like email, a consistent REST implementation or a well described SOAP WSDL. Interoperability would follow rapidly because novel packages of data will be sent to support real business needs without any barriers of how to get the data from endpoint to endpoint.

The “addressing” part of the NHIN (Nationwide Health Information Network) Direct specifications is almost complete. The “implementation” workgroup is part of the fast moving NHIN Direct project which is developing lightweight standards for machine-to-machine communication of medical information. Read more »

*This blog post was originally published at a few thoughts from a tumor surgeon*

Personal Health Record Service: Who Does It Best?

A personal health record (PHR) has been touted as a way for patients to better keep track of their health information. Google Health and Microsoft HealthVault lead the way. But what happens if the company storing your data gets bought, goes bankrupt, or simply decides to discontinue their system?

Well, those who stored their data with Revolution Health are finding out first hand. The troubled company, which started off with so much fanfare yet died in a whimper, recently announced they’re shutting down their personal health record service. According to American Medical News: “Industry insiders say Revolution joins a long list of vendors who launched PHRs with a big splash, only to find little interest from consumers.”

Most of my patients don’t use a personal health record, and prefer that I enter the data in myself, or export it from from my electronic record system. The problem is: a) there isn’t enough time in a 15-minute patient visit to help patients enter in their data (apart from what I already do in my own system), and b) many online personal health record sites aren’t compatible with the systems doctors are using.

Leaving the data entry to the patient is inefficient, and a sure way to minimize the adoption rate. Indeed, “the most successful PHR-type systems have been created by healthcare organizations and have benefits to patients, such as e-mailing with physicians, online appointment scheduling and the ability to look at information entered by their physicians.”

That means a successful personal health records have to be well-integrated with or designed by existing hospital and physician systems, making it harder for a third-party system, such as the defunct Revolution Health service, to gain traction.

*This blog post was originally published at KevinMD.com*

Latest Interviews

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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How To Make Inpatient Medical Practice Fun Again: Try Locum Tenens Work

It s no secret that most physicians are unhappy with the way things are going in healthcare. Surveys report high levels of job dissatisfaction burn out and even suicide. In fact some believe that up to a third of the US physician work force is planning to leave the profession…

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Latest Cartoon

Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.

***

Click here for a musical take on over-testing.

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Latest Book Reviews

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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Unaccountable: A Book About The Underbelly Of Hospital Care

I met Dr. Marty Makary over lunch at Founding Farmers restaurant in DC about three years ago. We had an animated conversation about hospital safety the potential contribution of checklists to reducing medical errors and his upcoming book about the need for more transparency in the healthcare system. Marty was…

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