American College of Physicians: Internal Medicine — Doctors for Adults ®

Friday, February 17, 2017

Why health care information technology may never improve

One of the topics I write most about and have also done a considerable amount of consulting work on, is improving and optimizing health care information technology. I hate to say this, but after a few years of doing this, I'm starting to despair a little by what I'm seeing. It's a question I never thought I'd ask: But will health care IT ever really get to where it should be? Improvement is desperately needed—even small tweaks can be made to our electronic medical record (EMR) systems to help improve workflow for doctors. Information technology in its current format is the number one frustration for doctors (and nurses) across the United States—and responsible for much misery at the frontlines of medicine, as an unacceptably large amount of time is spent navigating them. Here are 3 reasons why improvement is uniquely difficult:

1. Wrong customer: administrator not end-user
Watch this post as a video

Attending many events and networking meetings in health care IT, one thing has become abundantly clear to me. We (meaning doctors) are not the people that health care IT folk are catering to. It's the hospital administrations. Can you imagine if great companies like Apple totally disregarded the end-user experience like that? This is one of the prime reasons we find ourselves in this preposterous situation. As an example, I recently used the latest version of Siri on an Apple device. And how brilliant it was. Far, far superior to any voice recognition software I've used in health care, and designed with the user in mind

2. It's a monopoly once installed

Once health care organizations have spent millions of dollars on a particular EMR, the IT vendor is truly “in”. The organization is stuck with it no matter what—and can't just switch to another one if they don't like it. Therefore, what incentive is there for the IT system to really get better?

3. Lack of strong voice

I was talking to a very intelligent doctor recently who was bemoaning how he was spending the vast majority of his day at a computer screen. Certainly not why he went to medical school. He said something very thought-provoking: “I'm surprised that the medical profession has allowed themselves to be so quickly turned into data-entry clerks without making a fuss.” So true. What happened to the public perception of a doctor—the fierce patient advocate who always stood up for good medicine? Why is there not a strong national movement to improve health care IT?

Even the most hardened technophobe doctor would acknowledge that technology represents the future in all aspects of our lives. But we want good technology that is fast, efficient and seamless—enabling us to be doctors. We don't want reams of garbled data that transforms our patients' stories into tick boxes. We want rapid mobile order entry systems. We also want an acknowledgement that the medical profession has to remain a social and personable profession—not one where the frontline heroes are turned into “type and click bots”.

It frequently feels when I meet health care IT folk that we are in two separate worlds. I'm quite an optimist by nature, and hope I'm proved wrong about this never improving.

If you feel as strongly as I do, please consider signing the online petition here: care-improve-health care-information-technology-at-the-frontlines-of-medicine?recruiter=448220882&utm_source=share_petition&utm_medium=copylink

Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care. This post originally appeared at his blog.

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Combating the terror of chronic disease, and vice versa

Many of us listened to President Obama say his official goodbye. In light of the political turbulence in which we find ourselves, there is both abundant and diverse opportunity for attendant reflection. I choose to focus mine here on a simile that populates the space where my professional purview, and my anxieties as a citizen in the modern world converge. Terrorism is like chronic disease, and vice versa.

The relevance of President Obama's farewell to this rumination is the obvious: the POTUS who took office twice in the post-911 world began, and ended his two-term stay in the White House at war with global terrorist organizations. We have seen triumphs, and we have seen disasters, but we certainly see no end in sight.

This somber conclusion took me back to my impressions as a medical resident, training in Internal Medicine, in the late 1980s and early 1990s. For those who don't know, residency is the crucible of medical indoctrination, the harsh gauntlet of transformation. The hours and duress of it all have been attenuated over time, although they remain impressive by most standards.

In my day, the typical workweek spanned 100 hours, and sometimes more, running through night as well as day. Almost all of that time was spent tending to hospitalized patients who were inevitably, in this age of ever more outpatient care, very sick. Our mission was a combat mission; we were combating the ever-present threat of decompensation and death.

