Time to Say a Techno-Goodbye?

Increasingly, I find myself receiving direct calls, text messages, and de-identified images from colleages and support staff via cellphone. Really, it won't be long until I say goodbye to a permanent fixture on my belt that I have worn for years:

Good riddance!

-Wes

Rationing Health Care For Seniors

A sure-to-be controversial article appears in the Chicago Tribune this morning asking the sensitive question of 'Health care at any age, any cost?:'

"If you want to save all lives, you're in trouble," said Callahan, co-founder of The Hastings Center, a bioethics research institute in New York, and a faculty member at Harvard Medical School, in an interview. "And if you want to save all lives at any cost, you're really in trouble."

Callahan and co-author Nuland, a retired professor of surgery at Yale School of Medicine who wrote the best-selling "How We Die," were both 80 when the article was published.

"We need to stop thinking of medicine as an all-out war against death, because death always wins," said Callahan.

The article goes on the make some bold demands of doctors:

That said, McKoy believes doctors have a responsibility to spend medical resources where they do the greatest good. They must police themselves — otherwise, the government will come in and do it for them, she warns.

This is not easy, she said, describing the tremendous pressure doctors are under to perform procedures and prescribe medicine that will not help. And, she said, they often give in.

"We get selfish families, and it's often easier for doctors to pull out prescription pads," she said. "Doctors need more often to say no, to say (if a patient is dying): 'We will give you palliative care, but not give you chemotherapy. We will not give you new expensive drugs because it will not make you better.'"

Likewise, medical schools also need to train students to understand the cost-effectiveness of treatments, and to administer them based on medical research into their effectiveness — not just because they are available.

While I agree that the doctors on the ground should be making these decisions, I, too, have problems with a central regulator imposing a random age limit where all services to functional seniors stop. More importantly, this article ignores another reality for doctors who must make these difficult decisions: the nearly unlimited liability exposure if the family members disagree with all members of the health care team, including hospital ethics panels.

It's good we're having this discussion. And yes, since doctors are increasingly employed by hospital systems eager to fund their operations, pressure continues to mount on proceduralists to offer newer and advanced therapies to patients. But it's not all about the money. There really ARE wonderful therapies out there for seniors these days and, thanks to the virtually unlimited marketing of them to elders (especially via direct-to-consumer advertising) seniors will continue to demand them. Adding fuel to the procedural fire, lack of liability protections for health care facilities and doctors who opt not to treat a patient for some very good reasons will further add pressure on doctors and hospitals.

Once again, because of special interest resistance to malpractice reform, centralized government control will become the default option.

And maybe, just maybe, we need to rethink our stand on direct-to-consumer advertising of expensive medications to the populace on the Nightly News.

-Wes

What's the Most Important Question to Ask Before Getting Your Defibrillator?

Answer: How many have you done in the past year?

If the doctor says 37 or more, you should be in very good hands.

-Wes

Reference: Freeman JV, Wang Y, Curtis JP, Heidenreich PA, Hlatky, MA. "Physician Procedure Volume and Complications of Cardioverter-Defibrillator Implantation." Circulation 2011.

When Lipitor Goes Generic

When the world's leading cholesterol-lowering "statin" drug, Lipitor, goes generic tomorrow, doctors will bear the brunt of the conversion with little information about what the new drug will cost for their patients.

This, of course, is the plan.

Even the Wall Street Journal which has an excellent "user's guide" to making the switch from name-brand to generic Lipitor offers little help as it mentions "co-pays" rather than actual drug cost:

How much cheaper will generic Lipitor be?

Insurance copayments should drop considerably, if patients are getting Lipitor or atorvastatin on the generic tier of their health plans. Currently, Lipitor has been on a higher, branded tier for prescription drugs. Copays for branded drugs average either $29 or $49 depending on the tier, according to Kaiser Family Foundation. Copays for generics average $10.

In addition, Ranbaxy Laboratories Ltd, one of the generic manufacturers of generic Lipitor, won concessions to maintain elevated prices for 180 days from the government (a la our own Food and Drug Administration while the Federal Trade Commission stands idly by complaining how consumers are gouged with this arrangement) to assure prices stay high a bit longer.

But if we forget the insurers and copays, how much will the generic drug actually cost consumers?

No one will tell you.

