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What Obama's precision medicine plan needs to succeed

What Obama's precision medicine plan needs to succeed | Healthcare and Technology news | Scoop.it

President Obama's Precision Medicine Initiative to accelerate understanding of individual variability and its effect on disease and treatment is going to necessitate a regulatory system robust enough to facilitate big data analytics for genomics research – no small feat.


That's according to a white paper by the Center for Data Innovation and Health IT Now Coalition, in which the authors contend that to be maximally effective this initiative will require the public and private sectors to work in tandem to realize the next generation of medicine and overcome the institutional challenges that increasingly hinder progress.


Policymakers, in other words, must modernize the regulatory system. To that end, the authors recommend the following:


1. Improve interoperability and data sharing. Stronger federal requirements are needed to ensure that genomic and other health data can be retrieved and compared across health record systems


2. Engage patients. The public and private sectors share an interest in raising the tone of discourse on the role that genomics and other big-data applications might play in revolutionizing our expensive and underperforming health system


3. Re-think privacy law. The strict privacy requirements of the Health Information Portability and Accountability Act and complementary federal and state laws, including the Common Rule, present formidable obstacles to realizing the potential of genomic medicine


President Obama included $215 million in his latest budget to fund initiatives at the National Institutes of Health, the National Cancer Institute, the Food and Drug Administration, and the Office of the National Coordinator for Health Information Technology.

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Will Patients Embrace Wearable Health Technology?

Will Patients Embrace Wearable Health Technology? | Healthcare and Technology news | Scoop.it

Technology hype in the medical industry has been well distributed and plentiful for the last several years. Predictive analytics, personal health records, and other medical software have all enjoyed copious amounts of analysis, but none has garnered the attention that wearables currently enjoy.

And it's easy to see why: gathering biometric data directly from the patient and using that information to create more accurate treatment plans, deliver alerts, and generally improve population and individual health is a compelling use case.


Unfortunately, the wearables revolution remains stuck to the wrists of a particular young, affluent population, while patients who could truly benefit from wearable technology have yet to gain access to these devices.


If that access becomes viable on a broad scale though, it could invoke meaningful change.


A recent study by the Pew Foundation revealed that about 19 percent of people without chronic conditions track their health (with or without software). This is arguably the main demographic that use wearable devices or fitness trackers right now.


In contrast, 40 percent of people who have one chronic condition track their health, and 62 percent of people with two or more chronic conditions track their health.


Logically, these numbers may not be surprising — these people must monitor their health to avoid staying out of the hospital. What is surprising is the lack of penetration health wearables have made in this market. Patients with chronic diseases make up a huge portion of total healthcare expenses, and theoretically, their health tracking could be made substantially easier with the help of wearables.


Yet wearables have not reached this demographic, although there are industry stakeholders trying to change that. Here's a look the most prominent forces at work.


CMS and meaningful use


With the new proposed rules for meaningful use Stage 3, CMS has eliminated the rigid view, transmit, and download requirement for patient engagement. Now, at least 25 percent of unique patients must engage in some way with their personal health information within the provider's EHR.


This can be accomplished in a couple of ways: view, transmit, and download, or syncing the EHR with a personal health record (PHR) or health wearable device. Both of the more complex data transfer scenarios bring health wearables directly into play. Even if the data is transferred from a personal health record to an EHR, it's still possible to use the PHR as a repository for wearable data, before it travels to the provider's system.


Insurers


Though the lines are not yet clearly drawn, insurers would surely like to begin using biometric data from wearable devices to make their risk profiles for patients more accurate, and more influential.

 

Data gathered from fitness trackers would provide a realistic picture of a patient's lifestyle, especially if more complex trackers are used to record glucose levels that indicate caloric intake.


The relationship between insurers could be critical, because wearables have a short track life in the consumer market. It turns out, most people stop using them after a few months. However, insurers can offer incentives that other stakeholders can't.


For example, UK-based Vitality Health has been encouraging patients to use wearable technology since 2006. In exchange for the data produced by these devices, Vitality offers life insurance customers points that can be spent on movie tickets and coffee, as well as reduced premiums.


Of course, the downside to insurers having this much information is that they could use the wearable data to increase premiums for patients who don't meet certain criteria (which may or may not actually indicate health risks).


Either way, this offer appeals to the people: 57 percent of respondents in a TechnologyAdvice survey said that the possibility of lower premiums would make them more likely to use a fitness tracking device.


Providers


The final group in the equation is stuck in an interesting position. Though 66 percent of physicians would prescribe an app to help patients manage chronic diseases like diabetes, it's well-documented that physicians worry about receiving too much (read: irrelevant) data from wearable health devices. Although physicians are likely excited by the possibilities of wearable devices, it will likely take some for them to decide on exactly how (or if at all) they want to incorporate such data into their diagnoses.


As it stands now, the industry is rapidly adopting new medical software to fix processes like information exchange and chronic disease management that have made for such obstinate opponents over the years. Of the proposed technology, wearables seem most likely to catch fire, in part because of their consumer appeal and obvious use cases. They certainly have the stakeholder support.

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How health IT is a barrier to patient satisfaction

How health IT is a barrier to patient satisfaction | Healthcare and Technology news | Scoop.it

I was recently talking to a patient about having some extra help at home when she left the hospital with home nursing services. The elderly lady — highly intelligent and fiercely independent — politely declined with the reply: “No, I’m fine thanks Dr Dhand — all they’ve done before is just come in with their computers, barely talk to me, enter a few things on their keyboards and then leave.”


This reply really struck a chord with me (as someone who has written extensively on all that we need to do to improve the use of information technology at the frontlines of medicine). We then engaged in a brief conversation about all the changes she’s seen over the years and how medicine now seems so fragmented and impersonal. I finished with a strong feeling inside that I really couldn’t blame her for declining additional “robotic” services, and that she was talking absolute sense about her experiences.


Her reply is typical of dozens, if not hundreds, of similar complaints I’ve heard over the years about how doctors (and nurses) are simply too pre-occupied with their keyboards and screens and barely look at a patient nowadays. This problem particularly affects the more generalist medical specialties — including primary care — which should be the cornerstone of all health care. The last decade has seen the proliferation of information technology, mainly due to meaningful use and the government’s incentives for the computerization of the health care system.


Let me pause right here and say that I am far from advocating a return to the paper chart or the archaic days of yesteryear. Many of the aims and goals behind meaningful use are noble ones. We simply need to redesign the current systems so that they are fully optimized for frontline medicine, and design them to be as seamless and efficient as possible so that doctors and nurses can get back to where they belong: with their patients talking face to face. Likewise, doctors and nurses need additional training on how better to use the information technology so that it doesn’t come in-between them and their patients.


A study published not so long ago in the Journal of General Medicine showed that medical interns now spend only around 10 percent of their day engaging in direct patient care in hospital and almost half their time with computers. That’s a shocking statistic and an unfortunate imbalance. I’m sure if a comprehensive study was done on primary care doctors, and how long they spend looking at actual patients versus their screens, the results may be even more disappointing.

If it were expanded, the same study would probably also show that one of patients’ biggest let-downs would be when their doctor keeps glancing in between them and their screens. So if we are really serious about improving patient satisfaction and the health care experience, how can we let this situation go on?


I hope that in the not too distant future the world of frontline medicine, IT, and hospital administration, can all get together to solve this problem. I gave a presentation last year in Boston titled: “Healthcare IT: What the frontline of hospital medicine really needs.” The audience was a mixture of entrepreneurs, techies and clinicians. The biggest round of applause I got was from the clinicians when I opened with the provocative statement that health care IT has done more to destroy the doctor-patient relationship over the last five years than any other one single thing. I stand by that statement and hope that we can change things. Until that happens, we continue to massively let down our suffering patients.


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Engage Patients through Medication Education

Engage Patients through Medication Education | Healthcare and Technology news | Scoop.it

Patient engagement was one of the main buzzwords at HIMSS this year. It’s the kind of topic that can ignite a passionate game of tug-of-war. Some folks define patient engagement to patients accessing their health records or securely messaging their doctors. Others consider patient engagement as medication adherence, a reduction in readmissions, or even the use of mobile health apps.

From a patient’s perspective, a common place to “engage” is at the pharmacy, when they receive drug directions that are more than an arm’s length and include pages of side effects and warnings. Like many notoriously long Terms and Conditions agreements, a common response to these details is to just tune them out.