We were pretty good at it, and the never-ending advances in medicine make us better at it all the time. We can treat astonishingly complex and grave diseases effectively. In the ICU, technology can take over for almost every failed organ system, albeit much less well than the native article. Death, more often than not, can be forestalled.

But we ourselves are forestalled, now as then, in moving past combat to the solace of success. The hospital was all about people who mostly had serious chronic diseases that never needed to happen, and were never going away. We care providers and our technical wherewithal were and remain all the King's Horses and all the King's Men; and our patients, alas, were Humpty Dumpty. What we could not put together for them was genuine vitality, long gone, and gone for good. Famously, you can't unscramble an egg.

But Humpty Dumpty conveys another message, more important: why is that fall off the wall necessary in the first place? Let's put a seat belt up there; or cushions at the base of the wall. Or lower the wall. Or replace it with a bench; who needs to sit on a wall, anyway?

The simple fact is that most of what lands people in hospital beds is preventable. We have known how to prevent roughly 80% of all chronic disease and premature deaths for decades.

For me, the lesson in knowing that 8 out of 10 hospital beds never needed to be populated in the first place if people would only make better use of their feet (more physical activity), their forks (better diets), and their fingers (no tobacco products held there)- along with attention to a short list of other modifiable hazards- was that combating the consequences of established disease simply wasn't good enough. I wanted to go back to a time when vitality was still intact, and try to keep it that way. It was obviously already too late for those patients I was treating in the hospital; but not for their children.

So, I followed my residency in Internal Medicine with another, in Preventive Medicine, and the rest, as they say, is history. For the better part of the past 30 years, I have done both to the best of my ability: combating established disease by treating patients, and working to promote lifestyle as preemptive medicine. Treated disease is better than untreated disease, but not nearly as good as untrammeled vitality.

Which brings us back to the end of the Obama era, with the terrorism war ongoing, our troops still in harm's way, seemingly never able to leave Afghanistan. These troops are combating terrorism like medical personnel combat disease in the hospital; the situation is already bad in both cases, and the job is to contain the threat.

There is no real victory in either case. The killing of terrorists inevitably begets more terrorists; the war is self-perpetuating. So, too, is a medical model far more devoted to combating chronic diseases it knows how to prevent, than preventing them.

The remedy is a far greater emphasis on prevention. That view requires patience, because we cannot prevent what has already happened. If the already sick inspire better attention to prevention and health promotion, it is the next generation that will benefit fully. The current cohort gets treatment; the next gets vitality.

If that view pertains to terrorism, too, as seems likely- questions about preventing terrorism a generation from now should be at least as salient as saber rattling. But of course, they are not. Our leaders are all but obligated to talk tough, and tell of our strength in bombs and bullets and walls. These are needed for the already hostile, just as scalpels, and dialysis, and coronary bypass are needed for the already sick. But far kinder, gentler treatments suffice to keep the healthy well. Shouldn't we be assessing, discussing, and investing in whatever it would require for our children to need bombs and bullets less?

The ultimate remedy to terrorism is likely as slow as preventive medicine; desired effects span decades, and generations. Populations stewed in the hate of echo chambers need to die out in time and be replaced by progeny who can find their way to a common humanity through the advent of understanding. Education and opportunity are anti-terrorism vaccines.

Saying so does not make administering them easy, and I don't mean to imply anything of the sort. But not saying so, renouncing global connections, and hunkering behind walls- all but guarantee we will simply keep getting, and treating, the same disease indefinitely. Vaccinating the world against smallpox wasn't easy either, but had we not done so- we would still be treating it.

No trauma response at the base of a wall will ever be as good as preventing a fall from it in the first place. No border wall will ever be hard enough to get over to rival the protective power of genuine understanding. More focus on prevention could give our children a world mostly free of chronic disease and terrorism alike. For now, both wars rage on- in part because we seem inclined to accept that's the best we can do. It's not. We can do better.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.

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Pan-resistant NDM-containing K. pneumoniae lacking MCR-1

I wanted to let you know about a new case report in MMWR while simultaneously raising the MMWR Altmetric Score. Seriously, how can such a case only have one blog mention in 24 hours—Jon Otter must be just getting back from holiday.

