What's On Dr. Voran's Mind

What's all about 90 @ 90?

2012-01-08T14:48:00.001-08:00

Where it all began

A number of us in leadership positions at the University of Kansas Medical Center back in the mid 1990's had a retreat at Deer Creek in Overland Park, KS. One of the assignments given to each of us was to craft a personal mission statement.

It just so happened that the year before one of my Japanese patients said that I needed to join a club and play golf if I was going to be the physician for the Japanese Counsulate still located in Kanas City, MO at the time. I joined Deer Creek which was near to my house and found my soul in the process. So many life lessons were learned that first year of seriously playing golf. In addition I observed and admired the physical and mental fitness of those 70 and 80 year old members who were playing most days. Many of them were shooting their ages (something all golfers aspire to) and were living engaged and vibrant lives in their retirements.

Reflecting back on the task at hand; "your mission statement." The moderator emphasized this statement should be short, clear and be able to guide. I played around with a few inane, wonkish phrases that all seemed good but didn't really reflect me. Then suddenly it came to me as my gaze drifted down on the 9th and 18th holes that flowed up to the clubhouse. What about shooting my age? At the time it was a long shot as my good scores were barely breaking 90. Hmmmm. Ninety. That's a good age to live to and even though it's not a good score in your 40's it's a great score in your 90's. The doodling stopped an I scratched out "90 at 90" and then changed it to "90 @ 90" with conviction.

That became my mission statement. For the last 16 years virtually every little decision has been aided by answering, "Will this help or hurt my chances of shooting 90 at 90?" Now I'm at my high-school sophomore weight, fitter and enjoying life more than I ever thought possible thanks to a crazy little mission statement.

That's what 90@90 is all about.

A few "simple" technologies that have helped my practice

2011-06-02T14:57:00.001-07:00

Was asked for a short list of what technologies have made a difference in my practice over the last year and I rapidly jotted down the following:

Large screen devices
- Our clinic started with small notebook computers primarily designed for the physician and nurses to carry from room to room. Severaly years ago it became apparent that we often needed to share what was on those screens with patients (primarily diagnostic imaging and lab results). The hand-held devices didn't cut it.
- We moved to 19" regular monitors and after some experimentation ditched the notebooks and took the minimal added time to log into inexpensive autologon desktops and increased the size of the monitors to 21" swivel devices
- Now have gone to 24" HP All-In-One touchscreen devices for nurses and patient rooms because we discovered productivity is proportional to screen real estate and the added dimensions of the touch screen enabled us to include patient input into the documentation process in the exam room
Photos and videos
- Having a current patient photo on every page view of the chart (usually in banner bar) reduces errors of performing actions on the wrong patient, reduces the need to dig for information (pictures jar our memories in ways names cannot)
- Having pictures of rashes, wounds, deformities provides more information for downstream readers than any amount of words
- Including videos of tremors, gaits, movements improves diagnoses
- Provides excellent teaching tool
- Has dramatically decreased the amount of descriptive text and time to completion of notes without sacrificing information
- Enables visit-to-visit comparison that is just not possible with text
Electronic Messaging, especially with patients
- Asynchronous messaging reduces interruptions for both the clinician and the patient and is more efficient than voice. Patient's complaints are in their own words eliminating the need for redundant recording of the interaction
- Improves communication without adding cost and dramatically reduces time spent on the phone. Secure messaging enables electronic transfer of patient information to outside physicians in need of that information when normal record transfer mechanisms are not available
ePrescribe
- Especially the External History has the potential to change the conversation (discovers those who have not filled prescriptions as well as those that are doctor shopping)
- Also having access to the medications covered by specific plans and the co-pay for those medications is what I call REAL DECISION SUPPORT ... now if only we could get the same push for covered services
Point of Care use
- Improves timeliness and also accuracy of the interaction
- Increases the perception of time spent with the patient
- Increases confidence and satisfaction
Patient Access to chart, especially visit notes
- Improves the accuracy, integrity and timeliness of the notes
- Try to review and write the note (even though I'm using 100% template driven documentation in the clinic) with the patient as the next reader and editor of the note. Takes a little more time but forces me to be judicious and accurate in my documentation which I'm convinced improves patient care
Interfaces and connections ... Health Information Exchanges
- The power of an EHR increases logarithmically with the number of systems to which it is connected
- HIE connections have the potential to increase productivity (see new patients in the same time as established patients) and why they are not catching on is beyond my comprehension as they enable a clinic to schedule and see new patients in the same time slots as established patients by dramatically reducing the amount of de novo data entry required to make medical decisions

There are many more technologies and infrastructure changes that are positively impacting health care but these are the ones that came to mind as fast as I could type them.

Comments?

Posted via email from Dr. Voran's Posterous

A Quick Blog from Windows Live Writer and wheres NHIN when we need it?

2010-10-15T19:26:00.001-07:00

So I get a page from my answering service about a patient of mine who I saw late this afternoon. Turns out the treatment I gave her isn’t taking and she’s in excruciating pain. Logged into my EMR from home, pulled open her chart, reviewed the radiology image and the radiologist’s over-read. Nothing. No reason she should be feeling the way she is now.

After a brief discussion it’s obvious there’s nothing I can do over the phone so I ask her which emergency room she’s closest to. It’s a hospital outside of our system but I tell her to go there as she can barely walk.

Call the ER and let them know she’s coming and ask them if they’d like my note from this afternoon. Of course they would. A couple of clicks later I’ve “printed” it to a secure PDF file and zipped it into an e-mail and off it goes.

Shows the importance of electronic access to information and also why we need a National Health Information Network (NHIN) so I wouldn’t have to take even these few steps.