It’s a tough pill to swallow, but one in three Americans are considered low health literate and struggle to understand their often complex medication instructions. Medication mistakes are the most common form of medical errors in the U.S., resulting in 3.6 million office visits, 700,000 emergency room visits, and 117,000 hospitalizations each year, according to an Institute of Medicine report.

It should come as no surprise then that health literacy is strongly tied to patient engagement. When patients understands their condition as well as how to manage it, they are more empowered to make better health decisions.

One company is not satisfied with the status quo and is flipping the traditional model of disseminating drug directions on its head.
They’re turning this:

Meducation instructions are written at a 5-8th grade reading level, clearly identify drug, dose, time of day, explain what each drug is for, and even link to video tutorials for the more complicated directives, such as how to use an inhaler or give an insulin shot. Meducation is available in 22 languages and in larger fonts. It can be printed onto a single sheet and posted on the fridge or patients can enter the barcode number assigned to them on the website to access supplemental education materials.

Turns out that when patients have a better experience with their directives, they are safer, they have better outcomes, and their provider’s satisfaction scores go up. It’s a win-win.


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Patient Satisfaction and Patient Engagement Race to the Top of CIOs’ Agendas: HIMSS Leadership Survey

Patient Satisfaction and Patient Engagement Race to the Top of CIOs’ Agendas: HIMSS Leadership Survey | Healthcare and Technology news | Scoop.it

Patient satisfaction, patient engagement, and quality of care improvement have raced to the top of healthcare CIOs’ and senior IT executives’ agendas in the past year, according to the industry’s leading executive survey. Those were among the findings of the 26th Annual HIMSS Leadership Survey, sponsored by the Chicago-based Healthcare Information and Management Systems Society, and released at a press briefing held Monday morning, April 13, at the vast McCormick Place Convention Center in Chicago.


At that same press briefing, HIMSS senior leaders announced that attendance at the HIMSS Conference this year had reached an all-time high, at 41,044, versus the 35,509 at HIMSS14 in Orlando, or an increase of 15.5 percent, based on Sunday evening registration numbers. What’s more, 1,326 vendors are exhibiting this year, versus 1,211 last year. And the entirety of the space that the annual conference is taking up, HIMSS senior executives announced, was more than 541,000 net square feet at McCormick Place. The gross square footage of the conference, or 1.3 million square feet, said Carla Smith, executive vice president-HIMSS North America, is actually larger this year than the Willis Tower, Chicago’s tallest building, is tall.

With regard to the HIMSS Leadership Survey, most dramatically, respondents ranked “improve patient satisfaction” and “improve patient care/quality of care” as their top business objectives, both at 87 percent, and above “sustain financial viability,” at 85 percent; “improve care coordination,” at 76 percent; “improve operational efficiency,” at 72 percent; “improve physician satisfaction,” at 68 percent; “achieve meaningful use,” at 68 percent; and “increase market share,” at 66 percent. Jennifer Horowitz, HIMSS’ senior director of research, in response to a question from Healthcare Informatics regarding the unprecedented nature of this survey result, noted that the methodology of the survey has changed in this year’s survey, compared to last year’s.


This year, Horowitz noted, survey respondents were asked to rate on a scale of 1 to 7 (7 being the highest), various items on a list; whereas last year, respondents were asked to rank items. Still, the contrast with the results of the 2014 survey is noteworthy, despite the methodological difference in question-asking. Respondents to the 2014 survey ranked the following as their top business objectives: “sustaining financial viability” (25 percent); “improving operational efficiency” (16 percent) “improving the quality of care” (14 percent); “achieving meaningful use” (14 percent); and “increasing market share”(10 percent).


Among a panel of four senior healthcare IT leaders, Paul Kleeberg, M.D., CMIO of the Bloomington, Minn.-based Stratis Health and clinical director for the Regional Extension Assistance Center for HIT (REACH), a REC serving Minnesota and North Dakota, commented that “I think what’s really driving that [survey result] is the Stage 2 requirements to get patients engaged and achieve 5 percent patient engagement according to that meaningful use measure, which I think is a good thing. It’s raising awareness,” he added.


William W. Feaster, M.D., CMIO at CHOC Children’s Hospital, Orange, Calif., added, with regard to the connection between patient engagement and population health, that his organization is involved in a concerted push around both. “Our focus right now is really what this survey is saying,” he said, adding that there are four keys to achieving success in those broad areas. “The first is how you communicate data about care. The second one that we’re really starting to engage in, more than just standing up a portal, is patient engagement. We’re not going to improve the health of populations unless we can engage patients. It’s a bit easier as a children’s hospital, because what parent isn’t engaged in the health of their child?” The third and fourth keys involve organizing data and information about patients via such mechanisms as patient registries; and engaging in concerted care management.


This year, for the first time, survey respondents were asked the degree to which they could credit the ability of IT with helping them to achieve success in a variety of areas. Seventy-four percent of responded said IT was helping their organizations achieve success in care coordination; 73 percent said it was helping them with mandated quality metrics improvement; 69 percent said it was helping them to achieve primary care provider efficiency; and 58 percent said it was helping them to be successful with patient experience management.

When asked what IT strategies they were pursuing for engaging patients, 87 percent reported that they were providing a patient portal to their patients; 82 percent were using an organizational website; and 57 percent were leveraging social media.


With regard to staffing and budgets, 49 percent of respondents said their staffs were growing; 35 percent said their staffs were neither growing nor shrinking; and 11 percent said their staffs were shrinking. Meanwhile, 62 percent reported that their IT operating budgets were increasing; 21 percent were seeing no change; and 11 percent had budgets that were decreasing.


In addition to the broad survey findings, HIMSS’ Smith noted that more than 50 percent of U.S. hospitals are now in Stages 5, 6, or 7 according to the HIMSS Analytics EMRAM schematic.


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Debating a Physician's Role in Assisting Patient Death

Debating a Physician's Role in Assisting Patient Death | Healthcare and Technology news | Scoop.it

Physician-assisted death, physician-assisted suicide, and physician aid in dying are all variations on the same theme: the use of our knowledge and craft as physicians to help a patient end his or her life.

Our choice to become physicians compels us, not only to heal but also to alleviate the suffering of those who entrust their lives to us. It is the latter aspect of our duty that is at issue here. As a surgeon, I know there are times when our attempts at healing can cause pain and suffering.


What we seldom reflect on is: What happens when we can no longer heal? What happens when our patient does not wish to be treated? What is our duty then? What is our moral and professional obligation when we can no longer heal? It is specifically at this time when our responsibility transfers from healer to caregiver, educator, mentor, counselor, and friend. What do we do at that time when death is known, and we're helpless to defeat it? Despite our narcissistic view of our invincibility, we must change our paradigm from fixing the disease to fixing the problem of pain and suffering. It is a complicated but necessary intellectual transformation. And it is a moral and right change.


This transformation brings forth the issue of how to alleviate pain and suffering at the end of life. How do we quantify the pain? And most importantly, is death the ultimate and only option for relief? Should we as physicians use our craft to cause or assist our patient to die to fulfill our obligation to alleviate suffering?

I will answer and illustrate two opposing positions. Then I will summarize and offer a personal conclusion.


Yes, we should assist patients in dying.


The proponents of physician-assisted death (PAD) establish the base of their position with the concept of "death with dignity." Dignity, grounded primarily on the principle of autonomy; that the dignity of a human being is violated when their natural right to free exercise of will is removed.


Respect for autonomy is a fundamental guideline for the moral physician. Autonomy in medicine is not just allowing patients to make decisions. Physicians have an obligation to create the conditions necessary for those decisions. At such a critical and final time as death, the ability to decide for ourselves, i.e., how and when to die, is implicit in our dignity as a person. It is the physician's obligation to respect and enable that request as part of our obligation to alleviate suffering. Assistance in dying is not inconsistent with the principle of beneficence, as recognizing and creating the environment of autonomy is beneficence.


The other grounding of PAD advocates is the idea that the pain of dying patients can only be removed with death. Compassionate physicians should recognize that suffering is not always physical but is also existential.  Death is at times the only treatment.

Finally, and probably the most contentious point, is that PAD already happens despite the laws against it. In the 2004 book, "Physician-Assisted Dying: The Case for Palliative Care & Patient Choice", the authors note that several studies of U.S. physicians indicate "a measurable, fairly consistent incidence of physician-assisted suicide whether legal or not."


