New Series: EMR Diaries.

Golive PicIt’s time. After thousands of hours of hard work by the IT department, and lots of fretting by pretty much everyone else, the time has arrived. Our hospital is going live with it’s EMR Stage 2 meaningful use system. And it’s starting during my turn in the hospital rotation. (I want to believe that this is purely coincidental, but if I see my office scheduler walking around with a new pair of shoes, I might have to say something.)

What is Meaningful Use? As part of the nearly $800 billion economic stimulus bill known as ARRA (American Recovery and Reinvestment Act) of 2009, the government sought to  electronify (yes, that’s a work, look it up!) medical records. To accomplish this CMS (Medicare/Medicaid) began giving out incentive payments to physicians and hospitals for electronifying their medical records, which would eventually transition into fines for not complying.

By now you’ve probably looked up “electronify” and found that it’s not really a word. My bad. But in a way, Medicare did the same thing. They realized that “electronic medical record” does not really have a definition, either. So they said “our bad” and came up with a set of parameters that would determine if your medical record could be used in a meaningful way, or whether it was just a note pad with a reading light attached to it. Continue reading

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“When I Was a Resident”: Duty Hour Rules Do Not Define Me

Recently, Rebecca Ulep wrote a rebuke of recent resident duty hour restrictions and their potential negative effects on physician education in a post entitled “When I Was a Resident”: How Duty Hour Rules Are Creating a Lost Generation of Physicians. Many practicing physicians agreed with these sentiments, while most residents did not. Our expanding #PulmCC community brought me  into the acquaintance of one the latter, who agreed to write a post taking the other side of the argument. Scroll down for the article, and hit the link above to read the original post. And follow the #PulmCC hashtag on twitter to keep up with relevant material and participate in future #PulmCC twitter chats. 

I argue with my father a lot. He works as an intensivist at a community hospital in Indianapolis while I am about to graduate from a highly academic internal medicine program in Chicago. Needless to say, we have very different perspectives.

He sometimes expresses views similar to those written in a previous article, “When I Was a Resident”: How Duty Hour Rules Are Creating a Lost Generation of Physicians. I started residency the first year that the new intern duty-hour regulations were put into effect. After explaining these rules to my father, he asked me: “How do you guys learn? When I was a resident, we did not have limits to how many patients we saw. I would be working until five or six in the evening on my post-call day and then stay to work a moonlighting shift.” I, then, delightfully asked him if that was before or after penicillin was discovered.

The field of medicine has undergone many changes (yet we still carry pagers…that’s for another rant), some for better and some for worse. There has been much debate over potential benefits and detriments that come with the changes in duty-hour regulations.  I can only speak to the culture at my own institution, but in my experience, there is one thing that has not changed: the pride we take in our work. This is why I take particular issue with the overly dramatized notions brought up in the aforementioned article. Continue reading

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“Doctor, can I record this conversation?”

It’s happened to me a couple of times already. But the question in the title of this post was never asked. Rather I was informed later on that my conversation with a patient or family was recorded without my knowledge. Smart phones have made it all too easy for patients to secretly record conversations with their healthcare providers. Simply hit a button,  lay it innocently down by your side in the office or hospital, and patients get an instant video or audio capture of a conversation with their physician.  When my medical team and fellow physicians found out about the unauthorized recording of our conversation, the news was met with a combination and anger and disgust.

That reaction, it seems,  is typical of what most physicians would feel in the same situation. Why would a physician be upset about a patient secretly recording a conversation with them?

Well, simple, really. Most physicians are in chronic fear that the next person to hear/view that recording will be a malpractice lawyer, dissecting it,  consonant by consonant,  probing for potentially actionable material. The recording, in the physicians mind, changes the nature of the physician-patient relationship. It makes the patient a potential adversary, it makes the doctor feel as if they are in front of a jury and can not speak frankly, it makes them feel as if they are unworthy of trust. In other words, physicians do not like being recorded because they assume that the person recording them has negative motivations.

But let’s pause for a moment and look at this a different way. . . what if they don’t have negative motivations? Continue reading

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The PROCESS Trial: End of the Line for Central Lines?

A lot of things change for doctors once we’re done with training. Most of us leave behind the ivory tower that is the academic medical center to plow the common fields of private practice. We no longer have the weekly journal clubs, the Grand Rounds, the CME lectures. But what we gain is practical hands-on experience with what works, and what doesn’t. A nuanced knowledge of what’s accepted vs. what’s acceptable.

