ACP Internist Blog

Friday, December 15, 2017

Looking in the wrong place?

It is no secret that there is a lot of waste in health care. Even if one leaves aside the most egregious examples such as duplication of tests and patient harm that necessitates more care, we still collectively do a lot of stuff that does not improve health. A recent report in Health Affairs changed my assumptions about what that stuff looks like.

The authors analyzed claims data from an all payer database in Virginia for services provided in 2014. They prospectively defined 44 services that were of “low value” defined as providing no net health benefit in specific clinical circumstances. Their assessments were based on nationally recognized standards, including the “Choose Wisely” campaign of the American Board ofInternal Medicine, the U.S. Preventive Services Task Force, Centers for Medicare and Medicaid Services criteria, and others. They then scoured the database to see how frequently these services were provided, and calculated the aggregate costs associated with them.

Two findings stand out:
1. The services were prevalent: patients in Virginia received a total of 1.7 million low value services in 2014, for a total cost of $586 million.
2. Because low cost services were so much more frequently performed than high cost services (think useless blood test instead of useless MRI), almost two-thirds of the total cost was driven by the low cost ones.

The conclusion that more money is wasted on “a lot of little things” instead of “a smaller number of big things” ought to change how we approach efforts to lowering the cost of care. It suggests that tight utilization management of “big ticket” items may not have the impact of changing more “every day” patterns of care. That seems harder to me, but it also seems like work that has to be done, and it will require strong physician leadership to accomplish.

What do you think?
Thursday, December 14, 2017

When electronic medical records crash

The computerized era has introduced all of us to a genre of errors that never existed during the archaic pen and paper era. The paper medical chart I used during most of my career never crashed. Now, when our electronic medical records (EMR) freezes, malfunctions, or simply goes on strike, our office is paralyzed. Although I appear to the patients as a breathing and willing medical practitioner, I might as well be a storefront mannequin who appears lifelike, but cannot function. We cannot access the patients' records, write a prescription or enter a new office visit.

Of course, like any business who faces this crisis, we expect instantaneous rescue from our IT professionals, as if we are their only client and they are permanently stationed in our waiting room just waiting for us to sound the alarm.

This is among one of the most frustrating aspects of EMR for medical professionals. We simply don't have the time or psychic reserve to absorb unexpected loss of computer service. We are not playing computer games (although sometimes it feels as if we are.) We have a live patient facing us as we face a blank screen. It is frustrating and awkward. The patients understand this reality as they undoubtedly have endured similar frustrations in their own lives.

Yes, we resort to writing a note in longhand and scanning it into the EMR later, but this is problematic. First, a scanned document cannot be read by our EMR as this document is not “part of the EMR family.” It can't be tracked, as we do routinely with laboratory and X-ray data. More importantly, I will be offering medical advice without any access to the prior medical record, which may span years. If the patient has a complex, chronic condition with a history of extensive testing and medication changes, moving blindly could lead me into a blind alley or through a trap door.

I propose no solution to all of this. No technological system can perform perfectly. It's another example of our ever increasing reliance and dependency on technology, more than we really need, in my view. I have no choice but to accept EMR in my professional life. But, there are opportunities when we can stand up and push technology back.

Do we really need Alexa to turn on our lights?

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.
Online communication for early diagnosis

The Internet and social media have transformed society. I remember when I was in high school, the concept of being able to retrieve any information you needed or communicate with the world via the click of a button would have seemed the stuff of science fiction. Future generations will be stunned when they hear stories of people trawling through libraries or debating questions for hours over dinner tables. They will also be shocked at how in the old days, information could easily be restricted or controlled.

It's a completely different world we live in now. News can be spread globally in an instant, authoritarian regimes and governments find it increasingly difficult to control the information flow, and any unpleasant events can be videoed and shared with millions in the few seconds it takes to upload to YouTube. Social media may have its detractors, but all of these things are fantastic for humanity. And as far as individual communication is concerned, we can stay in touch with friends and relatives across the world, share photos, and generally have a feeling of connectivity that no prior generation could have imagined (waiting weeks for that pen and paper letter to arrive is something that so many of us still remember).

As with anything else in life, too much of anything is bad, but it would be difficult for anyone to dispute the overwhelming benefits of the online revolution to mankind.

There is however one aspect of social media and online communication, which is also a major health care issue, that absolutely nobody is yet talking about. Use of these methods of communicating are soaring among the older population. It's no longer just something for millennials and the tech-savvy generation (and that's a good thing). Statistics suggest that around two-thirds of seniors are now online, a number that's steadily going up with smartphone use.

This is at the same time as the prevalence of another scourge of old age, dementia, is also increasing. Currently more than 5 million Americans are living with Alzheimer's disease, the sixth leading cause of death in the country. By 2050 as the population ages, this could be closer to 15 million. In addition to the personal and social devastation caused by the illness, it also costs hundreds of billions of dollars every year to the economy. Treatments and, hopefully, cures may be on the horizon, but dementia looks set to remain a problem across the world for some time—and not just confined to America.