The latter argument is assigned to the principle of non-maleficence, i.e., do no harm. Being dishonest with our patient's request to die using disingenuous legal or moral validations is doing harm.

No, we should not assist patients in dying.

The perception that pain and suffering at the end of life removes human dignity is not in question. The question is whether ending life is ever protective of human dignity?


Physician and medical ethicist Daniel P. Sulmasy defines human dignity in three ways: Intrinsic, inflorescent, and attributed. Intrinsic dignity is what dignity we have just for being a human person. Intrinsic dignity obliges us as members of the human kind to comport ourselves consistently and to foment the flourishing of this dignity in all members of the kind. Inflorescent dignity is more complex. Inflorescent dignity is used to refer to individuals who are flourishing as human beings, living lives that are consistent with and expressive of the intrinsic dignity of the human. Attributed dignity is more material; it is based on what is given by society or community.


As a result, dignity is sometimes used to refer to a state of virtue in which a human being acts in ways that expresses the intrinsic value of the human.  For example: "He faced the onslaught of cancer with dignity."


To reduce the concept of dignity, as the proponents of PAD do, to exclusively exercising one's autonomy is to ignore 1,000 years of theology and philosophy.


To actively participate in ending a life by acceding only to the patient's will is to deprive them of their intrinsic dignity by negating all other aspects of dignity.


Three arguments against PAD


Sanctity of life argument against:
Sanctity , according to the Old English Dictionary, is: What is secured by religious sentiment or the like against violation, infringement , or encroachment. Causing the end of life by any means is the prototypical encroachment, violation, and infringement of human "dignity."

Medical/ Psychological argument against:

A request for assisted suicide is a cry for help. The patient is depressed. Several studies dating back to the 70s conclude that at least 58 percent of terminally ill patients are clinically depressed by several assessment methods. When given viable alternatives to end their pain and suffering, most rational patients almost invariably choose them over death.  Wanting to die is a reflection of exasperation and depression. A perception clouded by pain, and they will it relieved regardless of the consequences.

Violation of professional principles argument:
Hippocratic Oath which states: "I will not administer poison to anyone where asked," and I will "be of benefit, or at least do no harm." Major professional groups such as the AMA oppose assisted death. PAD would undermine the fundamental principles by which physicians practice and further compromise the inherent trust of the doctor-patient relationship.


Conclusion


It is apparent that the proponents of PAD base their support on two points. First is preserving the principle of autonomy and its violation being perceived as an assault on dignity. Second is the perception that only death can relieve these patients' suffering.

The first is arguably rational. However, dignity is more than just autonomy. But, what is more important is that intrinsic dignity defines us as a human being. Immanuel Kant's concept of dignity is "intrinsic" and based on reason. It is not reasonable to wish death to the exclusion of all other means to relieve suffering. To end one's life even through choice violates that dignity.


The second is perceptive. The American Society of Anesthesiologists outlined in their syllabus on ethics : Pain and suffering can be relieved in the vast majority of cases without intentionally causing death. The latter is the conceptual validation for palliative sedation and pain relief that may sometimes hasten death.


In PAD, the death is not a consequence or a circumstance. It is an action of the will. An action incorrectly perceived as a zero option.

Palliative sedation has the advantage of relieving pain and suffering without the intent of causing death. The grounding philosophy of this position is found in the principle of double effect. The principle of double effect states: Accordingly, the bad effects of an action that would be morally wrong if caused intentionally are permitted if these effects are foreseen but unintended. As a result, if the intent is to alleviate suffering even with death as a consequence, the action is morally permissible.


In conclusion, wisdom compels me to do all within my power to alleviate suffering even if the action hastens death; however, my intention will always remain to preserve that intrinsic dignity of the human being. The latter opinion grounds my ethical stance. As physicians, we have an obligation to act in the best interest of our patients. If I can be virtually certain death is the only option, then so be it.


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Title 1: The problem of assisted-death: a medic's exploration of how knowledge helps or hinders the solution.

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Patients, doctors see benefits of sharing medical records

Patients, doctors see benefits of sharing medical records | Healthcare and Technology news | Scoop.it

When Stacey Whiteman was diagnosed with multiple sclerosis two years ago, she didn’t realize the toughest challenge would be its impact on her brain. The 53-year-old from Massachusetts was forced to quit work as an executive assistant after becoming easily confused and prone to forget, even about priorities like doctor appointments.

When her physician suggested OpenNotes, an electronic portal allowing patients full access to their medical records, including doctors’ notes, Whiteman was eager to log on.

“For somebody like me who has a hard time processing things, I need this convenience,” she said. Whiteman now refers to OpenNotes daily, to review what happened during appointments, be reminded of future ones and check lab results.

Patient access to physician notes, historically rare, has led to more collaborative doctor-patient relationships and more engaged health care consumers, according to a new paper online February 10 in the British Medical Journal.

“Regardless of one’s competence, health information is often quite opaque,” said coauthor Michael Meltsner, a professor at Northeastern University School of Law in Boston.

Meltsner and his two coauthors, Dr. Tom Delbanco and Jan Walker, both at Beth Israel Deaconess Medical Center in Boston, evaluated data on 19,000 patients and 105 primary care physicians using OpenNotes at three U.S. hospitals.

After one year, 99% of patients wanted to continue accessing notes. Despite initial concerns among physicians about additional work, none decided to discontinue use.

“It’s like oysters. Once you like oysters, you hang in there with them,” Delbanco said. “But it’s an acquired taste.”

According to the paper, patients described “a new understanding of the importance of medications and more motivation to adhere to treatment.” They shared notes with caregivers and “reminded harried doctors about follow-up that had not been completed.”

The participating institutions, Beth Israel Deaconess, Geisinger Health System in rural Pennsylvania, and Seattle’s Harborview Medical Center, have since expanded OpenNotes use throughout specialty and primary care. Overall, five million Americans now have access to notes, up from 20,000 two years ago.

Delbanco predicts access will soon be common nationwide. Electronic medical record software suppliers, such as Epic, are building note access into products. Health institutions may opt for or against activation.

The most surprising finding, Delbanco said, is that elderly patients and those with little education were as interested in reading notes as the young and well educated.

“We thought this would be a yuppie internet,” he said. However, at Harborview, a safety-net institution, patients read online notes by logging on to computers at public libraries and hospital kiosks.

“Patients have a right to information about themselves and the right to be told the truth,” said bioethicist Nancy Berlinger of The Hastings Center.

Note sharing can be particularly beneficial for patients with serious conditions like cancer, Berlinger said, as emotions are often high during appointments in which multiple issues are addressed and treatment plans formulated.

“A lot of these patients’ lives are happening outside of the clinic,” Berlinger said. “People can take in information in the privacy of their own homes.”

Berlinger said she questions how usable OpenNotes would be for non-English speaking patients and for those with dementia.

According to Delbanco, OpenNotes is like a new medicine, good for some and contraindicated in others. “Every medicine is designed to help some people, and OpenNotes is no exception,” he said.

Rita Charon, an internist and director of the program in narrative medicine at Columbia University in New York City, said any program opening the flow of information between clinicians and patients is beneficial.

“It’s easy to do, and something many of us do routinely,” Charon said. “It lets the patient know what I think, and it reminds me to write in English and not in abbreviations. It reminds me to faithfully repeat what happened in that twenty minutes.”

Measuring outcomes, she said, would help note-sharing practices to spread.

“This work has helped us see the important feasibility parts, that patients will put time into reading what we write, and that it does something,” Charon said. “Now we have to ask what does it do?”

Delbanco acknowledges that health outcomes are still unknown and difficult to evaluate.

However, he said, “We know that engaged patients have better outcomes.”


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Survey: Patients Open to Tech, but Few Use Health IT Tools Now

Survey: Patients Open to Tech, but Few Use Health IT Tools Now | Healthcare and Technology news | Scoop.it
Patients are increasingly becoming more willing to engage with their providers through modern technology, but the industry is only at the starting line of connected health, according to new research from Salesforce.

Salesforce’s first “State of the Connected Patient” report surveyed more than 1,700 Americans who have health insurance and a primary care doctor to look at how patients are currently connecting with their providers, as well as their technology requests for the future.

