April 17th, 2009 by John Briley in Expert Interviews, Uncategorized
Tags: Cleveland Cavaliers, Fitness, John Briley, Lebron James, NBA, Physical Medicine And Rehabilitation
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Midway through the third quarter of an April 2 NBA game between the Cleveland Cavaliers and Washington Wizards, a Cleveland guard tossed a lob pass toward the rim. Most of us sitting in the Verizon Center, in downtown Washington, D.C., had an idea what was about to happen.
Lebron James, the 24-year-old heir apparent to the NBA’s Best Ever moniker, elevated from the left baseline, caught the pass and, as he floated through the lane like a bird on wing, dunked the ball behind his head. The crowd roared its appreciation and even some of the Wizards’ players nodded in approval.
But the theatrical dunk, which came at a point when Cleveland was trailing by double digits, was one of only a small handful of highlights James – the leading candidate for league MVP for the 2008-2009 NBA season – had produced to that point in the contest.
He spent a good portion of his on-court minutes on the periphery, loping up and down the court with little urgency, distributing passes and setting an occasional pick but otherwise leaving the driving and scoring burden to his teammates.
The Wizards held on to win, despite a late flourish by James that left him with 31 “quiet” points.
The outcome hardly mattered: The Wizards were nearing a merciful end to a season that tied the franchise’s worst-ever record. The Cavaliers had all but wrapped up the top seed in the Eastern Conference for the playoffs.
Loafing or saving energy?
But from a health perspective, the on/off performance of James raised a question: How is it that NBA players – and many other professional athletes – are able to switch gears so readily and (seemingly) with few physical repercussions? How can someone go “half speed” without risking injury and still appear competitive on a court with some of the world’s best athletes?
I posed this question to Nick DeNubile, MD, who served as an orthopedic consultant to the Philadelphia 76ers for more than 10 years, and is author of Framework: Your 7-Step Program for Healthy Muscles, Bones and Joints (Rodale Books, 2005).
DeNubile made an important distinction between going half-speed and being tentative. If you’re tentative – in any sport at any time – that’s when you risk injury.
“You need to be relaxed,” DeNubile said, to ensure that all of your faculties are there when you need them (for example, to leap to the rafters of an arena and throw down a reverse dunk). But “relaxed” doesn’t mean you’re not ready to go full speed on a moment’s notice. It’s similar to the difference between a cat stalking prey (relaxed but alert and focused, ready to strike) and a skier standing atop a cliff, doubting that he can navigate the leap (frightened and tense, and becoming increasingly less focused). Skilled athletes can go partial speed and still stay relaxed, DeNubile notes.
But this doesn’t apply to all sports. Diving, for example, or pitching a baseball require a focused anaerobic punch that would be very difficult to perform lackadaisically.
Why players hold back
For NBA players, the decision to occasionally temper their effort is not always bad.
“Recovery is so important for the players [and] metabolic recovery can vary from athlete to athlete,” DeNubile said.
“A lot of players come into the season three-quarters fit and use the season to get in shape for the playoffs. You’re better off if you come into the season fit,” but in an 82-game season even some of the fittest players have low-intensity nights. They may do it for selfish reasons – a contract dispute, for example. But in most cases they do it because they have to keep some reserves in the tank to stay competitive throughout a season that, for playoff teams, can span almost three-quarters of the year.
DeNubile recalled the 2001 NBA Finals, when his 76ers faced the Los Angeles Lakers.
“When we went to finals some players were dangerously over-trained,” he explained. “We did blood work [on the team] and you could see the guys who were on the brink. When you push too hard the body can start to break down. It’s the reverse effect” of training well.
DeNubile didn’t name players who were over-trained but he did cite Allen Iverson as one player who rarely gives reduced effort. “Every game of the year he’s giving 100 percent, 150 percent, diving for loose balls, playing as hard as he can,” DeNubile said. “That guy is incredible. He just doesn’t have an off switch.”
Somehow Iverson has stayed competitive for 12 (and counting) NBA seasons, defying predictions from many analysts that his all-out, physical style of play would result in a truncated career.
Are you over training?
Most of us will never play professional sports. But that doesn’t mean we can’t learn from those who do.
While the great majority of Americans is in no danger of over training (see: obesity epidemic, 21st century), some of us become addicted to strenuous exercise and tend to push ourselves harder than we should. One easy marker to check for over-training is your resting heart rate. Check it in the morning, right after you wake up, DeNubile says. (If you fear you are already over-trained, take a week off and see if that morning heart rate drops by 10 to 15 percent; if yes, you were likely over-training.)
Most are NBA players are incredibly fit and have resting heart rates around 60 beats-per-minute.
“When you see it start to bump up 10 beats per minute, that’s one of the signs over overtraining,” he says. “Or if a player says he’s getting a good night’s sleep but is still feeling tired.”