Patient Safety - Maybe we're looking at the wrong audience

2010-09-14T19:03:00.000-07:00

I attempted to post the following comment on a post by Barbara Duck's entertaining and insightful blog (The Medical Quack) about in which she provides evidence that most applications that might have medical usage are not being used by people who download them. However, I received an error message when validating the post so I'll just post it here.
Today I spent a couple of hours with a physician colleague now working for a restart company designing an app for iPod/iPhone fitted with a medical grade bar code reader shell. The design is to replace the tethered bar-code readers used in medication administration in the hospital to improve patient safety. It was well designed and compared very favorably to other similar applications. But ...
... the bottom line is the whole time I was thinking that if this company's goal is patient safety they are targeting the wrong population.
Sure, medication errors occur in the hospital but when comparison to the medical errors that occur in total outside the walls of a medical facility, hospital based errors maybe insignificant. At least in the hospital there's a medically trained nurse selecting and delivering medications that are packaged and delivered by a pharmacist in the building with relatively clear instructions and tools on when and how to deliver them. Not only that the patient is observed taking the medications.
There are roughly 9000 hospitals in the United States and estimating the average beds per hospital at 100 we're looking at 900,000 beds. At any given time there might be 900,000 medications being administered.
In contrast there are roughly that many allopathic physicians probably averaging 20 patients a day and writing prescriptions on at least half of those patients so if my arithmetic is correct somewhere around 9,000,000 patients get prescriptions daily (some illegible). These patients go to the pharmacies receive their prescriptions, take them home and begin taking them without any medical supervision.
Now, I'm a physician and even I have difficulty taking my one medication daily as I'm supposed to. In casual conversations with my golfing buddies I know many of them rarely follow directions closely, even for pain medications where they may take many more than prescribed or skip doses. Others experiment intentionally or unintentionally in delivery methods, others have difficulty remembering, can't differentiate between pills or have work schedules that prevent them from taking medications as directed. Many also add over-the-counter medications without giving any thought to potential interactions.
I would venture to say that on any day there are as many patient safety medication errors in the home than there are in all of the hospitals in a given year.
Instead of an iPhone app for the hospital nurses what this company needs to do is write one for all of the millions of patients who take medications at home. We need a very simple app that makes it easy for the physician, pharamacist, nurse or patient to either download or enter their prescriptions, number dispensed and have it do the following:
    1) alarm when a medication is due to be taken
    2) show a picture of the pill(s)
    3) either have two buttons beside each pill labeled "Taken" "Not Taken" or just press the pill if taken and have a second button (X) if not taken.
That's it. In the background the application would store the medication, time of administration and advance the counter. When completed the device would automatically notify the physician or pharmacist the medication prescribed was completed or if a continuous medication that a refill or renewal was needed.
This app would also provide the patient with drug to drug interactions so if they stopped by the counter to pick up Claritin, ibuprofen, whatever, they could photograph the UPC code and it would automatically be added to their medication list, alert the patient if the new medication would interfere with what they were already taking.
It would also link to important drug information leaflets so they could review as often as they wanted by clicking on the picture of the pill how to take it, etc.
Finally, as mentioned above when the prescription expired the medication would drop from their list so they would always have a current, up-to-date list of medications to show their physicians (or better yet upload it) at the next visit along with a history of the administration over time (important for medications like warfarin).
By targeting medication administration applications at patients rather than nurses or physicians and designing the applications for home use we might actually affect patient safety effectively AND lower physician office visits, admissions to hospitals and GASP begin to lower the cost of medical care.
Continuing to focus on health care providers might be seen for the waste of time it probably is.

Uh, dibs on the patent!

From The Other Side - and the importance of Health Information Technology

2010-09-10T19:43:00.000-07:00

Three and half days ago my wife and I decided to mount two carved bears in our front yard before I headed off to work. As I hoisted one of the 45 lb bears up a few rungs on the ladder one of the ladder's legs sunk into the soft mulch. In slow motion the bear, myself and the ladder toppled over and in the process shoved my supervising wife into a pile of stacked rocks sending them flying.

Neither one of us seemed injured although my wife had the breath knocked out of her and the bear lost a toe. At the time she thought she might have cracked a rib but both of us being in medical field knew there wasn't much you could do about it. So we slowly dusted ourselves off and finished the job as you can see in the picture.

We debated having her come with me to my clinic to have X-rays to confirm whether or not she had fractured a rib or at worst case scenario didn't have a pneumo or hemothorax developing (even though she didn't have any signs of either). In the end decided against it as that would disrupt our normal activities.

Upon arriving home that evening she said her back and ribs were bothering her enough that I had to hold the leashes of both of our dogs as we took them for our customary evening walk around the block. We retired and upon arising in the morning she continued to complain about rib and back pain and the sensation that she couldn't seem to catch her breath when she inhaled deeply. Sure enough, the breath sounds on her right side were significantly diminished compared to the left and we headed off to the nearby emergency room.

Within 30 minutes the physician confirmed that her right lung was nearly complete collapsed and showed us the chest films. There was absolutely no question about the diagnosis and over the next hour she was admitted, taken directly to interventional radiology where a chest-tube was placed under flouroscopy and wheeled up to her bed.

What does this have to do with technology? Nothing so far but here's where information technology has made the last few days easier to handle than without technology.

First, the entire registration and admission process was electronic and took up less than 3 minutes of time. The registration clerk came into the ER exam room with her tablet, set it on the Mayo stand and flashed through the registration screens, then flipped and twisted the screen around handing my wife the Wacomm pen for her to sign the consent to treat and initial the HIPAA documents. Then she turned to me, pulled open another screen and "allowed" me to pay for the co-pay with a credit card then left the room. No paper, no fuss and no paper-work delays in getting us admitted. Technology allowed us to be seen and administrative "paperwork" collected quickly and in a way that did not interfere at all with patient care. Even I as a physician was impressed with how smooth it went.

Second, the physicians were keying in the orders leaving only a few hand-written floor orders to be carried up the the floor and as a result everyone knew what to do and when to do it minimizing angst and confusion.

Third, while this was going on I was able to slip to the side and log into my own clinic through the hospital's guest wi-fi system using my iPad that I had been using to read the morning's papers and keeping up with overnight e-mail while my wife was being examined. I did have a busy day scheduled with patient starting at 10am and going through 7pm that sandwiched an important meeting and as soon as I saw the chest film began the process of notifying the patients via our patient portal (or the nurses and schedulers for those who were not signed up with the portal) that they would be receiving a voice call as soon as the office opened up. Then I broadcast an regular e-mail to all of our clinic's staff as well as those who were scheduled for that meeting. All of this took place before office hours and, like the registration and admission process, was accomplished without having to leave my wife's side or be tied to the phone. No interruptions and misscommunications.

Fourth, and this might be the most important, one of my wife's first requests when she finally resigned herself to being admitted was for me to bring her laptop along with a good cup of her favorite Kuerig coffee and knitting bag. Within a few minutes of getting settled into her room she was connected through the hospital's guest wi-fi network and happily watching the US Open in HD on her computer as well as researching her condition so she could explain to all of her friends what had happened.