The report found many millennials have a limited or even non-existent relationship with their primary care doctor, as 40 percent reported saying their primary care doctor would not recognize them walking down the street. However, the report further found that:

60 percent of millennials are interested in using telehealth options (e.g., video chat with a doctor) so they don't have to come into the office for an appointment.
71 percent of millennials would be interested in a doctor/provider giving them a mobile app on their smartphone/tablet to actively manage their well-being for preventative care, review health records, schedule appointments.
63 percent of millennials would be interested in proactively providing their health data from WiFi/wearable devices to their doctor/provider so they can monitor their well-being.

What’s more, the report did find that few patients currently use health IT tools to connect with their doctors and access their personal health data, according to MobiHealthNews. Less than 10 percent of those surveyed said they use the web, email or text to set up appointments, compared to 76 percent that still do so over the phone and 25 percent that schedule their appointments in person. When it comes to looking at their own health data, only 21 percent said they used the Eleven percent use the phone, 10 percent use email, and 40 percent said they review their health data in person.
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Searching for Creative Patient Portal Solutions

Searching for Creative Patient Portal Solutions | Healthcare and Technology news | Scoop.it

This year, as you may already know, both hospitals and physician practices participating in Meaningful Use must offer patients a way to access their health records electronically. The patient electronic access objective specifically calls for providing patients the ability to view online, download, and transmit their health information. Those familiar with this objective often call it VDT for short.

Although having a patient portal is a requirement of Meaningful Use, it’s not required to be helpful, relevant, responsive, attractive, or even usable. It’s just got to be “there.”

From a patient’s perspective, there are plenty of reasons to delay logging on, even beyond the well-documented reasons of not having an email address or access to the internet. Many patients have no idea what to look for on the portal and if they don’t understand the benefits of having access to their medical records, why should they care? Frankly, a bad online experience could seriously hurt a practice’s chances of meeting their VDT goals.

So What Works?

Everyone’s trying something. Here are some strategies practices are implementing:

  • Offer more amenities on the portal: the ability to see statements, pay bills, schedule visits, or access educational materials specific to the patient’s conditions.
  • Instead of listening to smooth jazz while on hold,  patients are given instructions on how to access the portal and told about what information they will find there.
  • A TV monitor on the wall of the waiting room cycles through testimonials about how convenient it is for patients to schedule, access their records, or email their doctor.
  • Signage is in place throughout the facility including hallways, triage rooms, exam rooms, bathrooms, elevators, stairwells.
  • Staff members are trained to talk articulately about the portal starting at check-in and at each point along the visit – because face it – if staff don’t buy-in to the benefits of the portal, then patients certainly won’t.
  • Offer tablets or other hand-held devices for patients to log in to the portal before they leave the office. Make sure staff are ready to help if patients have questions.
  • Do some investigative work – start taking notes about what patients call into the practice about most. Then find out if you can address these issues in the portal. This could automates a task for your staff while simultaneously addressing a need for your patients.

There are lots of challenges to getting patients to engage online, no doubt. But that means there’s a lot of opportunities for creative solutions.


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Doing More for Patients Often Does No Good

Doing More for Patients Often Does No Good | Healthcare and Technology news | Scoop.it

Given the remarkable advances that have been made in the last 50 or so years in pharmaceuticals, medical devices and surgical procedures, it’s not a surprise that people want more, and more invasive, care than they have had in the past. Just as it’s hard to do nothing when you’re ill, it’s sometimes hard to do less than the maximum when there are different treatments to choose from.

Unfortunately, doing more often does no good. Sometimes, it even leads to harm.

In the United States, when it appears that someone might be in trouble, emergency medical services are dispatched. Many patients die from an out-of-hospital cardiac arrest, but steps taken out in the field can make a difference. Basic life support, the kind you might be taught in a CPR class — involving the use of bag valve masks, cardiopulmonary resuscitation and automated external defibrillators — can absolutely save a life.

Advanced life support, usually requiring a trained paramedic, involves much more. Trained providers may put in endotracheal breathing tubes; start intravenous lines; deliver sophisticated cardiac drugs; and defibrillate patients manually.

We’ve assumed, for the most part, that advanced life support is better than basic life support — so much so that in most areas where both options are available, advanced life support is almost always used. But a recent study in JAMA Internal Medicine brings this assumption into question. Researchers examined Medicare patients who were billed for either advanced life support or basic life support before admission to the hospital from 2009 through most of 2011. They looked at how often patients survived to hospital discharge, and then months later.

What they found was that about 13 percent of patients who received basic life support survived and were discharged versus 9 percent of patients who received advanced life support. More patients who received basic life support lived for 90 days after discharge, too (8 percent versus 5 percent). Basic life support patients also had better neurological outcomes.

Now, of course, this is not a randomized controlled trial. It’s possible that sicker patients received advanced life support and that people who didn’t appear as sick received basic life support. But the authors called all of the state agencies, and they reported that this can’t really happen. After all, a 911 dispatcher can’t tell if it’s a “mild” or “severe” heart attack from a third party on the phone with no medical training. Dispatchers send out advanced life support if it’s available, and basic life support if it’s not.

It’s also possible that there could be differences in bystander CPR administration until help arrives. But the authors attempted to control for that, too. They conducted a number of sensitivity analyses, and in none of them did advanced life support outperform basic life support.

It would also be easier to dismiss this finding if it weren’t corroborated in many other studies. In 2004, results from the Ontario Prehospital Advanced Life Support Study were published in the New England Journal of Medicine. This was a multicenter controlled trial in 17 cities in Canada comparing advanced life support with basic life support. They found that if an instance of cardiac arrest were witnessed by a bystander, the chance of survival significantly improved. They also found that CPR administered by bystanders improved survival, and so did rapid defibrillation. These are all components of basic life support. The addition of advanced life support, however, made no difference in survival.


A 2007 study conducted in Taipei also found that advanced life support did not improve survival to discharge. Even the main components of advanced life support have failed to show results in studies. A 2008 systematic review showed no efficacy for emergency intubation. A 2010 cohort study found advanced airway methods — basically, putting in an airway tube rather than using a bag mask — to be associated with decreased survival compared with basic life support methods, as did a 2013 study in Japan.

A 2012 JAMA study found that the use of epinephrine was associated with worse outcomes, and a 2008 New England Journal of Medicine study found that adding vasopressin (another drug that, like epinephrine, constricts blood vessels to raise blood pressure) didn’t improve things. A randomized controlled trial of these drugs, published in 2009 in JAMA, found that their use didn’t improve survival either.

The evidence is compelling. Advanced life support does not seem to provide any benefits in the randomized controlled trials, and it’s often associated with worse outcomes in the cohort studies. How can this be so? Some theorize that the things that work have already been incorporated into basic life support. All that the advanced life support may be doing is slowing things down in the field, distracting people from the useful basic life support measures, and delaying the time until a patient can get to the hospital.

It’s hard not to do more if we can, though. We see this in all sorts of areas of care. A few months ago, a study was published in JAMA that examined the outcomes of women with stage 0-III unilateral breast cancer who underwent breast conserving surgery with radiation compared with those who had a unilateral mastectomy and those who had a bilateral prophylactic mastectomy. The 10-year survival differences between the groups were negligible. Breast conservation therapy is more tolerable, is much less invasive and costs less.




In fact, breast conservation therapy has become a “standard of excellence” in breast cancer care. But a study published even more recently showed that from 1998 through 2011, the odds of a woman eligible for breast conservation therapy receiving a mastectomy increased. Rates of bilateral mastectomy went up over this time period as well, from 2 percent in 1998 to 11 percent in 2011.

And based on the data from many randomized controlled trials, we know that women who have radiation therapy for early breast cancer do well with less of it. The use of “hypofractionated” whole breast irradiation, which consists of fewer treatments with higher levels of radiation, has been shown to be equally effective for women without any excess side effects. It’s cheaper, easier and just as good. Hypofractionated whole breast radiation has been endorsed by the American Society for Radiation Oncology for women who satisfy certain criteria since 2011.

But a study published a month ago that looked at the use of radiation in women with early stage breast cancer found that in 2013, only about a third of women who qualified for hypofractionated radiation therapy were getting it. The rest got more, but not better, care.

The reasons for this are varied. With respect to the radiation therapy, it’s hard not to lay some of the blame on economics. After all, in a fee-for-service system, more visits and more treatments mean more money. Research shows that twice as many women want hypofractionated radiation therapy as want conventional therapy, but only half of radiation oncologists offer it.