This made me wonder how much fuel NBA players burn during a game.
Interestingly, they’re burning about the same number of calories – 10 to 12 calories per minute – as you or I would during vigorous exercise. But because they are so fit their bodies use available energy stores much more efficiently than would a less-fit body, and thus they can accomplish more physically with less energy.
But DeNubile says that doesn’t make NBA players immune to basic exercise risks. “It can get dangerous when you’re tank starts to get low. People who sweat big can get dehydrated. You’ll see a player come off [the court] and he’s not happy about how he was playing or whatever and the trainer will offer him water or Gatorade and he’ll wave it off. That always worries me.”
These guys need to replenish lost fluid just like the rest of us. It’s nice to know we have at least that in common.
April 8th, 2009 by Dr. Val Jones in Expert Interviews
Tags: Disability, Disability Benefits, Disabled, Martin Prahl, Nationwide Health Information Network, NHIN, Social Security Administration, SSA
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Marty Prahl is the lead contracted health IT architect at the Social Security Administration (SSA). His personal experiences have led him to become a passionate advocate for digital data sharing. Several years ago one of his uninsured relatives was diagnosed with a devastating disease. She applied for disability benefits through the SSA but the process took over a year for her approval. During that year her medical condition caused her to lose her job, and she had no means by which to pay her soaring medical bills. The bank repossessed her home, her husband left her, and she had to move in with Marty’s family. As they waited for her disability benefits to be approved, Marty tried to make payment on her bills, which put enormous financial stress on his family.
Living through this nightmare galvanized Marty into action – he decided to devote his IT career to speeding up and streamlining the disability determination process. Thanks to Marty’s work, and the many people who created the Nationwide Health Information Network (NHIN), the SSA is now participating in an electronic medical record and data sharing network. This means that transfer of the records required to make an individual disability determination (if everyone sending data to the SSA is part of NHIN) can occur in under a minute. If the information supports the disability claim, an approval could be made within 1-2 days.
Prior to becoming part of the NHIN network, the SSA had no choice but to receive information by fax and paper. In order to make a disability determination, all medical records (from all healthcare professionals involved in the patient’s are) had to be gathered and analyzed by hand. If a doctor’s office didn’t send in the patient’s medical record in a timely manner, then the process would halt. Of course, compensation for sending records to the SSA didn’t generally cover the cost of doing so for the doctor, so the financial incentive to get the documents in was low. It’s no surprise that this resulted in wait times of 3 months to 2 years.
But some people simply can’t afford to wait – disability determinations are the gateway to Medicare and Medicaid funding, and there are other programs available for those who don’t qualify for Medicare and Medicaid. But those programs cannot be accessed until an official disability determination is made by the SSA. There are approximately 3 million new disability claimants annually in the United States – and without electronic data sharing, those people will have to wait for the paper process to run its course.
However, early adopters like MedVirginia, in Richmond, VA are already members of NHIN and can easily share medical records with the SSA. If more hospital systems and providers joined the network, disabled patients would gain rapid access to much needed government insurance benefits, and hospitals would no longer be offering them potentially bankruptcy-inducing “charity care” while they wait for a determination from SSA.
So what should Americans do about this? Spread the word about NHIN, and ask your hospitals to join the network. The software is free and available online (the CONNECT “open-source” code is here). As for me, I guess I hope that if I’m ever in a terrible car accident I’ll be taken to a NHIN participating hospital. A couple of days seems like a much better wait time than 2 years for disability benefits. I think Marty would agree.
April 7th, 2009 by Dr. Val Jones in Expert Interviews
Tags: Cisco, Cisco Nurse Connect, Cisco Nurse Connect Solution, Cisco Systems Inc., Communications, Dr. Val Jones, Focus Group, HIMSS, HIMSS09, Hospitals, Network, Nurse Connect, Nurses, Phone, Technology
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Network technology giant Cisco Systems, Inc. invited nurses to offer focus group feedback on a recent study that showed that 92% of nurses believe that communications lapses adversely affect patient safety. I joined five nurses in a cozy break out room at the HIMSS convention center and asked about their real-life experience with communications lapses in the hospital. Here are the highlights:
1. Technology Isn’t Perfect – although some hospitals have instituted bar code scanners and wireless computers to help to reduce errors, these devices often drop their connections. One nurse said that the devices actually slow down the process of distributing medications, and bypassing the system simply results in a loss of automated medication cross-checking. The devices don’t perform well in the case of an electrical surge, and nurses often waste time finding computers on wheels (affectionately known as “COWs”) that have a full battery.
2. Where’s The Patient? – the group of nurses all agreed that poor coordination of care inside the hospital can harm patients. Some nurses expressed frustration at having proceduralists and radiology teams remove the patients from their rooms without scheduling it with the nurses. They explained that nurses give out medications at specific times, and when the patients are taken to another part of the hospital without their knowledge, then they can’t plan to give them their medications appropriately. Missed doses or missed meals (for patients with diabetes for example) can result in dangerous hypoglycemic episodes, syncope, and various other harms.