The Centers for disease Control and Prevention has reported a case of New Delhi metallo-beta-lactamase (NDM-1)–containing carbapenem-resistant Enterobacteriaceae (CRE) and Klebsiella pneumoniae isolated from a wound specimen of a woman in her 70s who had returned to the U.S. after a log visit to India. She also reported prior visits with multiple hospitalizations in India. The isolate was resistant to the 26 antibiotics tested, including all aminoglycosides and polymyxins (despite being MCR-1 negative), while it was intermediately resistant to tigecycline. The fosfomycin MIC was 16 μg/mL. Unfortunately, the patient developed sepsis and died. Fortunately, the patient had been isolated and screening revealed no evidence of transmission.

CDC offered three take home points:

Most CRE remains susceptible to at least one aminoglycoside or tigecycline,

When patients with this highly resistant organisms are identified, they should be placed under contact precautions*, and

Facilities should obtain travel histories and consider screening for CRE if patients are from high-risk areas.

*Note: nice to see that somebody still loves contact precautions.

Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands). This post originally appeared at the blog Controversies in Hospital Infection Prevention.

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Thursday, February 16, 2017

Repeal and replace Obamacare--STAT!

Am I referring to Obamacare here or Obama himself?

I am glad that we have a new president. Like most of the country, I was ripe for a change of direction and a new approach to foreign and domestic affairs, and we are certainly getting that. New readers here might erroneously suspect that I voted for Trump. I didn't. For the first time in my presidential voting history, I wrote in my choice for our top two office holders.

I have written multiple posts on my unfavorable views of Obamacare since it was jammed through congress without a single Republican vote. (Do I sound slightly partisan here?) Interested readers are invited to peruse posts on this blog within the Health Care Reform Quality category, if you dare.

There are two kinds of people who oppose Obamacare:
• folks who believe it is wrong on policy grounds
• folks who wield it as a political cudgel to bash Obama.

Some opponents are a hybrid of both of the above.

I was also suspicious that the Affordable Care Act (ACA) was always an interim step preceding a full nationalization of our health care system. Obama is on the record favoring such a policy during his 2008 campaign. If Obama could have achieved this politically in one step, he would have. The ACA represented the political upper limit that he could achieve, hoping that this would make a full would bring us within reach of a government takeover. Some conspiratorial skeptics believe that the ACA was designed deliberately to fail so that private insurance companies would have to abandon it, as they have. Then, the beneficent government would have to step in to rescue Americans who needed medical coverage STAT! While I offer no opinion on this wild charge, there were many smart people who averred when the ACA was delivered to us, that the numbers would never add up. And they didn't.

It is my belief that government is simply not equipped to assume control of the entire health care system and operate it at the highest level of quality possible, while controlling costs. Remember how smoothly the web site release was? Do you think this would have happened if Google or Facebook was in charge? Which company do you have a higher opinion of in terms of quality and efficiency, the Bureau of Motor Vehicles or Amazon? If folks want to have a government insurance plan like Medicare, I am fine with this. But, give us access also to the free market. I like choice because competition breeds excellence. When FedEx came onto the scene, it forced the U.S. Postal Service to really step up, which they have.

And, we all know that the plan's proponents were somewhat less than truthful. Feel free to Google Jonathan Gruber to become reacquainted with his 2014 comments which make reference to stupid American voters and other niceties. How long did it take the Obamians to admit that the statement, “If you like your doctor, you can keep your doctor,” was known to be false from the outset?

Let's face it. The ACA promised us quality and cost control and in my view it has failed on both counts. I do congratulate the president here, as I have previously, for taking on the challenge of health care reform. Republicans over several presidential administrations failed to seriously confront this challenge. And the plan does cover more Americans, which we all agree is a necessary goal. But, the collateral damage of this achievement warrants a new direction, admitting that it may not be possible to uproot the entire tree.

The replace part is going to be tougher than the repeal part. Will the GOP take a lesson from their adversaries and jam it through without a single Democrat vote?

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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