That's because everyone else has to make sure they make their cut first. Pharmacy benefit managers, the leeches attached to nearly every prescription written today, have to strong-arm their position in the ever-competitive pharmaceutical profit by "pre-negotiating" prices for consumers wed to even more insurance plans with varying deductibles and co-pays.

Even Pfizer, not wanting to exclude itself from the profits inherent to such a non-transparent system is offering it's own "generic version" through Watson Pharmaceuticals. Theoretically it would be good for the public to have multiple generic manufacturers competing for generic Liptor's market, driving prices down. However, this natural self-regulating market function cannot occur to the benefit of consumers due to the blocking of actual drug price comparison.

Insisting on tranparent retail pricing of the medication's pre-insurance costs would greatly facilitate consumer choice of statin in the doctor's office. Someday, one could imagine a Consumer Reports spreadsheet in the same way they rate appliances and automobiles.

But then again, it seems we can't do that because it would serve the function of weeding out our hidden pharmaceutical middlemen.

-Wes

When a HIPAA Security Breech Occurs

It wasn't the fact that pop-star Lindsey Lohan's father, Michael Lohan, was hospitalized that caught my eye, nor was it the splashy headline: Michael Lohan Struggling to Speak, Breathe. What caught my eye was the picture that accompanies the article that reportedly shows Mr. Lohan asleep in his hospital bed.

Is this picture of a man who is "short of breath" authentic? Since there is no oxygen tubing and no pulse oximeter applied to the pictured patient's finger, we are left to wonder.

But what if the picture IS authentic? What will happen as a result?

Will this photograph be ignored? For hospital administration and government regulators, this would pose an enormous problem.

If not ignored, will the perpetrators be brought to justice? What financial "lesson" will be levied against them?

It is frightening to consider how an investigation of such an obvious lapse in patient privacy might be conducted thanks to the implications to health care facilities imposed by HIPAA. Will all the nurses on the unit be placed on administrative leave until someone squeals? Or maybe the cleaning staff? Maybe the family themselves? Perhaps the whole hospital will have to attend HIPAA refresher courses. Perhaps the ward should be closed until the problem identified. And what about the hospital administration who have permitted such an egregious lapse in governmental policy? What fines will be levied against them as a result? Will hospital costs for future patients be adversely affected as a result of these fines?

What is clear is that the ability to maintain patient privacy is quickly becoming impossible to manage, thanks to the explosion of hand-held cell phones and miniature cameras, not to mention the requirement for electronic medical records for those receiving government-funded health care.

Real patient privacy remains a local challenge, not a universal, governmental one. Sadly, in our attempt to provide global governmental privacy protections, we forgot to protect those that are most affected when breeches occur: the innocent workers and patients themselves.

-Wes

Grand Rounds: The Medical Blog-o-Sphere Gives Thanks

... over at the Diabetes Mine blog. Yes, I'm thankful I don't have to use this old medical kit either (but the pics are cool).

-Wes

Something to Be Thankful For

I was sent an e-mail from Amy Tenderich of the well-respected Diabetes Mine blog asking for contributions for this Thanksgiving’s edition of Grand Rounds. I sat with this a while and really struggled to find a topic. “It would be nice to creative writing,” I thought.

So I sat and stared at the computer.

Nothing.

I sat some more.

Still nothing.

It was complete and utter writers’ block. Then I remembered a similar time many, many years ago:

"... but I don’t know what to write.”

“What is it you’re trying to say?”

“That I want to get into medical school. That I like biomedical engineering. That I like people and kids and migrating monarch butterflies and music and art and all kinds of stuff! How the heck am I supposed to write something that makes sense of all this? How does one write something that will get you into medical school, for goodness sakes! This stinks!”

“Just write. It’ll come together,” she said as she returned to the afternoon’s dishes.

After I calmed down, I took out a fresh piece of paper and wrote. I wrote mountains of disjointed sentences without a central core. A stared at the page, dissatisfied. I wrote some more. Somewhere in the back of my might hid a thought, an overarching theme that failed to materialize despite my best attempts. I kept writing and writing as if somehow, some way, I’d force it out of me. Finally, out of frustration, I brought my work back to her.

“Here’s what I’ve got so far.”

“Wonderful!”