Over the next 3 days my wife has been confined to her room and the only thing that has made this hospitalization tolerable for not only my wife but me is access to information technology.

Note to hospitals: make sure you are providing this service to your patients or if not for them their family and loved ones. It allows so many things to take place that otherwise would be disruptive.

My wife's only complaints so far has been the food and not being able to access her own records, particularly the X-ray images.

Note to hospitals: a web portal for hospitals should be in the planning stage as it is for just about every ambulatory office.
Patients have a lot of time on their hands and a lot of questions that just never seem to get answered by either the nurses or the physicians that make rounds.

This hospital is probably halfway to being fully digital but even so we've been able to see how several measures can speed up the process of admission. I'm confident the same will be said about the discharge process.

We've already been electronically appraised of our co-pay estimate and have been able to address this virtually. I'm sure that the total cost will be a shock to us (even though we're both in the medical field) and it remains to be seen whether the remainder of the stay and discharge will be as smooth as most of her stay.

Now if we could do something about the food!

The importance of screen real estate in a clinical setting

2010-07-27T20:01:00.000-07:00

90 day ROI on all-in-one touchscreen PC's for office nurse workstations.

The Heartland Clinic of Platte City (10 minutes north of Kansas City International Airport) has been using Cerner's PowerChart for over 2 years in a nearly paperless environment. We initially started with notebook and tablet PC's with the nurses and the physicians carrying their machines into the patient exam rooms. That quickly went by the way-side as we discovered patients wanted to see what we were doing and we needed to review lab results, digital images and other patient information with the patient. The small screen devices just could not meet this need nor did we have a good place to set the devices without interrupting the visit.

Inexpensive PC's with wireless NIC cards (the rooms were not wired) replaced the mobile devices and very soon after that we installed 21" swivel monitors that hit the sweet spot with the patients, nurses and physicians.

Total cost for these inexpensive devices was less than $1,000 and we've been using them to complete the majority of our encounter notes in the exam room at the point of care as well as leveraging them to look up and deliver patient educational material from a variety of online resources.

We all saw productivity enhancements (less clicks, screen manipulation, etc.) with the larger screens. If they were inexpensive we feel that 27 or 30" swivel monitors might be even better.

Similarly I, along with others, have found attaching a separate monitor to our laptops have improved the functionality and productivity by reducing the manipulation of windows on smaller screens and enabling the frequent side-by-side comparison of data.

I've found that it's very beneficial to have one screen in landscape and the other screen in portrait mode. Many applications (like the New York Times Reader) are designed for landscape while others (USA Today and most web sites) are more functional in portrait mode.

The same thing is true with our electronic medical record. Cerner's PowerChart is split into a section called the "Organizer" consisting of messages, tasks, patient lists, schedules, etc. It works best in landscape mode as shown. Opening a patient chart creates a new window that is independent of the organizer. Using 2 screens it's quite obvious that most sections of the chart fit the portrait arrangement better than the landscape and in my office this is the way I set up the application when not seeing patients.

Lately I've been watching our nurses who are using the notebook computers given to them. Day in and day out they have to juggle many parts of the patient's chart, the web (for accessing insurance information, locations of clinics and facilities to which we refer patients and other productivity applications). It seemed logical that they too would benefit by additional monitors.

However, when we attempted this we discovered that there were enough quirks in how remote hosted applications (like our EMR) treated two screen arrangements and often they couldn't put the second screen on the right (the preferred arrangement for Windows applications). Secondly there wasn't enough space to accommodate large second screens and all of the cords were a nuisance.

I was impressed with the iMac that I was using at home but there were cost constraints (as well as push back from our IT department) that prevented experimenting with iMac nursing workstations. Instead we tried HP's new Touchsmart 600's and received permission to purchase one of them to test.

Within minutes of setting it up one of our better nurses who admits to being computer phobic was jumping all over the Aerosnap and other Windows 7 features including the touch screen functionality for web page and windows arrangements. Her response triggered us to purchase several more refurbished units for under $900.

This device, like the iMac, has a wireless mouse, keyboard and NIC card and due to it's vertical positioning actually increased the usable space around the machine on the nursing island while at the same time nearly tripling the effective screen real estate.

We started calculating the time saved by counting how many times during a routine phone interaction the nurse had to open close or manipulate a window to answer various questions. The other party at times would want specific visit, lab, insurance and past patient data that necessitated jumping around to different sections of the chart.

In addition the nurses usually had to bounce back and forth between patient's charts and their message center in the organizer section of the application.

On average a minimum of 5 window changes were required to complete that interaction. Each of these changes added 5-10 seconds to close or bring to the front the desired window and then locate the data.

The very large screen devices with the Aerosnap feature enabled the nurses to have most of the needed windows open on the screen with minimal manipulation and the number of screen changes plummeted to a little over 1, a savings of 25 - 30 seconds per phone interaction.

Each nurse said that in the course of a day they fielded close to 50 phone interactions (this despite having nearly 80% of our patients using our web portal and saving nearly 8 hours of phone conversations a week per nurse). This means in the 1st day of setting these devices up we were saving each nurse an average of 25-30 minutes a day in wasted PC manipulation. Based on our average wage our calculated ROI on these devices is well under 90 days.

In short, you just can't have enough screen real estate and productivity gains is proportional to the amount of that real estate.

Incorporating photograph in an routine exam room visit

2010-06-24T11:41:00.000-07:00

I've been incorporating photographs in PowerNotes for nearly 2 years and after a wide variety of experiments am now refining the process to where nearly 50% of my notes have images in them without adding any time to the documentation at the point of care in the exam room. This blog reports on the technique and methods that allow this value added process in a primary care ambulatory setting using existing tools, devices, features and functions in PowerChart 2007.19 code.

Basically the process involves using virtually any camera, transmitting the images in real-time to a secure network folder that is accessible by PowerChart running on Citrix application servers, loading those images into the Multimedia Manager, Clinical or PowerNotes during the visit. Here's what it looks like:

We've been testing a variety of cameras to determine whether there is an optimal camera and have concluded that virtually any image capturing device will work and the one chosen should be dictated by the nature of the image and potential downstream use. The iPhone works as does the inexpensive point-and-shoot cameras, mid-level and high end cameras. All have their advantages and disadvantages but they all work (more about this later).