But it’s not all money. It’s also probably fear. Many radiation oncologists are concerned that doing fewer treatments will lead to worse outcomes. That’s most likely the concern of women who choose much more invasive surgery than necessary as well.

It’s certainly the rationale for why advanced life support is so prevalent. The Ontario Prehospital Advanced Life Support Trial was supposed to be a randomized controlled trial, but the paramedics evidently refused to do it because they felt that holding back advanced life support was unethical. This was in spite of the lack of evidence that it was effective.

More is expensive. More sometimes does no good. Sometimes, more is even harmful. When our policies and care ignore these facts, we all suffer.


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8 Ways to Improve Patient Satisfaction, Patient Experience And (By The Way) HCAHPS Scores

8 Ways to Improve Patient Satisfaction, Patient Experience And (By The Way) HCAHPS Scores | Healthcare and Technology news | Scoop.it

In light of Medicaid’s announcement that it may expand the use of Child HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) results, let’s do a roundup of what actually increases patient satisfaction and improves the patient experience, for hospital systems, primary care providers, and ambulatory care centers alic.

Although I feel that these CAHPS assessments are a largely positive development, it’s also true that patient satisfaction and the patient experience can suffer if your institution takes the wrongheaded approach of trying to “game” the assessment process, of aiming too narrowly for success on the specific questions asked in the assessment.

The power of the halo effect

A better approach is to look at the survey questions only as they fit within your broader attempt to create an overall experience of caring that will in turn translate into better responses on the individual assessment questions due to a positive “halo effect.”  The halo effect I’m referring to is the tendency of humans–including patients and their loved ones–to cut you slack when they have a generally positive impression of you, how a positive experience with you will spread in their minds (and in their survey responses) to areas where, literally speaking, your institution may not have been entirely up to snuff.

“Always” is impossible–but if patients love you, they’ll cut you some slack

Consider an assessment question where your goal is to have an answer of “always” (for example: “During this hospital stay, how often were your room and bathroom kept clean?”). Always kept clean” is, strictly speaking, an impossibility. Not even a five star hotel can achieve that level of housekeeping; they may tidy your room three times a day, but that’s plenty of time to trash it in between. Yet it is possible to get an “always” response from a patient. Because the way patients remember is more holistic than you think it is.  An overall extraordinary experience with your facility and organization will subliminally inspire a patient to cut you slack while a generally poorly treated patient is going to grade you literally on your survey. And a literal reading of/response to the HCAHPS survey questions isn’t going to turn out all that well for anyone.

Here, therefore, is a roundup of my suggestions for how to improve patient satisfaction and the patient experience–and, as an aside, improve your HCAHPS scores. 

1. If you want to stem patient dissatisfaction, stop giving off cues of indifference and uncaring.   Such as: Healthcare professionals avoiding eye contact with “civilians.” Med students hurrying self-importantly down the halls, nearly running down the slow-moving patients who won’t get with the program.  Patients ignored by nurses who haven’t yet clocked in and therefore don’t realize they are already (poorly) representing their institution. Doctors in the hallway loudly carrying on about the relative benefits of different Canyon Ranch vacations they’ve taken. Two radios playing at once from two administrative areas (with the waiting area for patients and their families located equidistant to both). Vending machines that are left out of service indefinitely. Vending machines that require exact change, but there’s no change machine.

2.  Strive actively to experience your care the way that your patients do.  Park where the patients do.  See how easy it is/isn’t to get to the front door on crutches.   Take a tour of your hospital with someone who hasn’t been there before, and let them show you whether they can really find where they’re going.  You’ll be amazed how many mis-aligned, out of date, confusing signs you have. It all makes intuitive sense to you, of course, because you have been in your building enough times that you know your way around in your sleep (Literally, I suspect.)  And, once a year, do a “full bladder exercise”: Everyone who works with patients should drink two or three liters of water–it is incredible how your perception of a “reasonable delay” between call button and response changes when you have a full bladder.

3.  Get every employee thinking about purpose, not just functions. A particularly crucial aspect of great patient service is ensuring that every employee—from orientation onward –understands her particular underlying purpose in your organization and appreciates its importance. An employee has both a function—his day-to-day job responsibilities—and a purpose—the reason why the job exists. (For example, ‘‘To create successful medical outcomes and hospitable human experiences for our patients” is a purpose.   “To change linens” is a function. A properly trained and managed employee will know to—and will be empowered to—stop changing linens if creating successful medical outcomes or being hospitable require a different action at the moment. And afterward, she will be celebrated for doing so, not scolded for being a few short in the number of linens changed.

4. “Sorry” may be the hardest word, but it’s a word that everyone on your team needs to learn.  Resolving patient issues means knowing how to apologize for service lapses pointed out by a patient. It means getting rid of the defensiveness (or, at best: apathy) that tends to mar the healthcare industry when confronted by a patient upset with what she perceives to be a service gaffe. Instead, take your patient’s side in these situations, immediately and with empathy, regardless of what you think the “rational” allocation of “blame” should be. And spread this approach throughout your staff through role-playing and other training devices, so it will serve you fully every time a patient hits the fan.

5. Teach your employees – every single one – how to handle a patient or family member’s complaint or concern.   Even if handling the concern means “I’m finding you someone right now who can address this” it’s far better than “I can’t help you, I’m the wrong person.”

6. If you want to improve, strive to create a blame-free environment. As the founder of the Ritz-Carlton is fond of saying, “If a mistake happens once it may be fault of employee. If it happens twice, it is most likely the fault of the system.”  So, they get to work fixing the system. This blame-free system has worked to help The Ritz-Carlton build a great culture, and it can do the same for your hospital.

7. Understand that improving patient satisfaction is about systems just as much as it is about smiles.  When we discuss improving patient satisfaction and the patient experience, physicians often think we are going to focus on making them “smile harder.” While genuine warmth and smiles are of value here, so are systems. For example, when Mayo Clinic overhauled their scheduling system they employed (according to the great Leonard L Berry) industrial engineers using stopwatches to time wheelchairs between appointment locations in order to ensure that correct scheduling algorithms were created.

8. Benchmark outside healthcare. One of the biggest obstacles to improving the patient experience in healthcare is the industry’s insular nature and the way this makes its problems self-reinforcing. In other words, healthcare providers and institutions compare themselves to each other – to the hospital in the next town, the surgeon in the next O.R. – and benchmark their customer service accordingly. And to do so is to set the bar too low.  It’s not as if patients stop being consumers – customers – when they put on a hospital gown. And it’s not as if their loved ones surrender their identities as businesspeople, twitterers, Facebook users, either, when they enter your institution. So, it’s time to benchmark healthcare customer service against the best in service-intensive industries, because that’s what your patients and their loved ones will do. Every patient’s interaction with healthcare is judged based on expectations set by the best players in hospitality industry, the financial services industry, and other areas where expert players have made a science of customer service.


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Does Restricting Physician Duty Hours Improve Patient Care? | The Health Care Blog

Does Restricting Physician Duty Hours Improve Patient Care? | The Health Care Blog | Healthcare and Technology news | Scoop.it

Do physicians in training take better care of patients or perform better on their exams when their work hours are restricted?  Two recent studies in the Journal of the American Medical Association suggest that the answer is no.  In one, patients of surgery residents showed no difference in morality or postoperative outcomes after duty hour restrictions were implemented.  Their test scores did not improve either.  In the other, hospitalized Medicare patients being cared for by physicians working shorter hours experienced no improvement in mortality or readmission rates.

US resident duty hour restrictions were born in 2003, when the ACGME, the organization that accredits medical residency programs, capped the work week at 80 hours.  It also mandated that residents have 10 hours off between duty periods and a 24 hour limit on continuous duty, with 1 day in 7 free from patient care.  In 2011, the organization revised its policy, further restricting the total number of continuous duty hours for physicians in the first year of training to 16.

How could well-intentioned attempts to ensure that hardworking young physicians get sufficient rest fail to benefit patients?  To begin with, simply restricting duty hours does not guarantee that residents will use their extra off-duty time to sleep.  They might, for example, use it to study, exercise, or socialize.  It is also possible that the outcomes being assessed by these studies are influenced by so many factors that merely changing duty hours is insufficient to cause a change.  Yet if such changes do not benefit patients, how strong is the case for their implementation?