She sat and read what I had written. Occasional smiles would appear from her lips, then a look of confusion. I knew it wasn’t great since science and math were my thing at the time, not writing. She read the entire mess, start to finish, then stared up from the page, looked upward and contemplated her next move. Her radiant eyes turned toward me and pierced my stubborn façade. “You’ve got good stuff here, but I don’t get how it makes you feel. It’s too disjointed. Don’t you mean to say…?”

And we were off. I watched a master at work. She had a remarkable knack for diction and the written word. She reveled at the chance to add a verb, an adjective, a noun that changed the ordinary into the extraordinary. She’d stop and ask, “So then what?” and I’d explain. Red arrows would link concepts and ideas; a roadmap to clarity formed before my eyes. “You need to expand on this,” she’d say. Then I would return to my thoughts, frustrated at how hard this was to complete. Would it ever make any sense? But as I sat and thought some more I realized that she was right, not so much about the topic, but about the process.

Think. Write.

Don’t think. Write.

Then write some more. Be willing to toss aside the perfect stand-alone nuggets of writing that make things too verbose and distract from your message. Keep those that clarify and sharpen it. Then process the thoughts and re-work them until the final composition develops to something larger than what you had anticipated.

Like an acceptance letter to medical school.

And before you know it, you’re not just a doctor, you’re a writer, too.

Happy Thanksgiving, Mom. (And sorry about all my typos.)

-Wes

HIPAA, Case Reports, and the "Small Cell" Problem

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. http://bit.ly/umnydc

Details about the case are quite specific and the case reports 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 not HIPAA compliant. Nor could such a case be mentioned on a blog, for that matter, even though it presents important information for people dealing with these patients.

There is an important quality-of-care role in telling these clinical stories. In fact, HIPAA states there are just "18 little rules" that doctors are supposed to follow when they report important clinical cases. But details about cases may need to be very specific. Specific case reports can bring important specific clinical details to the attention of the medical community. For instance, if doctors had not been willing to describe several cases of pulmonary vein stenosis or two cases of esophageal perforation in a major medical journal years ago, how many more people might have been injured as a result?

But there's problem giving such details about clinical details about patient cases: "the small cell problem:"

Clinicians should be sensitive to the "small cell problem": the existence of individuals with such unique or unusual diagnoses or illnesses, that it might be possible for others (or patients and families themselves) to identify the individuals in case reports or medical text books based upon limited information, such as state or city of residence, age and diagnosis.

The "small cell" problem violates HIPAA and HIPAA means business: millions of dollars of business that gets released in press releases from the Department of Health and Human Services when they catch their prey.

But doctors should not be afraid of publishing case reports especially since there are good reasons for them clinically. Further, when doctors make good faith efforts to conceal patient's personal information in those reports, they should not be subject to threats of HIPAA's "small cell" problem. Simply put: the "small cell" problem is HIPAA's, not the doctors'. Extending the definition of personal health information as defined by HIPAA to include "any other unique identifying characteristic" about a patient's case limits doctors' ability to improve care to our patients while greatly increasing our legal culpability for that effort.

-Wes

UpToDate for EMRs

It's Friday. I sat down to work, saw this, and it made me smile:

It's not easy keeping up with technology when things move so fast.

-Wes

Doctors Passing Fake Sick Notes Get Reprimand

From the Wisconsin Journal Sentinel:

The Medical Examining Board reached stipulations with seven doctors Wednesday in which they were formally reprimanded for failing to make adequate records on the patients they saw during the protests. The stipulations also required the doctors to pay $225 to $350 each for costs and take four hours of continuing education courses within 90 days on medical record keeping.

The reprimands will stay on the doctors' records permanently and will show up in a national database of physicians, Murray said. The doctors' reprimands would be a factor in determining discipline in future cases if any of the doctors come before the board again, he said.

A mere hand slap.

Pity.

-Wes

h/t: Instapundit

Pacing Without Wires

From Medgadget via The Medical Quack:

EBR Systems, a start-up out of Sunnyvale California, and Cambridge Consultants, the technology design and development firm, have developed a leadless pacemaker system for patients with advanced heart failure. The Wireless Cardiac Stimulation System (WiCS) comprises two units, an implantable electrode and an external control unit. The electrode incorporates an ultrasonic, wireless receiver and delivers an electrical stimulus to the heart based on triggering signals from the external control unit.