One such area has been the approach to sepsis. Manny Rivers et al published  their game changing study on early goal directed therapy (EGDT) in the treatment of septic shock in 2001, and the result became scripture in the field of Critical Care Medicine. The knowledge that tying sepsis resuscitation to the measurement of central venous oxygen saturation (ScvO2) and central venous pressure (CVP) using a central venous catheter, lead to a surge of recommendations.

The brain trust spewed forth these recommendations in various forms;  Surviving Sepsis Campaign, Sepsis guidelines, Sepsis bundles, Sepsis video games and Sepsis action figures. Somewhere in that sentence I may have transitioned to hyperbole.

Those of us in clinical practice didn’t always follow the drumbeat. Many of our patients with sepsis it seemed, did just fine without a routine central line or blood transfusions, or dobutamine drips. Why use invasive measures when we don’t really need them, and we’re not really sure that they’re helping? Still, when I talked to my ivory tower friends, the response was same, “We always use central lines and follow the EGDT”, they would say.

In case you’re thinking that I’m a maverick, well, it wasn’t just me. Surveys/studies that have looked at compliance with EGDT show compliance anywhere from as low as 0.1% to just above 50%. Clearly people were pushing back against the guidelines, and many began to publicly question whether results of EGDT could be generalized to the general population with sepsis. Continue reading

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How to Fix Healthcare, From a Doctor on the Frontlines: Part 3.

This is the last of a 3 part series by Dr. Moeller, the infamous Doctor on the Frontlines. In this series he explores ways in which our healthcare system is failing, and how it can be improved from the perspective of those who live and breathe healthcare every day. . . doctors. Click the links to read Part 1 and Part 2.

I want every person in America to have access to quality health care all at a reasonable price because our citizens deserve this. Unfortunately, universal access to care at a reasonable price cannot materialize unless lawmakers look to doctors on the front lines of care for specific input.  We as doctors know in many ways why costs are high and why the public is unfortunately misinformed about how it all works.  But we need a representative sample of practicing doctors in Congress discussing these issues so that these “insider” insights can be applied to our current laws. In post, I look at the last of three central  ideas that would lead to better and more affordable care.

3. Health Savings Accounts.

The third solution highlights increasing patients’ roles in their own health, which would lead to more patient satisfaction, and actually lower costs.  This could be accomplished with health savings accounts.  These accounts would be funded by patients with pre-tax dollars and contributions made by employers and/or government subsidy stratified based on the individual’s income and job status.   With actual money in these accounts, patients would be able to discern costs better and use this money as if they were consuming any other good or service, such as handyman services.   This money could grow each year like an investment account and even be passed on to heirs at the time of death, keeping that sense of ownership with loved ones. Continue reading

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How a Journal Club and a Blog Challenged the Mighty NEJM

Could this be end of the Tonka-Scope?

Much has been written about how Web 2.0 tools can change the healthcare landscape.  It would appear a recent set of circumstances has upped the ante.

This story begins with a recent study that attempted to tackle the problem of ICU infections. ICU infections are a challenging problem, patients who are admitted to the ICU are at risk of worsening illness and death from infections such as MRSA which can be acquired while in the ICU setting. To counteract this risk, current practice is the performance of surveillance cultures on people who are admitted to intensive care. If the person tests positive for certain infections they are placed in isolation (and health care providers are asked to wear silly gowns and share a useless stethoscope).

The success of this strategy is dubious, ranging from successful in some studies to nearly useless in others. Based upon my personal observations of my own hospital’s isolation practices, my only conclusion has been that yellow is not a good look for me.

But I digress. In this study, patients underwent “universal decontamination” with chlorhexidine, a commonly used antiseptic. The study found a dramatic drop in the numbers of MRSA infections and bloodstream infections. The study was peer reviewed and published in the flagship of medical publishing, the New England Journal of Medicine (sorry JAMA). Continue reading

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A Dream About U.S. EMR’s; A Reality in th U.K.

I’m back at it again, talking about my continued love/hate relationship with EMR’s. From my conversations with doctors at different hospitals in our region, it seems that most docs appear to be falling into the “hate” column. Meanwhile, I’m still chugging along with the Allscripts Professional EHR that’s been installed in my office. And while it works just fine for the needs of a 3 physician single-specialty outpatient practice, it’s hardly the type of technology that, by itself, can change medical care for the better for a large number of people.

A recent study challenges that notion. In a study published in Chest, researchers in England sought to determine if inhaled steroids are a risk factor for pneumonia among asthmatics. It has already been shown inhaled corticosteroids are associated with an increased risk of pneumonia among patients with COPD. To determine this they looked at a database of medical information known as The Health Information Network (THIN).