Some educators worry that duty hours restrictions are undermining the quality of medical education.  For example, a survey of surgery program directors published last year showed that 21% believe that residency graduates are unprepared for the operating room, 30% believe they cannot independently remove a gallbladder, and 68% believe they cannot perform a major procedure unsupervised for more than 30 minutes.  Another survey showed that 38% of residents themselves lack confidence in their preparation even after 5 years of training.


Part of the problem may lie in the fact that the duty hours restrictions have reduced the number of cases such residents are able to learn from.  For example, one study of the caseloads of surgery residents found that the implementation of duty hour restrictions was associated with a 26% reduction in cases per resident.  Moreover, the complexity of operating room cases in which residents participated declined even more, 32%.  To compensate for such reductions, some critics have argued that if duty hours restrictions remain in place, the length of surgery residency will need to be increased from the current  5 to 6 or even 7 years.

But the problems with attempts to reduce duty hours go deeper still.  When residents spend less time in the hospital, the number of patient “handoffs” that need to occur between residents increases.   A resident who might once have cared for a patient for 24 consecutive hours now needs to hand the patient off to a colleague at 16 hours.  It is well documented that every time a patient’s care is transferred from one health professional to another, errors in communication tend to occur.  Studies suggest that such error rates can be reduced, but not eliminated.

An associated problem is the fact that residents operating under duty hours restrictions have less time to get to know their patients.  In addition to creating opportunities for error, this also has negative implications for the quality of relationships that young physicians develop with their patients.  Confidence and trust are built in part on familiarity, which the duty hours restrictions tend to reduce.  As a result, many young physicians may expect less from relationships with patients, and these diminished expectations may remain with them throughout their careers.

The intent behind duty hours restrictions is a noble one.  As sleeplessness increases, it takes a toll on mental performance, including reaction time and the ability to memorize new information.  But sleeplessness is but one factor in the performance equation, and it may be counterbalanced by other equally or even more important factors, such as the importance of the task at hand.  When a patient’s health or even life is on the line, it is possible that many young physicians are able to compensate for lack of rest.

Another drawback of the duty hours restrictions is psychological, perhaps even cultural.  A whole generation of physicians in training is being told, directly or indirectly, that their education is not as rigorous as their teachers’.  They do work as hard and are not being tested to the same degree as those who trained before them.  As a result, many complete their training questioning whether they have given less of themselves than they needed to.

Without doubt, the culture of hard work and sacrifice can be taken too far.  A colleague recently shared with me this story.  When he was an intern, he was taking call every third night, admitting at least 8 patients each call shift, and getting too little sleep.  One morning while on rounds with his chief resident he stopped and said, “I don’t think I can keep doing this.  It is dangerous for the patients.”  The chief showed absolutely no sympathy, instead responded dismissively, “Just suck it up and carry on.”

Duty hours restrictions represent an attempt to deal with a genuine problem, a dominant culture in medicine that says, “If you can’t do this, you are weak.”  Yet they are problematic because they represent a one-size-fits-all solution.  In many cases, a more tailor-made approach is called for.  It makes no more sense to treat all residents in all medical fields identically than it would to treat all patients as if they were cut from the same mold.

Before we impose blanket restrictions on duty hours for every training program and resident in the country, we should turn our attention to more pressing matters.  First, we should try to foster a culture in which young physicians can admit they need help without fear of reprisal.  Second, we should ensure that the work residents are being asked to do is truly educational and important.  And third, we should put more trust in the ability of program directors and their residents to discern for themselves the amount of work they are able to handle.


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More patients could soon be seeing a virtual "doc in a box"

More patients could soon be seeing a virtual "doc in a box" | Healthcare and Technology news | Scoop.it

For many people, getting an appointment to see their doctor can be challenging. And if you don’t have a doctor but need to see one, it can take weeks to months to get one of those coveted new patient slots.

As a result, “Doc in a box” and urgent care clinics have taken off across the country. And as with everything else in healthcare, that trend has gone digital. And this year, the success of two companies in particular could make this a breakout year for the virtual doctor visit.

Teladoc

Teladoc made headlines this week with a very successful IPO that saw share prices go up 50% in the first day of trading. Teladoc is a company that offers on-demand doctor visits to patients through their smartphones, computer, or regular old phone for under $50. Basically, you put in a request for a consultation to Teladoc and they connect you with a board certified internal medicine, pediatrics, or family practice physician. Teladoc boasts that patients get connected with a physician in under 10 minutes.


Teladoc offers members an EHR that is basically a patient-provided medical history. Consulting physicians review that record and get a history from the patient. If needed, they can e-prescribe medications to a local pharmacy.


Patients can sign up directly for Teladoc and pay out of pocket if they want. Health plans and companies are also contracting with Teladoc to provide this service to their members and employees in the hopes of averting more expensive urgent care and ER visits.

Doctors on Demand

One of this years most successful digital health companies is Doctors on Demandwhich, according to StartUp Health, has raised $50 million in just the first six months of 2015.


Doctor on Demand offers video visits to patients through their smartphone or computer. Like Teladoc, Doctor on Demand offers consults in general medicine and pediatrics. They are more varied in their physician pool; for example, their highlighted medical physicians include preventive medicine, emergency medicine, and internal medicine physicians. A really interesting feature here though is that they also offer mental health consults with psychologists and lactation support with certified lactation consultants.


Patients sign up directly with Doctor on Demand. Visits with a medical physician or pediatrician cost $40; visits with a psychologist or lactation consultant range from $40 to $95. And as with Teladoc, companies and health plans are signing directly with Doctors on Demand to provide that service to their employees and members.


The support that these two companies have garnered this year is a strong sign that this area is poised for some serious growth.

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Only 1.4% Of Physicians Are Ready To E-Prescribe Controlled Substances, Report Finds

Only 1.4% Of Physicians Are Ready To E-Prescribe Controlled Substances, Report Finds | Healthcare and Technology news | Scoop.it

As deaths involving prescription opioids increase, prescribers look toward other ways to curb patient overdoses. One fairly new solution in the medical community is to prescribe controlled substances electronically, but just how far along is this revolutionary approach, and will it help combat the ever-growing opioid epidemic in the country?

Health information network provider Surescripts on Tuesday released the results of research focusing on health data transactions in 2014. The report, titled the “2014 National Progress Report,” reviewed how prescribing controlled substances electronically could potentially diminish prescription fraud and abuse in the country.


The Centers for Disease Control (CDC) found that there were 16,235 deaths involving prescription opioids in 2013, an increase of 1% from 2012. In response, the CDC launched several initiatives. One of them included a campaign, titled “When the Prescription Becomes the Problem,” last month at the fourth annual National RX Drug Abuse Summit. The social media activity, designed to raise awareness of prescription painkiller abuse and overdose, ended on May 15 of this year. President Obama’s drug control priorities for the upcoming fiscal year included reducing prescription drug and heroin abuse by allocating additional funding to states with prescription drug monitoring programs (PDMPs), expanding and improving treatment for addicts, and spearheading efforts to make naloxone more readily available to first responders.


Dr. Sean Kelly, chief medical officer at Imprivata and emergency physician at Beth Israel Deaconess Medical Center in Boston,said in an interview that electronic prescribing of controlled substances (EPCS) has the potential to improve care, reduce fraud and identify potential evidences of abuse by “creating a secure, auditable electronic transmission directly from the prescriber to the pharmacy.”


“With EPCS, a paper prescription and a physician’s DEA number are never in the hands of the patient, which minimizes the risk of fraud or theft,” he said. “EPCS also improves care for patients with legitimate needs by reducing both wait times at pharmacies and the number of trips they need to make to the doctor’s office.”


He added: “EPCS also improves care by reducing prescription errors and inaccuracies.”


Prescribing controlled substances electronically can only effectively combat opioid abuse, misuse and overdose if both prescribers and pharmacies are willing to hold up their part of the deal — but that doesn’t seem to be the case. Nearly 75% of pharmacies across the country are ready to receive electronic prescriptions for controlled substances, the report found. Their counterparts are not: Only 1.4% of controlled substance prescribers are set up for EPCS.


EPCS for controlled substances is still in the early stages of development, and this is one of the main reasons why prescribers are slow to embrace this new kind of technology, Kelly said. This, however, shouldn’t worry early adopters.