In its current iteration the WiCS system is designed to work with conventional pacemakers/defibrillators pacing the right ventricle of patients requiring biventricular pacing. The WiCS external control unit senses the pacing stimulus delivered to the right ventricle and initiates a burst of stimulus from the electrode implanted in the left ventricle. According to the company, the wireless left ventricular pacing approach removes the need for complex surgery and the complications often associated with the coronary sinus leads used to pace the left ventricle.

Nice.

But to suggest that a left heart catheterization to place their little device in the endocardium of the left ventricle "removes the need for complex surgery" is a stretch. Embolic complications, valvular complications and the potential for stroke complications (with the need for at least some anticoagulation) will quickly temper their enthusiastic press release. And what happens when a patient needs an ultrasound of their heart or has a capsule endoscopy? Could there be significant electromagnetic interference?

But we should not rain on these companies' parade too quickly, even if they are a bit late to the party. The implications of this technology as we move forward with more sophisticated pacing therapies are profound. One only needs to consider complex congenital heart cases with anomalous venous return, epicardial delivery of this technology, or its capability to paired with drug delivery systems in the future to see where things might go with such a novel means of pacing.

-Wes

Welcome to My Office

It sure beats the heck out of a desk, chair and desk phone:

At the start of each case, I still have to pinch myself when I contemplate the wonder of it all.

-Wes

From the AHA: You Are Here

Thanks to Larry Husten over at Cardiobrief for posting this great picture from the American Heart Association meeting going on now in Orlando, FL. It's a helpful sign if there ever was one:

With all the mobile devices and internet connectivity available to doctors attending these meetings now, perhaps a more relevant sign should have read: "Be Here Now."

-Wes

When Screening Teenage Athletes for Sudden Cardiac Arrest Risk, History Matters

Before reaching for tests like EKGs to screen teen athletes, we should first ask ourselves if we've taken a careful history:

The new study consisted of Madsen and his fellow researchers sending out surveys to every pediatrician and family practice doctor in Washington State. They received a good response–surveys were returned by 72 percent of pediatricians and 56 percent of family practitioners.

The results were disheartening:

• 28 percent of doctors surveyed failed to always ask if a teen experienced chest pain during exercise.
• 22 percent of doctors surveyed failed to always ask if the teen ever fainted without a known cause or explanation.
• 26 percent of doctors surveyed failed to always ask about early deaths in their family history.
• 67 percent failed to always ask about heart disease in their family history.

Dr. Gaurav Arora, associate director of electrophysiology at the Children’s Hospital of Pittsburgh and an assistant professor of pediatrics at the University of Pittsburgh, was surprised to see the number of physicians in the new study who said they didn’t ask every teen athlete about fainting or chest pain. He said, “Those are red flags in young athletes.”

-Wes

From the Archives: Twice Shocked

I still think this case was cool, so I'll link to it once again.

Have a nice weekend.

-Wes

Miss Manners Goes to the ACCF

Dear Ms. Manners:

I am a fellow of the American College of Cardiology and I just learned that the American College of Cardiology Foundation (ACCF), the same foundation that publishes most of our patient care and treatment guidelines, is providing training to medical device and pharmaceutical personnel so our interactions with them become “effective and efficient.”

How nice.

Is this how Multaq (er, dronedarone) got such an early mention in our latest atrial fibrillation treatment guidelines? I've always wondered, especially after we later learned that there might be a few unsavory issues with this drug.

Still, I have no doubt the need is there. Glad to see that my annual membership fees are being put to such good use. After all, up until now, it really HAS been hard interacting with industry reps when they brought lunch. Don’t get me wrong, it wasn’t their professional demeanor or their knowledge of their device or drug. No, that wasn’t it. It was just so hard to explain to them why I had to dine and dash.

Now, thanks to you, I won't have to. I'll just spend more of my limited time getting down with industry personnel so we can share. Imagine: having smart people we can talk to about our latest, coolest case so they can record how much money they spend on our get-togethers. That's efficiency exemplified.

