Participatory Medicine: My First-hand Account

Jonena Relth, President and Leadership Evangelist, TBD Consulting, Inc.

I was being prepped for surgery last week and my surgeon, Dr. Davies, came in to discuss the procedure.  He explained to me that he had reviewed my file several times and decided that he would prefer to perform a less invasive surgery which would result in  less recovery time.  He said the positives outweighed the negatives. I was thrilled that he had taken so much time to thoughtfully consider my specific needs.

He asked my permission and told me his recommendations, but ultimately he said it was my decision. I had been pondering over the same option during the previous week as well.

Our conversation opened up the opportunity for me to ask him if he was familiar with the Society of Participatory Medicine.  I told him about the organization and he quickly made notes of how he could learn more.

I had told him about ePatient Dave and his experience with Stage 4 cancer.  Dave was able to work along side his physicians and ultimately beat the cancer. At that point, my surgeon told me about a relative who had given up on traditional medicine after being told that he was dying and was out of medical options.  He was cured by non-traditional medicine practices.

My surgeon then told me that the phrase he least likes to hear from his patients is, “You decide, you are the doctor.”  He firmly believes that medicine is most effective when patients and doctors work beside each other; the same stance held by the Society of Participatory Medicine.

After much discussion, I decided to have the less invasive surgery.  Going in, I believed my doctor was a competent surgeon, but after my discussion with him, he increased my faith in his abilities ten-fold.  Doctors should be appreciative, not be intimidated by a patient who wants to be involved in their own care.  By the way, surgery went well and I should be back to work shortly.

Related Article:

A Physician’s Experience as a Cancer of the Neck Patient: The Importance of Patient Participation

1. A present and worsening shortage of both primary care physicians, and an even greater shortage of specialists, coupled with healthcare reform which is aimed at increasing access of healthcare will make face-to-face care more difficult.  This, in some areas, has promoted the telehealth industry, whereby a physician will literally see you over the Internet.  Physician shortages and the cost of this technology (most services charge as an office visit and require insurance) limit the widespread potential success of such endeavors.  MHealth initiatives will actually increase contact of the provider and patient via text messaging, email and communication of sensor-derived physiologic data (see below).
2. Obesity is now the biggest threat to the health of Western countries.  It is responsible for the skyrocketing rise of high blood pressure, diabetes, coronary artery disease and even stroke in young people. Most chronic diseases like these are preventable with simple lifestyle changes.  MHealth can effect these changes with educational messages, lifestyle reminders, and the transmission of physiologic sensing data (blood pressure, heart rate, blood oxygen levels, EKG tracing, and others).
3. The cost of healthcare is now literally prohibitive as a percentage of our total national budget. Technological and pharmaceutical development costs due to research, development and regulatory requirements are also at unsustainable levels.  Therefore, both the public and private sectors are embracing mHealth as a solution. The government is making significant funding available for mHealth development.  Large medical device companies are looking to smaller mHealth companies as a vital future of their business plans.
4. The shift of hospital and provider reimbursement from diagnosis-related fee for service management of diseases to to one of outcomes measured goals necessitates better patient participation.  MHealth is a tool that can facilitate better patient care coordination once a patient leaves the hospital.  It will hopefully prevent many office clinic visits and hospitalizations as well. Outcomes based care will necessitate close provider-patient contact upon hospital discharge.  It may decrease the need for home visits by nurses and others due to transmission of information, both clinical and descriptive by the patient.

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Also join our LinkedIn group EMR/EHR Clinical Transformation.  Engage in discussion with more than 2,500 professionals. This group is for physicians, health informatics and medical professionals, IT and performance improvement professionals. Join this group if you wish to learn from peers, get up-to-date news feeds, and share best practices for implementing EMR/EHR systems to equip clinical staff with the skills necessary to make the transition from paper to paper-light electronic records.

Jonena Relth, President and Leadership Evangelist, TBD Consulting, Inc.

Is it just me, or are you ok with the fact that your physician, PA or RN can’t access your records unless they are physically in the office?  After pondering this, I had to ask, “Is it because the doctors in charge are nervous of the cloud, a money issue, or…?  Whatever reason they choose not to allow virtual access to patient records negates a primary purpose of EMR/EHR: patient safety.

Yes, that’s what I said:  Security.  As we’ve experienced in the last few years, patient data is much more likely to be stolen due to employee errors such as leaving patient records, hard drives, etc., in their cars which are then vandalized.  Or, what about the old, dusty files in the back room?  We’re kidding ourselves if we think locks and security alarms are totally protecting paper records.