The critical component for fast, secure and seamless incorporation of images in the point-of-care documentation process is a wireless SD card. We found that physically having to connect the cameras using USB cables and/or removing the SD memory cards and inserting them into the local device was problematic on two major levels.

First, the active of manipulating the camera, cable or chip detracted significantly from the patient-physician interaction and interrupted the flow of the encounter as well as added time to the encounter.
Second, enabling USB and SD imports increased the security risk of the in-exam room computers unnecessarily.
There's an Eye-Fi app for the iPhone so smart phones can be used securely as well and this allows the smart phone to direct the photographs in a secure fashion to the same secure as the cameras with the Eye-Fi cards although it seems to take marginally longer (1-2 minutes at most).

We are having significant success using wireless Eye-Fi SD cards widely available at different price ranges ~$40 - $100 primarily dependent on size and speed. These cards look like any SD camera memory card except they have wi-fi capability in which images are encrypted and routed wirelessly to the desired location. The cards come with an Eye-Fi Center application that installs on any PC or Mac allowing the user to specify which Wireless Access Points to connect to (up to 32 private/secure SSIDs may be specified for each card) and the target network folder to which the pictures will be routed. All of the cards can be managed by the same application as shown below:

Net result: A picture is taken in the exam room > camera begins immediately to transmit the picture without any intervention by the physician > physician and patient continue their interaction without being disturbed > image is usually available to PowerChart's drawing tool within 30 - 120 seconds (there are many variables that vary the copying of the image from the camera to the network folder). The physician can then incorporate the image in the note that (in our case) is being compiled at the point-of-care in front of the patient.

We're using images for anything that is difficult to describe or will need to be followed (rashes, lesions, wounds, physical findings like edema, varicose veins, etc.).

It's fun, the patient's love it and it has certainly enhanced the physician/patient/exam room experience without adding time to the visit or taking attention away from the clinical condition/event that prompted the visit.

The Active Challenge - 300 in 60

2010-06-11T21:12:00.000-07:00

Yesterday I finished my Active Challenge and here's the video of that event. Since I'm turning 60 this year I decided to play 60 holes of golf in one day; WALKING and carrying my own bag AND breaking 300 (5 strokes per hole). Enjoy and find out whether I completed it and whether I met my goals.

iPhone, iPad and application licenses

2010-04-03T14:40:00.000-07:00

Just discovered that Skyscape's (http://www.skyscape.com) applications that many of us physicians used have to be uninstalled on the iPhone before they can be installed on the iPad. Alternatively the physician is free to purchase them again to use on both the iPhone or the iPad even though the likelyihood of them being used at the same time is remote.

This is simply not right and as of now I'm recommending that all physicians who use Skyscape products refuse to purchase separate copies for each device they use. The license should be to the individual, not the devices.

Technology to the rescue?

2010-03-01T06:31:00.000-08:00

So reviewing this morning's news a couple of interesting articles caught my attention. One, a discussion of Foursquare which provides a social networking app tying into their GPS devices that quickly allow people to "check in" to bars, restaurants, shops and other venues ostensibly to share tips and receive points. The complete article by Rob Pegoraro can be read in his Fast Forward column on the Washington Post.

The second, another release from Duke on a "New smoking cessation therapy proves promising."

And then this add on 7A of this morning's USA Today about a GPS enabled ESCORT radar detector.

What if you put all of these together in a medical application? A GPS enabled, location specific inhaled glucose delivery system for insulin dependent diabetics. Would know what restaurant you walked into, calculate the average carbohydrate load of the items on the menu, adjust the inhaled insulin device so that you could eat or drink your fill without raising your blood sugar and then guide you safely around any police checks?

It's getting pretty freaky but let's take it one step farther and have all of this available as an implant. Now go back and remember the Cyborgs from the old Startrek shows?

Are we there yet?

We are the problem ... and the solution

2010-02-28T08:58:00.001-08:00

We Are the Problem ... and the Solution

An article by Reed Ablelson in this morning's New York Times illustrates clearly why no matter what happens in Congress over the next few weeks our Health Care will never be the same. Our current system is simply unsustainable and incremental changes have done nothing to curb the escalation in health care costs. It is apparent that large changes are coming. The question is not if but when and by whom?