I'm not aware of any serious body of thought that has addressed the issue of online activity combined with dementia, so let me do it right here. Because as older people using social media inevitably unfortunately start getting the illness, we will very likely see some of the first clinical signs in their online activity and other technological communication including text messages. This could manifest as follows:
• Their messages and posts will start becoming more erratic or inappropriate, not in tune with prior online behavior
• Large scale spelling or grammatical errors will occur that did not previously exist
• Unusual and out of character interactions with other people online

These manifestations are of vital importance for the following reasons:
1. We can utilize these online communication signs for early diagnosis and better detection, mainly noticed at first by family and friends. Physicians and all other health care professionals need to be aware of this and ready to address and respond to concerns
2. We can educate people in at-risk age groups about this upcoming problem and how to prepare
3. From a legal perspective, this is a minefield. Consider the following hypothetical question: can someone with early dementia be held fully responsible for the content of their online postings and interactions?

We as a society have not even come close to acknowledging this upcoming technological dementia ticking time bomb, and are totally unprepared for what's about to start happening. The speed of the online revolution has caught us on the back foot. Am I really the only person who has thought of this? Physicians, technologists, health care and even legal experts need to begin the discussion and start talking about it now—as we are sleepwalking into a major issue.

Suneel Dhand is an internal medicine physician, author and speaker. He is the founder of DocSpeak Communications and co-founder at DocsDox. He blogs at his self-titled site here.
Monday, December 11, 2017

Time to save the world

More than 15,000 scientists from nearly 200 countries have signed their support for a scientific publication reminding humanity that we are soiling our nest. This is thought to be the largest assembly of scientists ever to co-sign and directly support a journal article, and I am proud to be one of them.

I hope our unity of voices is audible above the din of our seemingly oblivious culture, but I have my doubts. An hour of watching television is enough to indicate that despite the urgency of our peril, it's business as usual down here: the relentless peddling of ever more material goods and bigger bacon-cheeseburgers we don't need at devastating cost to the planet we do, to ever more of us. As James Cameron so compellingly put it: we are sleepwalking off a cliff.

We have been doing so for decades. The new publication, and the global scientific support of it, is, as noted, merely a reminder. The original memo was delivered 25 years ago in just the same manner: a publication by the Union of Concerned Scientists as a “warning to humanity,” signed by some 1,700 scientists, including most Nobel laureates living at the time. Then, as now, leading scientists from around the world pointed out that we are using up the planet's resources far faster than they can be replenished; overpopulating the globe with our own species and wiping out others in a mass extinction event; disrupting ecosystems; and putting the survival of our own kind in question.

I commend the report itself to you for the particulars both of how bad things are, and how we yet may fix them. Let's acknowledge simply that this is a crisis of the first magnitude, and like most crises- a mix of danger and opportunity. The danger is that we will do far too little far too late, and Homo sapiens may join the ranks of the innumerable other species our ravages are consigning to extinction. That's depressing news for us, and far worse for our children and grandchildren.

The opportunity is that this time, while there's still time, we will snap out of it- and save ourselves and them by saving our home. Neither you nor I, nor our children, have much hope for real vitality if our world is critically ill.

Why, 25 years after the initial warning, have we done so little to correct our course? There are, I believe, two basic reasons: uncertainty, and time.

Uncertainty about the future is routinely invoked to discredit scientific predictions those in profitable power find inconvenient. This is invalid and inappropriate for two reasons.

First, while we carry on about not trusting science or scientists, we demonstrate our trust in both with our actions every day. Every time we board a plane or drive our family over a suspension bridge, we are casting a vote of confidence in science. Every time we send a text or email, we are pledging our support for the prodigious aptitudes of science. Let's acknowledge that typing a message on a handheld device in Chicago and having it show up with perfect fidelity on exactly one other handheld device in Mumbai or Tokyo instantaneously would be magic if it weren't science. When we bought special glasses in advance of an eclipse we knew would happen. We were saying we trust science whenever it's not inconvenient to do so.

Second, we know that some degree of uncertainty is inevitable. In clinical care, for example, we are never entirely certain. We can never know for sure what condition a patient has. In the absence of a crystal ball, we are always less than sure about an individual response to any given treatment until after it happens.

But the opposite of certainty is not utter ignorance and inaction. The opposite of certainty is humility. We clinicians don't withhold treatment from our patients because we don't know the future. We use the information we have, make the best possible decisions, and leave room for adjustments if things don't go as hoped.

Doubts about climate change are themselves now an endangered species. Admit it: you see the signs all around you. Climate change is now a tangible thing, up close and personal. But even for those who want to claim we are still uncertain, the argument must cut both ways. Uncertainty means things might not be as bad as our predictive models indicate, but it also means they could be worse. How disingenuous to point out that we can't be sure about how bad things may be, while insinuating we can be sure about how bad they won't be. What humbles the goose should humble the gander. Fine, let's not be sure, in both directions. Which way would you prefer to be wrong?

The one remaining issue is time. We recognize the cause and effect of sending and receiving a text message because the two are connected across the span of an instant. If it took years for text messages from Chicago to reach their destinations in Tokyo or Mumbai, we would have all the same reasons to doubt and debate cause and effect that we have for diet and health, or the impact of our exploitations on the planet. More importantly, we would lose interest as the message inched its way across the globe. We like our gratification, like our texts, tweets, and effects in general, immediately.

Many of us will assemble with loved ones this week to declare our thanks for the things that matter most. This gem of a planet, in sustainably habitable condition, belongs on everyone's list.

Time, though, is of the essence, because we are running out of it. There are simple and powerful actions each of us can take that can add up to make an important difference. There are other actions we can take together, as citizens, that can make a bigger difference still. Both require that we stop sleepwalking, and wake up before we fall irrevocably down.

We were warned 25 years ago that it was time to save the world. We are warned again now that while there's still time. It still is.

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.