And back to patient safety.  I moved to a new city a couple of weeks ago and am currently doing my due diligence to find a physician who uses EHR in his/her office as well as virtually.  Additionally, each physician, PA and or RN that has patient contact after hours and on holidays must have virtual access to my records.  I have some medical conditions that I’ll not detail here, but if prescribed the wrong antibiotic, I won’t be here anymore running my company or writing blogs.   

So … I was “feeling poorly,” as they say, sick over the weekend.  Here’s the saga:

• I called my physician’s practice early Saturday morning and explained my symptoms to the service and asked to speak with my physician.  I was told that I would need to speak to an RN first.  (This was ok with me.  I fully agree with this practice as it is more cost effective for the provider.)
• An RN called me 1 1/2 hours later to ask me 40 questions that she would have known the answers to if she had access to the office’s EHR.  I politely answered all her questions, but I was a bit miffed knowing that all my records are on the practice’s EHR just waiting to be utilized.
• I explained that I moved recently and don’t have a new physician yet but knew that my family practice physician would approve the medication I requested — he knows my medical history and what I asked for was exactly what he has prescribed in the past.
• The RN said she didn’t know which physician was on call and could not tell me if that person would prescribe an antibiotic — let alone the one I requested.  (Remember – I’m allergic…so I don’t take new antibiotics unless there is no other option for my symptoms.)
• The RN called me back an hour later and left me a voicemail informing me that the doctor on call had o.k.’d five days of the medication I requested, not the necessary 10 days and that she had called it into the pharmacy.
• When I got to the pharmacy, the prescription wasn’t filled because the RN hadn’t supplied all the necessary information to the pharmacy — simple stuff like the physician’s whole name and ID.

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Accountable care organizations (ACOs) are groups of institutions and healthcare providers that the government is hoping will become the future of the health establishment in the future.  They are based on assumptions of delivering care while limiting costs and improving care.  These are expected to come about by paying the groups based on patient satisfaction and improved measurable outcomes.  

The plan has met significant resistance, initially by physicians wary of operations and reimbursement schemes.  The whole ACO will receive payment based on a patient’s diagnosis and will be shared by the institution and all providers caring for the patient under that diagnosis.  The payment will also include post-hospital care.  The skepticism raised by physicians is that the reimbursement formula will be so complex that it will be impossible to check whether they individually will receive appropriate payment.  In addition, the layers of bureaucracy added to healthcare with this plan will conceivably in itself drive up costs of healthcare, some say.  Admittedly, the designers have stated that they expect ACOs to lose money in the first few years.  The hesitancy by physicians is also driven by the fact that losses by ACOs will be shared by providers as well as institutions.  The planners counter this with incentivizing the players with gain sharing of the decreased costs realized.

Recently, a survey of healthcare executives at the 19^th Annual Health Forum and the American Hospital Association Leadership Summit revealed that many executives are hesitant about signing on as well. 18.2% said they will definitely join and 27.3% will probably join.  11.4% will definitely not join and 25% will probably not join. The remainder were unsure. Read more about the study.  

Interestingly, executives were also asked how they viewed as a priority the following: EHRs: 93%, redesigning care delivery (89.5%), advancing diagnostic technology (61%), advancing therapeutic technology (34%) and social media 30%).

The hesitancy about joining ACOs is significantly greater among physicians than healthcare executives.  The reasons are likely many.  Physicians are concerned about losing even more control over their self-determination professionally and economically.  Their professional organizations are against ACOs presently.  Healthcare executives are looking at a landscape that will likely result in institutions going out of business if they do not align themselves properly in ACOs. Their operating margins decrease annually and they will be competing for patients that will flood the healthcare access market in 2014 when healthcare reform kicks in. They have already started situating themselves for ACOs by buying physician practices (over 70% of physicians are hospital employees now).

The ACO is still morphing into its final configuration.  It is, I believe here to stay for a while because of the investment that Medicare has put into its planning already.  How hesitancy by physicians and executives plays into the final appearance of the entity remains to be seen.  Stay tuned.

Dr. David Scher was a practicing cardiac electrophysiologist for 20 years with extensive experience as a clinical investigator, reimbursement committee member, and institutional review board chair. He is currently director at DLS HEALTHCARE CONSULTING, LLC with a focus on medical device and mobile health companies. You can reach Dr. Scher at dlschermd@gmail.com or on Twitter at dlschermd. 

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The legislation commonly known as ‘Obamacare’, the Affordable Care Act, contains requirements and deadlines for the implementation of electronic medical records, collectively known as Meaningful Use (MU).  There are many definite contributions to improved coordination of healthcare that these will realize.  The cost savings and improvement in patient outcome touted by the government remain to be proven.  