“This is similar to the early days of e-prescribing for non-controlled substances,” he said. “Initially, it was a new technology that providers were unfamiliar with, but because it significantly improved efficiency and the delivery of care, it has gained rapid adoption.”


Even though physicians seem hesitant, the practice of prescribing controlled substances electronically is growing. The study reported a 400% increase in controlled substance e-prescriptions in 2014, totaling 1.67 million nationwide.


Every state in the country handles combatting the opioid epidemic in its own way. Despite only 53% of primary care physicians using prescription monitoring programs (PMPs), the majority of state governments have continued to support them. Structural differences hinder EPCS adoption. To rank states on their readiness to prescribe controlled substances electronically, Surescripts looked at several factors: the percent of enabled pharmacies, the percent of enabled prescribers and the percent of controlled substances prescribed electronically. The study found that Nebraska, California and Michigan are best equipped to handle e-prescribing of controlled substances.

“Total EPCS transaction volume is still so low across the board, so it’s difficult to say why some states are doing better or worse than others,” said Paul Uhrig, chief administrative and legal officer, and chief privacy officer at Surescripts. “But it seems to mostly hinge on whether or not a state government makes it a priority. The elimination of regulatory barriers and the implementation of legislative mandates have been the primary drivers of the adoption of EPCS.”


He added: “This means we need to work collectively, across the industry, to educate and inform all stakeholders in order to drive utilization of the technology.”


As investments in technology to improve delivery and patient care continue to grow, prescribers will become more selective. “This means that it must enable, not impede, the delivery of care,” Kelly said. “If the technology is developed and implemented in such a way that it fits easily into providers’ existing workflows, EPCS can gain widespread adoption as a formidable weapon in the fight against prescription drug abuse."


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Medical providers should make health data free to patients

Medical providers should make health data free to patients | Healthcare and Technology news | Scoop.it

Technology makes patient access to medical records easier than ever, but the cost of such data prevents many from doing so, according to Niam Yaraghi and Joshua Bleiberg, fellows at the Brookings Institution.

Access to health information is beneficial for patients, allowing them to take a bigger role in their care and enabling them to share the information with other providers, Yaraghi and Bleiberg write at Brookings' TechTank. The latter is especially important because of the lack of interoperability of electronic medical records, they add.

But while there are virtually no costs of reproducing digital records, "many states still use the same regulatory model--which is based on the number of copied pages--for paper and digital records," they write.

Through a Google Survey, the two Brookings fellows asked 120 patients how much they would be willing to pay for their records. Sixty-eight percent said they wouldn't pay a dime to have access to the information; 10 percent said they would pay between 1 cent and $9.99; and 6.4 percent would pay between $10 and $19.99.


This is an area that involves not only healthcare professionals, but those on Capitol Hill, as well. Putting health information in the hands of patients has been one of the goals of the 21st Century Cures initiative. During a panel discussion that included lawmakers and industry professionals last June, the importance of giving patients a voice in their care was a primary focus.


To improve patient access, Yaraghi and Bleiberg say patient advocacy groups should educate patients on the value of their data, which may make them more likely to want access to the information.

In addition, because the cost is almost zero to reproduce medical information through electronic health records, "state regulations should undergo a major revision and require the medical providers to let patients have their medical data for free," they conclude.

Patient advocate Regina Holliday has been one voice in the industry calling for such change.


"You want to have access to that information before there is a crisis. You don't want to build that system up in a moment of need. [Y]ou want to be able to see the long tail of care, to be able to look for patterns," she told FierceHealthIT in an interview in October.

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Building Effective Patient Education Programs

Building Effective Patient Education Programs | Healthcare and Technology news | Scoop.it

Patient education programs have been around for a long time, but typically these programs have been geared toward only the chronically ill and those that needed extensive management. In this era of the Patient-Centered Medical Home patients and insurers are looking more to physician practices to provide effective patient education in all aspects of their care. In fact, many insurance companies are actively measuring physicians' performance on quality metrics. Current accountable care models factor in patient utilization of emergency rooms, hospital visits, and prescriptions, and attribute that cost to the patient's primary-care doctor, which may also include specialties such as cardiology.

So what does this mean to your practice? With more accountability comes the need to manage patient populations more effectively to be able to hold the line on costs. If you are not doing a good job in actively engaging patients to "self manage" their own care, and utilizing lower-cost opportunities for managing your patients' care, then you may soon find yourself failing to achieve a targeted level of care and cost utilization, and that will cost you money.


Creating and implementing effective programs


The most effective education programs are those that are customized to each patient. But don't let that daunt you. You can define general care plans and then customize those on a patient-by-patient basis.


• First, determine what conditions to tackle. Get to know your patient population. What are the most complex and costly conditions that you manage? What conditions apply to the most patients across your practice? Hone in on those areas to begin with, set up and fine-tune a program or two, and then you can replicate successful programs across your entire patient base from there.


• Second, assess your patients' needs. Determine what actual resources and help is needed by your particular patients. Do not hesitate to poll your patients by asking them directly what their specific needs and challenges for self-management may be. If you make assumptions about your patients' needs, you may only meet the goals of a small part of your population, which can be counterproductive and result in poor compliance with the program. In addition to assessing needs, assess the challenges (such as lack of family support) and skills (Internet use, reading ability etc.) of your patients and build a program that can adequately meet them where they are coming from.


• Third, use what's available. Don't reinvent the wheel. There are lots of good materials, courses, and programs available. It's OK to adopt a program you like; just make sure to thoroughly review all of the material and adjust the sections, ideas, concepts, and so forth to fit with your specific patients' needs and your style of practicing medicine.


• Fourth, communicate effectively and set small targets. Let your patients know about these programs and educate them about what they are expected to do. Priorities should be clearly stated, mutually understood, and mutually agreed upon, and patients should be provided with information about what to do if they go "off the plan." That will help to keep them empowered and engaged in their own care, and keep them communicating effectively with you and the office when there is a problem. Keep the goals small and manageable to begin with and don't overload the patient with information. Tip sheets and goal targets should be the core of the program; then add in more information as the patient progresses. Keeping material simple, clear, and to the point will help with comprehension.


Setting one target per visit is a manageable way for patients to begin working a program. For example, set a new diabetes patient the goal of reducing his intake of sweets to three desserts per week, and provide a cheat sheet of desserts that are diabetes-friendly to choose from on the plan. At the next visit, you identify a new goal to add to the first one, and repeat. While it may take a while to turn a patient's health around, research confirms that small, incremental changes are much more likely to be lasting changes, so think in terms of a marathon rather than a sprint to the finish line.


Lastly, make the plans, goals, materials, and office staff highly available to the patient. Post the educational material on your site, mail follow-up materials to patients, place outbound follow-up calls and/or e-mails to patients to check on how they are doing between visits. These touch points matter and can be the difference between a successful program and good patient engagement or wasted effort and time.


And don't forget, as of January 2015, you can now bill a monthly, per patient code for chronic care coordination, CPT 99490. Just make sure to check the guidelines for this code to adhere to the description of services before you bill it.



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The fallacy of patient engagement

The fallacy of patient engagement | Healthcare and Technology news | Scoop.it

You may have noticed the absence of my usual posts to HealthBlog. Here’s why. I was preparing for an out of town business trip on Monday of last week when I learned that my adult daughter needed an emergency appendectomy. As coincidence would have it, my business trip just happened to be to a city very close to where my daughter lives. I was able to keep my business meeting in the morning and still arrive at my daughter’s apartment soon after she was discharged from the hospital. I spent the rest of the week helping her get in and out of bed, doing some cooking, walking her dog, and making sure that she was well enough to be on her own before I headed home.


It’s at times like this that one is very grateful for access to good healthcare. After all, there was a time before modern surgery and the availability of antibiotics that appendicitis was often a death sentence. Today, that rarely happens if the patient receives timely care.


There’s no question that when we are in pain, injured or very sick that we are “engaged” patients. Not only is the patient engaged, but often his or her entire family. The problem is that when we are well again, we tend to disengage and fall back into our usual routines. The fact of the matter is that most people really don’t spend all that much time with doctors and hospitals. Most care happens in the home, and most of the contributors to good health are determined more by our genetic makeup, diet, socioeconomic status, education, exercise and other environmental factors than by the things that doctors and hospitals do in our lives. For most people, encounters with doctors and hospitals are  episodic and infrequent. So, when hospitals and health systems speak of the need for greater “patient engagement”, what does that really mean and how can it be accomplished?