I'm especially impressed that the ACCF training of industry personnel will occur every two years. I was worried about quality of our industry reps' knowledge base, so I'm glad you've made this effort a full-time job. (By the way, I had NO IDEA the ACCF now has a vivarium for all this training - when did you guys spring for that?) Impressive. Rest assured that I'll be SURE to check for your ACCF Training Logo on their business cards before I help myself to a gyro.

But do me a favor, will you? Would you mind passing on some of those fees you receive for that industry training to those of us helping ourselves to lunch? After all, those membership fees we're paying to the ACC are getting a bit stiff. (*wink wink*)

Just kidding.

I'm sure you're really collecting those fees to help lower the cost of my patients' medical devices and drugs in an effort to support their "positive health outcomes." After all, it's this cost thing that's reaking havoc on our health care system, right? (I wish I had thought of such a clever way to address this problem).

Ms. Manners?

Ms. Manners?

Right?

-Wes

h/t: Larry Husten over at Cardiobrief.

Planning

Years of college, medical school, residency, cardiology fellowship, and interventional fellowship training all comes down to this:

Click image to enlarge

Heh.

-Wes

Just Five Little Minutes

"I estimate these changes to your charting work flow will take only five minutes."

Five minutes is fine if it happens for only one patient. But when it is multiplied by as many as forty patients in a day, the multiples get impressive. Five minutes x forty patients = 200 minutes (more than 1.5 hours a day).

Minor five-minute changes to administrative charting requirements aren't so minor, especially when you add more time for quality assurance reporting or pay-for-performance initiatives. Suddenly huge swaths of time from a doctor's opportunity to take care of their patients. We need more care time and less data entry time. Doctors must insist that we not become data entry clerks.

Increasingly, I see the data entry burdens of regulatory health care documentation requirements falling on doctors. On first blush, this seems logical because only doctors (or very capable, highly trained surrogates) understand the nuances required to make potentially life-altering adjustments to the electronic medical record. But when new administrative documentation requirements are added to doctors and other care providers, it compromises our time with patients where we explain the mechanisms of their disease and its management nuances. Discussions of medications, therapies, and required follow-up get get short shrift to mandated governmental documentation burdens. If we want to maintain patient volumes to improve access for new patients, we must get creative. After all, time is not expandable.

And there could be a better way.

I believe we need to get patients more involved in their own care before they see their doctor. Imagine a patient entering proposed changes to their list of health problems, surgeries performed, medications and doses being taken and allergies before they are seen on their cell phone or local waiting-room computer terminal or iPad. These proposed changes could then be reviewed, validated, a approved (or not) by their doctor leaving the majority of the patient visit for what matters: actual patient care.

Then maybe, just maybe, I could salvage four of those five precious minutes for both of us.

-Wes

AMA Medical News: Social Media's Public Health Implications and Limitations

From a mention in today's AMA Medical News:

Many health professionals do not see social media-based research replacing more traditional study methods, because not everyone uses the Internet or social networking. But they expect data gathered from social media to play an increasingly larger role in addressing public health issues.

"Social media has huge potential for public health," Dr. Fisher said. "I don't think that people have even begun to realize that potential yet."

-Wes

Smile! You're on Candid Camera!

They sat anxiously waiting for their loved one to enter the holding area after the procedure, one nervously clutching her purse, another today's paper, and a third, her cellphone. The air was tense as they awaited the news of how the procedure went. All the preparation, the concern, and the questioning come down to this moment when they learn if they made the right decision to go forward with the procedure. Will there be elation or despair?

So of course they want to videotape the moment.

The door opened, there was their loved one, looking no worse for wear, followed by the doctor. As he came forth to tell them the good news, the cellphone video recorder captured the discussion, the elation, the "thank you's," and the specifics about the case. It was done discretely and not noticed until the end of the conversation with the group. The doctor was caught completely off-guard.

In this case, the news was happy. All went well. But what should happen if the news weren't so good or even devastating?

I wonder.

We have entered an era where instantly-available photographs and video loops are becoming a way of life for many. YouTube, Facebook, and Twitter are everyday household words. More and more people own cellphones capable of uploading photographs and video content in seconds to the internet. And people bring these marvels of technology into hospitals and clinics every day. What this will mean to patient privacy, HIPAA compliance, and the sanctity of the doctor-patient relationship remains to be seen. But one thing's for certain, surveillance cameras are showing up everywhere and not likely to go away.

-Wes