Truths

1. MU is expensive.  In one study, the average cost per primary care physician including training time is $47,000.  The maximum government Medicare MU incentive is $43,000. Hospitals on average are spending over $2M on this endeavor.  After 2017, penalties will be assessed for not meeting these incentives, based on a percentage of Medicare billing amounts. It is estimated that the net effect of penalties outweighing incentive payouts will yield the government $600M in income.    
2. MU’s requirements/deadlines are not in the real world.  The requirements for example of interfacing with labs and other providers cannot be reached in the allotted time because of technical challenges of interoperability among different EHR companies.  MU is divided into three stages.  Stage 1 in progress now and Stage 2 was supposed to start in 2012 but there are many issues for which the date is now in limbo. There are objections by many specialists because the requirements are primary care oriented and difficult for them to meet, as well as technology-limiting issues.  
3. MU will hopefully raise patient awareness about their own medical records, to which they are mandated to have access through patient portals.  This will only come about through public awareness campaigns.  It will create a burden on providers as they are mandated to review the EHR with the patient after each visit.  Emergency rooms and practices are required to furnish the patient with copies of their visits, instructions, and entire medical records in a very short time (ex., entire records need furnished within four business days of request).   
4. There are not enough qualified health information technologists in the country to make this happen as quickly as desired.  Computer programmers are not versed in clinical medicine.  There are six-month courses in healthcare IT but do not prepare them for the required jobs.  A whole generation of specialists in this field needs to come of age.

Fallacies

1. This will be completely adopted and will improve healthcare. 

   A recent review of the implementation of a national health information exchange in England found that it failed because many patients and physicians opted out of the program due to security concerns and burdensome implementation respectively.  Outcome studies will need to be done to prove EHRs’ clinical benefit.  There are significant obstacles (primarily by physicians) regarding universal adoption of EHRs. The advent of ACOs will be a test of the benefits of EHRs as well.  

2. An EHR system that is ‘certified’ by the CCHIT (the body designated by the ONC or Office of the National Coordinator of the government) has all the qualifications to meet MU.  This ‘certification body’s approval no longer means that the EHR meets all requirements set forth by the government.  The onus is now on the purchase to make sure that those requirements are met.  This means that the purchase needs to be thoroughly versed in MU requirements.   
3. Your EHR automatically talks to that of your hospital, labs, radiology sources, and other healthcare providers, and others.

   The exchange of information among these entities is called interoperability, which is the goal of MU.  However, we are a long way off in this regard.  This may incur additional charges from the vendor or the other entity’s IT source.

MU is a daunting project that may ultimately benefit patients.  It may eliminate duplicate testing of patients, improve patient safety by identifying drug-drug interactions and patient allergies quickly, and become a source of patient education.   The time for EHRs is here and they are welcomed for a number of reasons.  The time and content requirements of MU follow the planned course of its creators has already been challenged.  The security of EHRs remains a huge concern.  Let’s get in and observe the ride.

Dr. David Scher was a practicing cardiac electrophysiologist for 20 years with extensive experience as a clinical investigator, reimbursement committee member, and institutional review board chair. He is currently director at DLS HEALTHCARE CONSULTING, LLC with a focus on medical device and mobile health companies. You can reach Dr. Scher at dlschermd@gmail.com or on Twitter at dlschermd.

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The news could not be sadder. Premature baby boy Genesis Burkett was given an IV dose of sodium chloride 60 times greater than the physician ordered. The fatal infusion has professionals and loved ones all around the situation looking to place blame. It’s only natural. It is the worst of human tragedies and people need answers. Sometimes answers contain a kernel of peace – sometimes.

For the details, the READ MORE.

In any case of error, medical or otherwise, there is usually some responsibility to go around, no matter how well intentioned or trained the people involved. I don’t know every detail and will try to refrain from passing any sort of judgment on a situation this sensitive to which I am not intimately privy. I do have, however, a few general thoughts on the issues as presented in the article. Those issues:

1. Some people are looking to blame the use of electronic patient records
2. An IV bag was allegedly mislabeled
3. A pharmacy tech input the dosage information into the pharmacy computer from a handwritten prescription
4. An automated alert system was not active when the information was entered

The initial interface with any electronic health record is the human who enters the data. Humans can only enter data they can accurately interpret or believe to be true. The hospital involved, Advocate Lutheran General Hospital in Park Ridge, Ill., apparently has reached the HIMSS Analytics Stage 6 of its health IT implementation, out of a possible 7, meaning it should have computerized physician order entry (CPOE) integrated into its system. In this particular case, it appears the relevant parts were not online and this prescription was outside that loop.