I was struck by how much blame each of us carries in this dilemma. Most physicians in this country are payed by what they do, not what they produce. As a result we are all under pressure to bring in enough income to pay our nurses and staff. Estimates vary but most primary care physicians (of which I am one) need to post at least $400,000 - $600,000 a year in order to make ends meet (staff, malpractice, lease, equipment, supplies, etc.) and even then profit margins are very slim.
In large multispecialty groups where salaries are often calculated by Relative Value Units (RVUs), physicians need to crank out 5-6,000 units just to break even. What’s insidious is that a physician will tally up more RVU’s for procedures than brain work. So it’s much simpler to do something to a patient than work with the patient ... a lot simpler and a lot more profitable.
This has led to serious shortages of primary care physicians and an abundance of specialty physicians partially due to the high cost of medical school, the need for repayment of student loans and prestige that comes with disciplines with high revenue potential.
We physicians have lobbied heavily to keep our costs from dropping, forcing Congress to delay each year the implementation of the Sustainable Growth Rate formula that was voted into law in 1992. These small, yearly decreases in payment have gradually accumulated to where a massive 21% cut in Medicare payments is scheduled to go into effect this coming Monday, March 1, 2010. The AMA is confident that emergent legislation will prevent these cuts from taking effect and forestall them yet another year. Eventually, the system will collapse and the results will be catastrophic not only for physicians, their offices and staff but for Medicare patients who may not be able to get in to see a physician at any costs because doors will be shut to them as it is to many Medicaid patients around the country.
Physicians can still afford to do this because there are enough privately insured patients to generate the revenue needed to keep their doors open for now. At some point this house of cards crumbles.
We patients are also to blame. In the last 20 years we’ve seen an ever increasing cost of health care diverted towards chronic diseases that are in large measure preventable. Obesity, diabetes, high blood pressure, coronary artery disease and many forms of cancer can be directly linked to lifestyle choices.
In addition we choose ignore “natural” ways of preventing diseases through immunizations and dietary changes.
When we hurt our backs we refuse to go to physical therapy and instead insist on medications, MRI’s and even surgery when the evidence points to better results with simple physical therapy.
We patients insist on antibiotics when we feel bad even though repeated studies have shown for many of these conditions we will get better faster without them.
It is infinitely cheaper to stop smoking and avoid lung and heart disease than to pay for cigarettes, medicine and procedures. Yet we complain about the cost and effort involved in smoking cessation programs (even though they are less expensive than the monthly cost of a pack-a-day cigarette habit).
And it’s worse when we’re healthy! We often choose not to purchase health insurance, which only drives up the cost of health insurance for everyone. If only sick people purchased health insurance it would be more costly than medical care (providers of health insurance have the cost of medical care, their own business and profits to shareholders to address). Insurance only works when a critical mass of enrollees never utilize their insurance.
And then there’s politics. The cost of being a politician by its vary nature will prevent the politician from making the hard choices. It’s simply much easier and less costly for supporters to pull funds from anyone making a hard decision since most hard decisions adversely affect a critical mass of supporters in the short term.
So what are we to do? Well, for one we need to act because no one else is going to. For my own part I have resolved to be a role model for my patients. I am trying very hard to make the decisions I ask my patients to do. My diet has changed as have my exercise habits. In addition I have started listening more to my patients (it does adversely affect my income potential for the organization for whom I work). I make sure that each hour an appointment slot is left open for same-day appointments. I have encouraged patients to log into our web portal for routine things that can be treated without a face-to-face visit. We’ve stopped taking samples in our offices and are working with patients to chose generic medications wherever possible.
As patients it is usually less expensive to do the right things. First, change our lifestyles to maximize our genetic potential. We do need to stop smoking. We do need to move rather than sit. There’s no reason we shouldn’t all be at our ideal body weight and should constantly strive to maintain that weight. We do need to be proactive and strengthen ourselves to grow old rather than sit back and let it happen. We do need to leverage our own immune systems and get vaccinated (which is really the best natural approach to preventing diseases) not only for ourselves but for those around us. It is much less costly to get vaccinated than to get sick, no matter how minor that illness is. The complications from vaccinations are infinitely smaller than the complications from any of the diseases.
When we do get sick it is our responsibility to learn about our illness and help the physicians make decisions. It’s my experience that most bad decisions are made from lack of information than from malpractice. It is our responsibility to know what over-the-counter medications, vitamins, herbal supplements and our past medical histories. Make sure the physicians making decisions are aware of this. If the recommendation is something other than medicine we need to follow that advice (physical therapy and counseling are effective and even if they are not “covered” by most plans are the things that will cost you less in the long term). If medicine is prescribed we need to know the medicine and take them as directed along with redoubling our efforts to make the changes necessary in our lives to decrease the need for those medications.
We all need to purchase insurance. Purchase only catastrophic if nothing else so that we don’t wreck our lives, the lives of our loved ones or undermine public budgets when major illness or injury strike.
We all need to wear seat belts, stop driving under the influence of mind-altering drugs, alcohol or texting. We need to wear helmets on bicycles, motorcycles and other vehicles without roll-over protection.
We need to care for others and not be responsible for hurting others.
Finally, we need to begin rewarding those politicians who make hard decisions. We need to counter the fringes and participate in elections. Neither the left or the right are going to be able to solve our problems. The center will and we need to begin rewarding those who work with others and not those who are obstructionists.
The bad news? It’s always easier to do nothing and be a victim than it is to do something positive and avoid being a victim. But that’s what we need to do if we went to lower the cost of health care and become part of the solution, not the problem.

Posted via web from Dr. Voran's Posterous

The Ideal Exam Room: A Primary Care Physician's Wet Dream

2010-02-12T14:09:00.001-08:00

There's a certain irony in that the more specialized a practice gets the more technology available to help the physician. A retinal subspecialist is a good example where they have in office orbital CT scanners and a host of other extremely expensive tools available for the physician's use at the time of the visit. On the other side of equation the primary care physician who has to deal with the entire body and mind is often left with only with devices that haven't changed much in 100 years. Yet they are expected in the usual 10-15 minute visit to interview, examine the patient, derive a diagnosis and treat the patient.
The stark reality is that it is the primary care physician, with the greatest informational needs that should have most of the tools.
We're all familiar with the tricorder used in Startrek where Bones could scan a person in the field as well as the exam room, view the images and make a diagnosis.

What's silly is that by the time a patient is seen by the subspecialist the diagnoses have already been made (usually by several other physicians who have sequentially seen the patient at an ever increasing cost). By the time the patient gets to the highest technology it is used only to confirm the diagnoses and to complete the definitive treatment.

It's my opinion that if technology was available at the front lines many diseases would be diagnosed, caught and treated long before they require subspecialised therapy or treatment.

There are many devices such as a dermatoscope, tonopen, digital ophthalmoscope, otoscope, not to mention digital scales are available but outside the reach of most primary care physicians. Yet, if each exam room was equipped with these digital devices AND connected to their electronic medical records many diseases that now are missed could be diagnosed earlier, more accurately and treated at a much lower cost than they are now.

On the pure information front, I find the time cost of logging into multiple systems (our own EMR and those of nearby hospitals, reference labs not interfaced without our system, imaging centers, online reference sources such as UpToDate, ePocrates, MDConsult and a host of other tools that I wind up using in the exam room prevents me from exploiting them in the typical 10-15 minute appointment. Even though we’ve equipped the PCs in each exam room with 21” swivel monitors we find there’s a lot of visit time that could be saved if the all of the information needed at the time of the visit didn’t need to be navigated to.

When not seeing patients I usually grab all of the computers to which I have access, splay them up in front of me (including one of the units from the nearest exam room). Productivity increases dramatically. Most information resources are at my fingertips in parallel rather than serially if restricted to a single machine or reduced screen real estate. This is exactly why traders in most brokerage houses sit behind multiple displays in order to work. Time is money and faster, better (well, maybe) are made if one doesn’t have to waste time navigating to that information.

So what am I saying?

I am confident that if we would put the most technology possible into the hands of front line physicians who have to address the broadest spectrum of patient concerns we might be surprised at how much more efficient, productive and cost effective healthcare would be.

So one day I see myself practicing in a room with all of the tools at my and my patient’s fingertips. Any questions could be quickly answered, the record would not have to be populated with vague text but actual images of the pathology observed, sophisticated imaging and testing could be accomplished at the point of care before the patient left the room. The patient and I would have a very good understanding of the next steps rather than waiting for all the ordered tests to come back as the patient is sent across town for them, paying higher and higher prices the closer we get to the definitive diagnosis.