In the UK, EMR’s have been in use for years, and general practitioners are encouraged (but not required) to participate in THIN. When a general practice elects to participate in THIN, software is installed in their EMR which runs in the background. The program collects data, while de-identifying it. The anonymized data is then uploaded to THIN, where approved researchers may have access to it.  There is no cost to the practices for participating, and in return for their participation practices not only receive in depth practice metrics, they also receive a percentage of any research revenue generated from the use of the THIN data. At the time that the study was conducted, the database contained data from 9.1 million patients.

But back to the question at hand. From a cohort of 359,172 people with asthma the researchers were able to identify 6857 people with pneumonia, along with 36,312 control subjects.  They were thus able to find a positive correlation between inhaled steroids and pneumonia. (for more on these findings, see my previous post: ) Continue reading

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How to Fix Healthcare, From a Doctor on the Frontlines: Part 2.

This is the second of a 3 part series by Dr. Moeller, the infamous Doctor on the Frontlines. In this series he explores ways in which our healthcare system is failing, and how it can be improved from the perspective of those who live and breathe healthcare every day. . . doctors. Click the links to read Part 1 and Part 3.

I want every person in America to have access to quality health care all at a reasonable price because our citizens deserve this. Unfortunately, universal access to care at a reasonable price cannot materialize unless lawmakers look to doctors on the front lines of care for specific input.  We as doctors know in many ways why costs are high and why the public is unfortunately misinformed about how it all works.  But we need a representative sample of practicing doctors in Congress discussing these issues so that these “insider” insights can be applied to our current laws. In this post, I look at the second of three central  ideas that would lead to better and more affordable care.

2. Tort reform.

We as doctors have a calling to help patients.  But, as we all are human, mistakes can happen. It is very important that patients who are injured by mistakes be compensated in a way that the law is supposed to provide.  However, the point of law is to provide reliable decision-making that can sort good health care from bad health care.  Instead, currently, it is run ad hoc jury by jury with no set standards. The system currently favors a doctor if in fact something was done wrongly or it may favor a patient even if no mistake was made.  This unreliability leads to defensive medicine, ordering tests and procedures just to prove that you did something, or excessively documenting trivial facts to prove you looked at everything.  The estimates for defensive medicine has been estimated up to $200 billion per year.  The current laws neglect both the patient and the doctor and drives up costs with administrative and attorney fees.

Here is an example of the evolution of defensive medicine. If a family physician determines a patient’s headache is likely due to tension and there are no warning signs for something serious, the doctor may choose not to order a CT scan and have the patient follow up if symptoms do not improve. Rarely, a tumor or bleeding in the brain could present in such a way despite a normal clinical evaluation by the doctor.  If that patient ends up having a tumor or bleeding, they can sue the doctor for not ordering the CT scan earlier.  In turn, that doctor doesn’t want that to ever happen again, even though he did everything right by using his clinical knowledge to determine nothing serious was likely going on. Continue reading

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A Comedian Learns That He Has Sleep Apnea (Video)

Sleep Apnea is a serious condition that afflicts millions of people. The condition leads to reduced breathing during sleep which causes reduced oxygen to be delivered to the heart and brain. The condition may increase the risk of developing diabetes, hypertension, stroke, and depression. The reduced sleep quality can also lead to daytime sleepiness which can cause traffic and workplace accidents. In the video above comedian Jo Koy relates how he learned about the diagnosis of sleep apnea (he later got treated). Learn more about the disease and how you can get tested at SleepEducation.com.

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Controversies Surrounding Brain Death

by Chris Carroll, MD, MS.

The death of any person can be tragic, even more so when that person is a child.  Recently, there has been significant media coverage of the case of Jahi McMath, a 13-year old girl who according to news reports, underwent medical procedures to try to improve her obstructive sleep apnea and arrested following surgery. She was resuscitated and placed on a ventilator, but was pronounced brain dead on December 12th.  Our thoughts and prayers go out to the family during this difficult time and to the medical staff caring for Jahi and her family through this challenging and emotional situation.

 Although this case presents an opportunity to provide education about the determination of death, there has been little reasoned discussion.  Emotional discussions are understandable in situations like this one.  But for situations with as serious consequences as this, thoughtful discussions need to occur as well.

 The facts of this case are clear.  Although I am not involved in the care of this patient, from reading the outside neurologist’s report, her condition is not in doubt.  Legally and medically, she is dead.

 Brain death has been formally defined in the US since the 1980’s.  In a Presidential Commission that consisted of doctors, lawyers and bioethicists, brain death was defined as “the irreversible cessation of all functions of the entire brain, including the brain stem” and established detailed clinical steps needed to make that determination.

 So why do we have so much trouble with brain death? Continue reading

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