3. Where’s The Pharmacist? – easy access to hospital pharmacists is critical for all clinical staff. One nurse relayed the shocking story of a med tech who was unable to get in touch with a hospital pharmacist to confirm I.V. zinc dosing in the NICU, and gave such an overdose that one of the premature babies died.
4. Where’s The Doctor? -during an audience poll at the Cisco booth, most nurses rated physicians as the hardest staff to get a hold of in the hospital setting. There is regular confusion about who’s on call, and there is often no direct line to call the physicians.
5. Where Are The Nurses Aides? – when it comes time to transfer patients (who are often very heavy) or move them in bed, nurses often have no way of finding peers to help them lift the patients safely. This results in wasted time searching for staff to assist, or even worse, can result in low back injury to the staff or patient falls.
6. Language Barriers – when patients are transitioned home from the hospital, they are often given complex instructions for self-care. These instructions are particularly hard to follow for patients whose native tongue is not English. Nurses see many re-admissions based on language-based miscommunications.
7. Decision Support Systems – one of the nurses suggested that a recent study showed that the number one source of clinical information for nurses was their peers. That means that nurses turn to other nurses for educational needs more often than they turn to a textbook or peer-reviewed source of information. Nurses would like to have better access to point-of-care decision support tools for their own educational benefit and the safety of patients.
8. Change of Shift – nurses identified shift changes as a primary source of communication errors. Technology that enables medication reconciliation is critical to safe continuation of inpatient treatment. One nurses said: “shift changes is when all the codes happen.”
And so I asked the nurses what their ideal technology would do for them to help address some of the communications problems that they’re currently having. This is what they’d like their technology to do:
1. All-In-One – nurses don’t want more devices to carry around. They want one simple device that can do everything.
2. Call a code – with one press of the button, the nurses would like the device to contact all staff who should participate in resusscitating a crashing patient.
3. Lab Values – nurses would like the device to alert them of all critical lab values on the patients under their care.
4. Clinical Prompts – nurses would like reminders of clinical tasks remaining for individual patients (e.g. check blood pressure on patient in bed 3)
5. Call and Locate Colleagues – the device should function as a full service cell phone with pre-programmed staff names/numbers and team paging lists
6. Locate Equipment -nurses would like to be able to track and locate wheelchairs, electronic blood pressure cuffs, and other equipment throughout the hospital.
7. Translate Verbal Orders To Written Orders – verbal orders are more prone to errors than written ones. An ideal device would have a voice recognition system in it that would translate physician orders to text.
Is there such a device on the market today? There are many different devices that have the capability to do some of above, but to my knowledge there is no device that can do it all yet. Companies like Cisco are working hard to provide integrated solutions for nurses – and the Nurse Connect phone is an important first step. What technologies would you recommend to nurses?
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More information about the phone (from press release):
Cisco Nurse Connect is a newly introduced solution that integrates nurse call applications, including Rauland-Borg’s Responder product lines, with Cisco Unified Wireless IP 7925G Phones to deliver nurse call alerts to mobile caregivers.
The Cisco 7925G Phone was specifically designed with the features necessary to support the unique safety and biohazard requirements of hospitals, including a battery that supports up to 13 hours of talk-time, ruggedized and hermetically sealed, and Bluetooth support for hands-free use.
The Nurse Connect Solution offers many benefits. For example, by reaching nurses on their mobile devices, the need to continually walk back to nursing stations or patient rooms is greatly reduced. Nurses can also have two-way communications with patients and send immediate requests to different levels of personnel after talking with the patient.
April 7th, 2009 by Dr. Val Jones in Announcements, Expert Interviews, Health Policy, True Stories
Tags: Cartoons, Chicago, Dr. Robert Kolodner, Dr. Val Jones, HIMSS, HIMSS09, ONC, Rob Kolodner
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I had another exciting day at HIMSS today in Chicago. I interviewed a team of nurses about hospital communications lapses, met with the COO of Healthline, the CMIO of Elsevier, HHS’s National Coordinator, Dr. Rob Kolodner, and had dinner with Rich Carmona, the 17th Surgeon General of the United States. I have about 10 blog posts that I need to publish about all of the above – but just wanted to mention one of the funniest things that happened.
I nervously approached Dr. Rob Kolodner with my husband in tow today, wondering what interesting thing I could possibly say to the father of health IT interoperability (we had never met in person before). Just as I was searching for an interesting opening line, Dr. Kolodner says to me:
“Oh you’re Val Jones! I have your shirt!”