And then I wake up only to have had a wet dream. I have to return to the small, cramped, jail-cell exam room with the one computer and a variety of relatively low-cost analog devices and try to answer difficult questions. Often having to disappoint the patient by sending them on to another person or facility to eventually get to their answers.

Posted via email from Dr. Voran's Posterous

Why I like taxes

2009-12-27T08:53:00.001-08:00

The first Christmas blizzard ever in Kansas City reminded me why my wife and I chose to live in Overland Park, a suburb of Kansas City on the Kansas Side of the state line Taxes. We chose it because property taxes were significantly higher than just across the border in Missouri. Huh? Doesn’t seem to make sense, you say. Apparently we’re not alone because we’re surrounded by neighbors who frequently get reminded of the benefits of living where taxes are higher and reaping the benefits of those shared expenses.

The blizzard? Right. Three hours into the blizzard we saw city snow plows clearing our neighborhood streets. And they came back several times in a 24 hour period. None of us had problems getting out when we needed to. Today we went to Church, 2 days after the snow. The minute we crossed the state line we found ourselves maneuvering snow-packed streets littered with cars stuck in their driveways and communities locked in. Almost all of those who were at the early service lived on the Kansas Side while many on the Missouri side who lived only a few blocks from Church were homebound. Snow plows may never make it to their side streets before the snow melts.

In our neighborhood most of us were out shoveling not only our driveways but our sidewalks. Those with snow blowers went from house to house without being asked wishing their neighbors a Merry Christmas. Even teen age school children put aside their Play Stations and cell phones to help. Why? I think a large part of it was that the streets were plowed and therefore the mobility barrier was only our driveways. That wouldn’t be the same if the streets were filled with 10 inches of snow. What good does it do to get out and shovel your driveway when you still can’t go anywhere?

So what does this have to do with taxes? When people see their money going to local services like snow plows, good schools and civic government a stronger sense of community and pride exist. Ironically the more selfish people are in the short term the more isolated and costly it becomes for them to live as a community. Communities are made of those who are fortunate and those who are less fortunate. Those who reach out and help each other socially, fiscally, spiritually and neighborly are those who are healthier and live better.

I was struck by an Randall Stross editorial by in the NY Times this morning titled, “Sorry, Shoppers, but Why Can’t Amazon Collect More Tax?” (http://www.nytimes.com/2009/12/27/business/27digi.html?_r=1&ref=technology). The article describes the elaborate efforts Mr. Bezos has gone to keep from paying taxes to the states in which they provide services. This gives Amazon a competitive advantage at the expense of teachers, civic services, public roads and a whole host of other tax-based services on which Amazon itself relies. Similar corporate measures are costing states up to $350 billion a year and we’re all suffering for it. Mr. Stross concludes “Amazon’s in-house counsel should help the company meet its civic obligations — and toss “entity isolation” in the trash can. Amazon’s employees are too scattered, its customer base and its sales too large and the states’ fiscal crisis too grave for it to continue to play tax-avoidance games.”

Here, here. And the next time it snows, storms or a crisis hits. I’m glad I live in a community that takes it’s taxes seriously.

Posted via email from Dr. Voran's Posterous

The Uncertainty of Diagnoses

2009-12-16T11:20:00.000-08:00

There was a sentinal event experienced when I matriculated into medical school at the age of 34. The dean of the medical school stood up and quoted a study that showed in 1983 up to 40% of the time the working diagnoses at Johns Hopkins were found to be in error on autopsy results. He then went on to say that by the time we finished residency most of the knowledge we'd memorized in medical school would be obsolete. That's when I went out and spent over $3,500 for a computer only to be crushed that there was very little software that would help me 1) get through medical school and 2) help with diagnosing and treating a patient.

A lot has happened since then but the promise of artificial intelligence, connected health information networks and computerization of health care hasn't really panned out the way I imagined over the last 25 years. But one thing that hasn't changed is the complexity of even simple diseases. Why?

Well, for one we don't practice medicine scientifically. Take a simple sore throat. We don't do viral and bacterial cultures on every one or even a random sample of patients to discover the exact pathogen with which we're dealing. There are probably over 200 viruses and 50 bacteria and a multitude of mechanical and environmental agents that will produce almost identical symptoms. We don't have instant tests with the exception of Rapid Strep, Rapid Influenza and Rapid Mono tests that can help us significantly. Thus for the vast majority of cases we are practicing blind. Fortunately most patient get well from this condition in 2 weeks no matter how we treat. The evidence suggests that with the exception of a very small minority of conditions NOT treating is better than treating but it is really hard to convince patients no treatment is better than treating.

I purchased QMR, Iliad and a subscription to AMANet to access Octo Barnett's DxPlain to help me come to correct diagnoses. What I and my colleagues discovered is that there were about 1,500 signs and symptoms that covered almost all of the known diseases (over 20,000 in the databases). That meant a large number of diseases presented with the same signs and symptoms. There were very few diseases that had pathognomonic signs or symptoms. Consequently we became pretty good at coming up the differential diagnosis (a list of the diseases that shared the same symptoms). Our goal was to rule in or rule out the diseases by ordering tests and procedures.

In primary care we see patients every 10-15 minutes. We go through the same process and usually have a relatively short differential list of diagnoses that we think we're treating. We order tests that are returned to us over the next few days. And yet we have to make a diagnosis for that visit at the time of the visit in order to get paid. We usually pick the most probably diagnosis at the visit and that goes on the claims that is processed electronically.

The labs will come back and either rule this diagnosis in or out. Guess what? There isn't a process for us to go back and amend the visit diagnosis with the correct one if a test ruled the original one out and replace it with another one. My guess is that over time up to 40% of the claims based diagnoses are totally bogus.

And then there are complicated diseases like Lupus Erythematosis or Fibromyalgia with no confirmatory tests. A patient may be seen up to 10 times before these "diagnoses of exclusion" are made. There is no systematic way to go back and amend the diagnoses of the previous 10 visits and change them to the final diagnosis made.

That's why most astute people will take claims based data in the ambulatory environment with a huge grain of salt. What may be more valuable is a big picture of all of the diagnoses over time to get an idea of what's going on with a patient. But that data is usually not available as it's hidden in many physician's charts, EMRs and insurance claims data.