My gut reaction to this (and I’d like to hear yours, so please comment from your perspective) is that electronic health record systems are being asked to carry a lot of water when the bucket is still full of holes. A fully integrated and implemented health IT system, with well-trained staff and backup systems, may very well be positioned to avert tragedies such as these.

But we will never – and I use that term sparingly – be able to completely rely on any fully automated system in the care of human beings. The best health IT systems will accept, transfer, organize, analyze and process data that healthcare professionals enter. Electronic patient record systems will not have the capacity to look at the patient in front of them, determine that it is a frail infant that can fit in the palm of its father’s hand, and conclude that the dosage prescribed is far in excess of what is reasonable. Highly educated professionals, interacting with well integrated and fully implemented electronic health records, can deliver state-of-the-art care with the assistance of meticulously kept records and perfectly metered doses that match treatment protocols appropriate for the profile of the patient in front of them.

Medicine is yet an art as well as a science. And it is the most caring and skilled human beings, working in concert with finely tuned equipment, that will deliver quality care. In this imperfect world, under those conditions they will deliver it almost every time.

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CNN posted a blog, “10 dumb things you [patients] do at the doc’s office.” Below is my version of what the docs and staff should do to “deal” with and hopefully eliminate some of the issues they encounter.

1. Patient talks on her cell phone.

This is a no brainer. Politely but firmly tell all patients not to use their cell phones while in your office! It’s her health, not her social commitments that count when with you.

2. He lies.

The character on TV, Dr. Gregory House, says “everyone lies.” If you even suspect that your patients aren’t being straight with you, tell them directly that the only way you can be sure that you help them get well is if you know all their medical history — and that includes personal life style issues, like their being sexually active with the same or opposite sex. Just be sure that you tell them that you won’t judge them!

3. Patients do a sloppy job of describing their pain.

Wow, this one made me giggle. As a performance consultant, I’m always happy if someone writes anything down! But seriously, when a patient calls for an appointment, have your front desk ask them to sit down now while the problem is on their mind and write down their symptoms, when they started and how long they lasted.

4. Patients don’t state up front all the reasons for their visit.

I don’t want to over simplify this one, but couldn’t this issue be eliminated if the patient uses their time wisely in the waiting room instead of reading old magazines? Have the front desk ask the patient if they had the opportunity to write down the issues they want to speak to the doctor about. Most will say no, so hand them a form and ask them to fill it out.

When the clinician takes the patient to the treatment room she should read the patient’s notes and ask for clarification of anything she doesn’t understand. The clinician should be sure to put the patient at ease by assuring him that you want to make sure that the doctor is fully informed and ready to help them when he/she sees them. Remember, it’s amazing how nervous some patients can feel the minute they are in the presence of a “white coat,” so keep your tone cordial…and better yet, dump the white coats!

5. Patients don’t state up front their expectations for their visit.

Once again the “process” part of me jumps in: Patient forms should include a space for patients to write down the expectations, hopes, results they want to get from their visit.

6. Patients don’t know what medications they are taking.

Refer you to question #3. I’ve developed a medication list that my docs really appreciate. Tab 1 has the meds I’m taking now for what disease, the dose and comments. Once I finish taking a medication, I delete it from tab one and add it to Tab 2 which lists the medications I’ve taken in the past. This page has the same headings. Tab 3 has the medications that I have taken and had negative reactions. In the comments column, I’ve detailed my reactions. Once the patient fills in their information, all they have to do is update it between visits.

7. Patients leave with unspoken questions and concerns.

Take time to listen to your patients. Ask if they have any questions or concerns about what you’ve discussed. This doesn’t just go for the patient you’ve just used the “CANCER” word for the first time! Tell the patient that he is is free to call your office if they need more information. Yep, it takes the clinician’s time and maybe the doctor, but overall it leads to more trust between the doc and patient and healthier patients, both physically and mentally.

8. Patients don’t bring their medical records or images with them.

I don’t mean to sound like a broken record, but go back to number 3 again. Add the request that the patient bring the medical records and images to the upcoming appointment. And this warrants a follow up call a few days before the appointment to make sure the patient has the medical records to bring with them to their scheduled appointment.

My dentist has an automated text or email sent to patients two hours before their appointment. As a techy, I’ve really appreciated this reminders.