Of all the things Dr. Kolodner could have said to me, that was NOT what I was expecting. I smiled quizzically at him, trying desperately to figure out how he’d come to possess one of my shirts. My husband shot me a sideways glance. Fortunately for me, Rob didn’t leave me confused for more than a few (very long) seconds.
“You’re the cartoonist… I picked up one of your t-shirts at the Health 2.0 conference last year. It’s really funny.”
“Oh, I see…” I chortled. “You must have the one of the ER nurse who can’t read the doctor’s handwriting.”
“That’s the one!” said Kolodner, beaming. “I got one for my friend who’s an ER doc.”
And so I asked my husband to take the photo of us above.
My husband just shook his head… I think we met my first fan.
March 26th, 2009 by Dr. Val Jones in Expert Interviews, Opinion
Tags: affordable, cash-only practices, Concierge Medicine, Doctokr Family Medicine, Dr. Alan Dappen, Health Insurance, physician visits, Quality, quality healthcare, saving money
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When most people think of “cash-only” medical practices, plastic surgery and dermatology procedures are top of mind. But there is a small contingent of primary care physicians who offer low-cost “pay-as-you-go” services. Yearly physicals, well-child visits, screening tests, vaccinations, and chronic disease management are all part of comprehensive primary care options available. And this costs the average patient only $300 a year.
It is estimated that 75% of Americans require an average of 3.5 office visits per year to receive all the medical care they need. If the average office visit is 15-20 minutes in length, then that averages out to 1 hour of a physician’s time each year. How much should that cost? Dr. Alan Dappen (founder of Doctokr Family Medicine, a cash-only primary care practice in Vienna, Virginia) says, “$300.” But insurance premiums are often closer to $300 per month for these Americans, and that doesn’t include co-pays for provider visits.
So why aren’t people buying high deductible insurance plans, saving thousands on premiums per year, and flocking to cash-only primary care practices? Dr. Dappen says it’s a simple matter of mindset – “People have been conditioned to believe that if they pay their insurance premiums, then healthcare is ‘free.’ In reality, their employers are taking out $3600 or more per year from their paychecks for this ‘free’ care. But since employees don’t see that money, they don’t miss it as much.”
A high deductible health insurance plan (where insurance doesn’t kick in until you’ve paid at least $3000 out of pocket in a given year) costs about $110/month for the generally healthy 75% of Americans (you can check rates at eHealthInsurance.com). That’s a savings of at least $2280/year for those who switch from a regular deductible plan to a high deductible plan.
What are the odds that the average, reasonably healthy American will outspend $2280/year? I asked Alan Dappen how many of his 1500 patients spent more than $2000 on his services per year. The answer? Three.
“Most Americans who buy-in to low deductible plans pay a lot more in premiums than they’ll ever use. They’re essentially betting against the casino, and we all know who wins on those bets.”
So I asked Alan Dappen if “the casino” was making most of its money on the “healthy” 75% of its enrollees to subsidize the cost of the sick 25%.
“Sure they are. And I suppose if enough people saw the light and switched to high deductible plans with cash-only physicians, it might force change in the health insurance industry. Perhaps the government would use our taxes to help subsidize the sicker patients.
The bottom line is that at this very moment, 75% of Americans could be saving thousands of dollars per year on their healthcare costs – and have their very own cash-only primary care physician available to them 24-7 by phone, email, home visit, or office visit. The cash-only doc can afford to offer these conveniences because they are paid by the hour to do whatever the patient needs done, without forcing the relationship to conform to insurance billing codes. In fact, the physician saves a bundle on coding and billing fees – and can pass that on to the patients.”
I wondered about the outrageous costs of laboratory fees and radiology charges for people who don’t qualify for the insurance company negotiated rate. Dappen explained:
“My practice has negotiated similar rates with local labs and radiology groups. Screening tests and x-rays are very reasonable.”
I asked Dr. Dappen who uses his services.
“I see both ends of the spectrum. The high-powered executives who don’t have the time to wait in a doctor’s office and enjoy the convenience of handling things with me via phone or house call. For them, time is money, and by losing half a day or more traveling to a doctor’s office and waiting for their 15 minute slot, they might lose $5000 in billable work time. On the other end I see patients with no insurance or high deductible plans. They enjoy the same conveniences, and end up paying an average of $300/year for their healthcare. This is high quality care that they can afford.”
I guess the only thing preventing this model of healthcare from taking off is the courage of individuals to try something new. I myself have switched to a cash-only practice with a high deductible health insurance plan, and have saved myself thousands a year in the process. I love the convenience of knowing that my doctor has all my records in his EMR, I have his cell phone number, and he can renew my prescriptions with a simple email request. I can’t imagine why more people aren’t doing this.
Alan Dappen says, “They just have to wake up out of the Matrix.”
**For more in-depth coverage of the rising trend in cash-only practices, check out MedPage Today’s special report.**