We need a national system for experts to go through reams of claims based data, compare it with the symptoms documented and then systematically modify the diagnoses to improve their worth. That's probably not going to happen.

Digital sharing of data and compliance conundrum

2009-12-12T13:38:00.001-08:00

The Situation
Saw one of my partner’s patients (new to me), a 71 year old woman with a history of hypertension, late in the afternoon with an 8 hour history of abdominal pain. She’d thrown up once but other than the epigastric pain was not that uncomfortable. Vitals were stable, EKG normal and acute abdominal films were unremarkable. Drew basic labs including pancreatic and liver enzymes and discussed with her the broad differential. She elected to go home and wait for the labs to be resulted. We batch our labs at the end of the day and since she was the next to last appointment of the day expediting the labs by ordering STAT would only add expense without improving the turn-around time.
Drove home, had a cocktail and enjoyed a meal with my family and then logged in to review that day’s labs (which by now were being resulted). To my dismay her liver and pancreatic enzymes were in the thousands. Called her cell phone to advise her to go to the emergency room right away. The patient’s choices were many including the hospital with whom I share an EMR. However, she was at her daughter’s home and there were two other hospitals very close by and she elected one of them rather than drive an hour to my own hospital.
Called the ER to discuss the case with the attending who said this was a “slam dunk” admission and transferred me to the Transfer Team so that the hospitalist could be notified. The hospitalist accepted the patient and asked if I could fax my visit note, recent labs, patient’s Face Sheet and summary to expedite care. No problem, I quickly gathered that information together, assembled them into a document while the physician was on the phone and was about to click the SEND on our e-mail and paused ...
The Problem

Was I doing HIPAA compliant? Probably not.
Even though I had the patient’s verbal consent to do “whatever was required” to get her into the hospital I doubted whether that would pass not only our own internal compliance officers but any state and federal regulator’s judgement.
Our system does have a HIPAA compliant Medical Record Printing (MRP) function that gathers all of the HIPAA variables (who, what, to whom and why) but only allows us to FAX to those devices that have been tested and validated. It doesn’t allow an end user to key in a new fax number. The MRP function has 2 options: Print and FAX. And then only to defined printers and fax numbers. There isn’t a way to generate a password protected PDF file that can be sent to where it’s needed. Nor can it generate HTML documents that could be sent to a secure web server into which anybody downstream who is given the correct password could log in to retrieve it.
Our system also comes with a patient portal allowing patients to access and then do whatever they want with their own information including a function that lets them share the record with another physician who can then log in as a new user and view that record. Over 80% of my patients are taking advantage of this but this was an elderly patient of my partner who is less aggressive in enrolling her patients. This patient didn’t have an account and therefore the other option of sharing her record with the next physician wasn’t available to her.
This information would significantly speed up the admission and workup process on this patient and it was needed in a matter of minutes, not hours or days. I had everything ready to go to the physician with one click of the SEND button. Should I? Which is more important? Compliance with old paper-based regulations or patient care?
Damn the torpedoes
I clicked the SEND button with only a little hesitation and felt good as the hospitalist thanked me profusely, complimented me on the thoroughness of the note which included the patient’s picture, all of the labs, radiologist’s preliminary interpretation and an image of the EKG. She wanted to know why more referring physicians weren’t more accommodating and suddenly realized how important leveraging technology was.
Solution?
There have been years of discussion in Healthcare Information Technology circles about standardizing communications between Health Information Systems, numerous detailed proposals and countless arguments on how Patient identifiable Health Information (PHI) should be transferred from one system to another. In the meantime these types of situations happen thousands of times each day. The overwhelming majority of them are accomplished by Medical Records department personnel locating a paper chart, scanning and faxing the appropriate material to another provider’s fax machine and then taken to the requesting physician. This process take time, often many hours transpire between the request and the fulfillment of that request and often involves many people and supplies. The process is at the mercy of the resolution of the scanner and fax machines so many times the data in the hands of the requesting physician is barely legible. All this time there are low cost solutions using everyday tools that enable the transfer of this information directly between the two physicians who are involved in the care of the patient.
Surely we can come up with better regulations to let us care for the patient without having to worry whether some compliance officer or regulatory will spank us after the fact.
Any ideas would be welcome and passed on to our vendor and our compliance officers. Uh, we’ll keep the regulators out of this one for the time being.

Posted via email from Dr. Voran's Posterous

What I believe about EMRs and Medical Information

2009-12-02T16:55:00.000-08:00

I matriculated into medical school relatively late in life (at the age of 34) back in '84. Purchased my first computer with all of our savings (more than $5,000 - can you believe they cost that much then?). My wife threatened to do nasty things to my gonads unless that investment paid off. Twenty five years later it has (thank goodness). Here's what I've learned in the interim:

First and foremost, unless information systems are aligned with human, bacterial and viral interactions they will never fulfill their promise of providing the "RIGHT information at the RIGHT time to the RIGHT people.
Second, unless the patient is the primary user of the information system it will have trouble delivering a return on investiment. This is what is meant by patient centered approach to care.
Third, the power of any electronic health or medical record is proportional to the number of other clinical information systems (hospitals, other doctor's offices, pharmacies, etc.) to which it is seamlessly linked.
Fourth; until physicians begin to think like patients they will have trouble communicating and improving the health of their patients.
Fifth; until we change the reimbursement formulas, we will never bend the cost-curve of medical care in the United States.

Incidentally, this is a corollary of #4

So those are the main things that I've learned after 25 years of attempting to push the envelope in medical care. Of course there are many other lessons but those pale in comparison to these 5.

Now there are equally several big lessons that I've learned in other areas of my life but I'm not sure I want to share those with the world now.

Healing Heat

2009-10-16T07:47:00.001-07:00

Some of my most pleasant memories growing up in Japan were trundling across the street with my family to go to the neighborhood public bath or sento. That’s where many of learned to swim and the underwater trip from the 39° soaking tub to the 41° tub was an adventure. Later on our high school basketball coach would reward the team by walking to the nearby ofuroba where the team would soak away the soreness and then saunter back to the dorm wearing only yukatas with the steam rising into the frosty winter air. The spas and saunas in southern Germany rivaled the Japanese onsens for providing relaxing sweaty conversations with locals and vacationers. Rounds of golf in Korea are completed with a hot soaking bath or you can go to the local Jjimjilbang to bathe. Around the world there are many countries that have a rich public bathing tradition and whenever I’ve been fortunate to travel have felt they play a very large role in promoting physical and psychological health.