9. Patient is too scared to disagree with You.

Ok, so see number 7. There have been various studies pro and con for white coats. If you ever find yourself intimidated by anyone, remember that feeling. That’s what patients feel in the presence of an intimidating doctor in a white coat. I’m just sayin…don’t think it makes for productive 1-1 conversation.

10. Patient doesn’t comply with the treatment plan.

I’ll go with CNN on this one: “For doctors, this is the granddaddy of them all. If your patients have verbal and written instructions you have reviewed in person with the patient, they should have a treatment plan that makes sense to them and one they should be able to execute.”

My eye doc’s office has this down pat. Before a patient goes in for outpatient surgery, the front desk goes over the instructions with the patient. During a subsequent conversation, the nurse reviews the information with the patient again and even adds dates and times to the form so they know exactly how to follow the plan. And yep, the nurse does her part and then the front desk asks the patients one last time if they have questions, as they leave. Later that day, a clinician calls the patient to check in and make sure they are ok and gives the opportunity to ask questions. This is patient care at its best!

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Courtesy Extended is Courtesy Appreciated

by: Jonena Relth, President and Leadership Evangelist,

TBD Consulting

Patients appreciate it and feel valued when their physicians review their chart BEFORE entering the exam room. By doing so, physicians are demonstrating that they value the patients individually and are not just going from room to room ticking off another patient’s ailments. A physician should come into the room prepared to meet with their patient and interact personally. If during the visit, he/she needs to look something up on the EMR/EHR chart, that is certainly acceptable, but it is optimal for the physician to be SITTING not standing next to their patient so the patient can see at least the side of his/her face while the computer is being used.

Positioning the computer at table height next to the exam table eliminates the barrier of not looking eye to eye with the patient, which is what they want. I have a dear friend who is a retired vascular surgeon and he told me years ago that to operate on a patient he only needed to read the charts. However, by getting to know the patient, sitting next to him, listening and answering all his questions, the interaction reassured the patient and built trust between the two of them. His patients that had his undivided, face-to-face time often had quicker and easier recovery times than those he wasn’t able to meet with personally. A positive, trusting frame of mind is strong medicine!

This is a time of transition with electronic charting and the office visit culture is changing which calls for compromise on both the part of patients and physicians. For the most efficient use of the EMR/EHR, it should be perfectly acceptable for a physician to type notes during a visit AFTER the patient and physician have talked and or the exam is completed. The physician should NEVER have his/her back to their patient as it sends a loud and clear message to the patient, “My using rude manners with you does not matter when you are in MY exam room.” This is not the right message to send. Studies have shown that one of the primary complaints physicians have with using EMR/EHR is the decreased face time with their patients. Believe me; patients want that face time too!

And one last note: Have you ever attended a “meeting” where you had to sit while someone else read their notes in front of you to refresh their memory of the reason for the meeting? I’m guessing we all have experienced this and it is just plain rude. For the physician to review the patient chart before entering the exam room is just plain courtesy. The logistics of the computer placement is just a matter of keeping the goal in mind – - physicians do what they do because they want to help/cure their patients’ illnesses. To do that requires face time.

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Measuring What Works – pt. 1

by: Peggy Salvatore, www.healthsystemed.com

Question of the Day: How Do You Know If You Are Paying For a Treatment That Works?

Answer: You Collect A Lot of Good Data.

Recently a tableful of health care big-thinkers gathered in New York City to cogitate on the future of the pharmaceutical industry. This happens all the time, all over the country – big thinkers thinking big things about healthcare around tables. The only thing different about this one is that I was invited to take notes and be a fly on the wall at this particular gathering, and the discussion triggered the thought that all of these conversations are starting to lead to the same place.

Bzzzzzzzzzzzz.

The issue on the table in New York was: What will payers pay for drugs? Will Medicare pay for a new drug? Will health plans pay? How will they decide what to pay for and how much to pay for it? These questions are couched in a single, larger question: What will payers pay for? The answer is in the data.

In the future, payers won’t pay for procedures and products. Payers (Medicare, Medicaid, health plans like Aetna, Cigna, etc.) will pay for outcomes. Did the patient get better? Prove it. We want to see the data. Lower cholesterol. ED use down. Shorter hospital stays. No hospital readmissions. Surgeries avoided. C’mon, show me the numbers.

Healthcare has been moving toward quality and outcomes measures for at least 20 years. But with health reform, we’re there. Health reform is bringing you Accountable Care Organizations (ACOs) as a mechanism to reimburse providers through the Medicare program. The model is expected to move out into the commercial payer universe after that. And ACOs don’t work without data to back them up.

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