Looking back I think there are two very important health promoting forces in play. First, and foremost, is the power of heat (whether dry or moist) in washing away or killing harmful disease promoting viruses and bacteria as well as reducing allergy causing antigens. Time spent in these cleansing environments reduce the chance of subsequent infections and allergies. Second, is the social health that improves when you shed your clothes and interact with other people. The baths, steams, saunas and spas taken with others is much healthier for the psyche than those taken alone. I’m convinced these two factors, when combined, boost the immunity, relax the mind and stave off diseases.

I wonder if there would be less obesity if every day we knew we were going to be spending time naked with our friends and neighbors? Maybe it is entirely anecdotal but it seems that in countries with a public bathing tradition people spend less time watching TV and more time in conversation with each other. This carries over to how they eat as well. It seemed we spent more time around the table communing instead of the table being a place to wolf down the food and leave to watch TV or do something else. It was a place to spend time and enjoy the food and the companionship.

As a physician I’ve been advocating to my patients with a variety of ailments to invest time in going to the local Y where there is an excellent steam room and sauna. Alternatively they should invest in steam generators and convert one of their showers to a steam shower. Unfortunately very few of them follow that advice and I see them all too often in the clinic with one physical or psychological problem after another. For the cost of many prescriptions they could be experiencing the healing power of heat and begin to enjoy life.

Testing Livewriter

2009-10-09T20:06:00.001-07:00

Am beginning to see a trend where applications, even those that are competing share the same information. This short blog is being written in the new Windows Live Writer and ostensibly will automatically post this to my Blogspot.com page and Windows Live Spaces.

I’m wondering how long it will be before this interaction translates into the healthcare electronic records? Right now there are a number of Personal Health Records enabling individuals to enter and have access to their health data from anywhere. The problem with most of these is that the data their doctor enters in their offices doesn’t automatically flow into their PHRs. There are some organizations, like Cleveland Clinic, who have formed relationships with Google Health and Microsoft’s HealthVault but most of us don’t go to Cleveland Clinic. We need to figure out how all EMRs being used in physician’s offices can be configured to automatically exchange data with each of the patients’ PHRs.

Recently gave a presentation about the importance of social media in health care. We’re a ways away from social media tools being integrated into EMRs but blogging, twitter, Facebook and other social media tools are laying the groundwork for the interoperability that we’re all wanting.

Playing around with what’s available and waiting for the plug-in that will allow me as an individual physician using a integrated EMR from Cerner along with other 100+ physicians and a hospital to concentrate on what I’m doing and seamlessly update my patients’ PHRs.

Littman 3200 BT Stethoscope & Zargis Cardioscan - Is the PC the problem?

2009-09-11T07:58:00.000-07:00

Am midway through testing the Littman 3200 BT Stethoscope and accompanying Zargis Cardioscan and StethAssist software. First, the scope and software do work as advertised. User interface on the scope was relatively simple and didn't really require much training. Similarly the software (both the StethAssist which ships with the stethoscope) and the $395 Cardioscan software do work reasonably well. The problem is in the logistics.

Most of us physicians practice out of several exam rooms and usually are under significant time constraints. In my clinic we have wireless desktop PC's with large 21" swivel monitors that are primarily for the patient to view along with the physician our digital records, radiologic images and patient information. The EMR software (Cerner's PowerChart) is running on Citrix servers. Each of these devices is networked autologon device that is rigidly controlled for security purposes (limiting SD, BT local CD connections).

The Cardioscan software runs on a PC and after inputing the patient information and wirelessly connecting with the stethoscope guides the physician through the steps of collecting heart tones from the 4 standard chest locations (takes nearly 2 minutes to collect all of the information). When finished the softare analyzes the data and produces a graphical and sound output that highlights any murmurs that might be present.

So far so good. The problem is when I move from one exam room to another it's not easy to manage both the PC softare, the scope, the patient and the EMR that is collecting information at the point of care. Installing the software on each of the exam room machines is possible but in our clinic that would entail loading it on 32 devices. More limiting is that each of us with one of these stethoscopes would need to carry around the BT dongle and plugging it in to the networked devices would entail security changes that would compromise the network. Right now we have to carry our own tablets or notebooks into the room along with the scope in order to use it effectively. Even so, the logistics would quickly prevent the effective and timely use of this. The extra time would convert to lost appointments and revenue.

What's needed is for the software to reside on the scope itself allowing us to record a complete sequence. The scope is able to record data but only short segments that can't be paired with specific locations for the Cardioscan software. Unfortunately the small user interface prevents a challenge. What I'd really like to see is the Cardioscan software be published as an iPhone App. This would allow us the flexibility and freedom to move quickly in the exam rooms, on the floor and other locations and collect heart tones needed for downstream analysis and documentation.

There's another problem. The stethoscope costs around $400. It ships with a virtually useless SethAssist software that does not provide any analytical tools and has very limited functionality. Zargis then hits the user with another $400 for the more useful CardioScan software (and also nails you for $17 shipping and handling!). Spending $800 for an 80% solution sticks in my craw as a primary care physician and especially for medical students and residents who would find this most useful.

Recommendations to Littman and Zargis:

Make sure the BT is BT2 allowing pairing with multiple devices.
Enable the software to be easily installed on multiple devices.
Lower the price of the software with residents and PCPs in mind
Dump StethAssist and ship the system with CardioScan
Create an iPhone, Pre and other BT enabled device App and enable pairing of the scope to all of these smart phones

Oh, the same advice goes to Welch-Allyn who also manufacture digital otoscopes and ophthalmoscopes. The problem to effective use is all in the logistics. It's not possible for a physician to control these devices AND click or manipulate an accompanying software on a PC or video screen in order to capture images to place in the EMR. The controls have to be on the device and the connection has to be wireless to a very mobile device that can be carried on rounds, into many different exam rooms, nursing homes and wherever the patient being examined happens to be.

It takes an comedian to make sense of the healthcare debate

2009-09-06T14:02:00.000-07:00

Twitterworld has bounced Al Franken's interaction with the Tea Party confontists. I watched in fascination how deference, respect and acknowledgement of other's points of view (no matter how idiotic) carried the day.

The more I watch this video the more humbled I am and vow to spend more time listening to others, making sure that I don't insult them (either on purpose or inadvertently).

We need more leaders like Mr. Franken.