As a physician I know from the get-go that patient engagement is hard to achieve. First of all, we need to understand that healthcare is something most people view as a kind of “grudge buy”. Just as I dread going to see my dentist, I also don’t particularly enjoy anything about visits with my doctor. While both my dentist and doctor are very nice human beings, the reasons I go so see them aren’t on my list of fun things to do. I imagine most people feel the same way. Likewise, I suspect most people hate paying medical bills. Who wants to pay for something they don’t enjoy? One person I recently met likened buying healthcare services to purchasing tires for her car—necessary but definitely not satisfying.


Engagement is made even worse by the fact that medical billing is such a nightmare and paying for, and dealing with, health insurance companies is absolutely no fun at all. The insurance industry long ago trained most of us to expect someone else (government or insurance) to pay for a lot of the healthcare services we received. Now the tables have turned. More and more of our healthcare costs are not covered by insurance until we reach a yearly high deductible. This has consumers feeling even more disgruntled about doctors and hospitals and high healthcare costs. Is it any wonder that people are not “engaged”!


I think the way to engage patients or consumers is to really help them understand the things they can do to avoid any more “engagements” with doctors and hospitals than are absolutely necessary. Show them the connection between the unhealthy choices they make and the chronic diseases and health encounters they would much rather avoid. Create financial incentives to help people stay healthy. Develop technologies that ease the pain of engaging and interacting with the health system when one must do so, and help consumers avoid as many unnecessary medical visits and costs as possible. I’d like to see doctors and hospitals acknowledge that they totally understand they are not on our list of the people we like to see and places we like to go, and that they are doing everything possible to help us take better care of ourselves so we can avoid doing business with them as much as possible. Now that is a cause that just might get me “engaged”.


How about you?


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What Patients Want: Flexible Access to Providers

What Patients Want: Flexible Access to Providers | Healthcare and Technology news | Scoop.it

One thing my organization is struggling with right now is urgent/acute/same-day care. Basically, the care provided to a patient for an urgent or acute need. Historically, this care can be found at the emergency department, a walk-in clinic, or your regular doctor's office. Nowadays, patients also have the option of getting virtual care over the Internet or visiting a retail clinic. Trying to figure out what patients need and what they most desire is challenging.

A couple of years ago, I was at a family dinner with relatives who were not in the medical profession. They were discussing their recent forays into obtaining acute care. What they said they wanted was care in a convenient location, at a convenient time, with someone who was clinically competent, and who knew all about them through access to their EHR. Seems like both a reasonable request and a tall order.

We, like many organizations, grapple with these same issues:

• When do patients most want to be seen, and is it different for pediatric and geriatric populations?

• Who is best able to provide urgent care?

• Where do patients prefer to be seen?

• Are patients comfortable with and willing to pay for virtual care?

• How important is it that the person providing acute care is the primary care clinician? Unfortunately, I suspect the answers to these questions are not "one size fits all" but rather reflect the diversity of our patients.

I believe that a patient's desire to be seen by their own primary-care clinician rises exponentially with the severity of the presenting concern. Of course, in our current practice environment, at a certain level, the primary-care clinician is no longer the right person to be caring for a surgical emergency, heart attack, or stroke. Similarly, most patients don't feel strongly about having minor issues — strep throat, urinary tract infection, or a sprained ankle — treated by whoever is available, as long as they are clinically competent. Yet, you will still have patients who eschew both more convenient care and more appropriate care, so that they can see their own physician for the strep throat and the heart attack. How do we build a schedule and a clinic that provides varied access?

As retail clinics advance from acute care to chronic disease management and preventive care, more traditional practices are left trying to decide how this will impact their own provision of medical care. While, it may be convenient for patients to get their diabetes managed at the local pharmacy, I suspect that many patients would opt for the relative inconvenience of going to a separate office for medical care if they feel aligned with their medical team and are confident that they get something extra from that interaction; whether it be the comfort of a familiar face, the kindness of the care team, or the confidence that their entire medical history is available to the treating clinician.

Finally, is predicting demand, which is done in a variety of fashions, essentially unreliable? In my neck of the woods, demand may be highly influenced by the weather, the football schedule, and whether influenza season coincides with the holidays. Two of those three are unpredictable.

I am curious what pearls of wisdom readers have learned as they and their practices try to best manage acute care.


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Patient Monitoring Market To Exceed 5 Billion By 2020

Patient Monitoring Market To Exceed 5 Billion By 2020 | Healthcare and Technology news | Scoop.it

An iData Research survey has projected the patient monitoring market will exceed $5 billion by 2020 as a result of double-digit growth over the next five years in the telehealth market. The study also predicts that telehealth for disease conditions management will comprise more than 50 percent of the total telehealth market, driven by increased chronic illness in an aging population, increasing demand for customized healthcare solutions, and financial pressures due to overburdened healthcare budgets.

“The goal of telehealth is to prevent hospital readmission, reduce in-office visits, better manage health of individuals with long term conditions and reduce costs for more remote and isolated health care providers,” Dr. Zamanian, CEO of iData explained.

Market growth is anticipated to be “further bolstered as awareness and implementation of standards for reimbursement and adoption of this type of care management increase,” according to iData, as public and private organizations each are expected to increase funding for telehealth expenditures as a fiscally responsible and efficient solution.

As Health IT Outcomes reported, there are three major hurdles for telehealth adoption including reimbursement, federal standards, and licensure. A policy report from ML Strategies explains, “Current federal law is extremely restrictive on how telehealth is paid for – resulting in a disincentive to provider adoption.” Restrictions only allow reimbursements for patients who receive virtual care at rural clinics and not in metropolitan areas.

However, some progress is being made in the area of telehealth reimbursement. For example, Governor Andrew Cuomo recently signed into law legislation that would require Medicaid to reimburse for telehealth service costs in New York. And in November, CMS issued a final rule updating physician fee schedules and boosting payments for telehealth services. This trend indicates there is growing recognition of the cost effectiveness and success of telehealth services in overall patient care and outcomes.

Other barriers still remain, including the fact that no federal telehealth standards are in place with each state having its own regulations. As ML Strategies explains, “Currently, there is no federal standard of clinical guidelines for telehealth,” creating a “patchwork of state laws that inhibit the proliferation of telehealth solutions in both the public and private sectors.” As telehealth grows in popularity, however, federal regulations will become necessary in order to guarantee consistency.

The final barrier to telehealth growth, according to the ML Strategies report, is licensure, as it raises issues of flexibility if a patient wishes to consult a telehealth provider across state lines. “With the advent of telehealth, licensing of health providers must be updated to reflect the flexibility provided by telehealth – allowing healthcare experts to bring their expertise virtually to where it is needed, even across state borders,” notes the report.

Nevertheless, despite the obstacles, the telehealth industry is set for unprecedented growth by 2020 as iData Research has asserted. According to a survey of senior healthcare executives released by law firm Foley & Lardner, “The reimbursement landscape is already changing, and there are many viable options for getting compensated for practicing telemedicine,” said Larry Vernaglia, chair of Foley’s Health Care Practice. “The smartest thing organizations can do now is to continue developing programs, and be ready for the law to catch up – because it will.”


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Lava Kafle's curator insight, February 18, 2015 3:48 AM

@deerwalkinc 

Patient Monitoring Market To Exceed 5 Billion By 2020 
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When My Resident Struggled with 10-Minute Patient Visits

When My Resident Struggled with 10-Minute Patient Visits | Healthcare and Technology news | Scoop.it
I teach residents in a community-based family medicine residency, a job both rewarding and eye-opening. Recently, one of my residents sat in my office just after completing a morning patient session. The nurses had already been in to see me earlier because this resident was again behind schedule and patients were complaining about the wait. This day the resident had finished just over an hour late, a common occurrence for him. He looked at me, almost pleading, for an answer on what he should be doing differently.

The nurses are frustrated with this resident because they receive the brunt of the patients’ frustrations. The preceptors know they will be waiting long past the session for him to review his caseload. Of course, the resident feels this pressure. He had been struggling with this since his intern year, and although he had made marked improvement with his efficiency and pre-visit planning, he still lagged behind.

Over the past few months, everyone from the clerical staff to the program director has asked this resident to hurry up, yet everyone knows that he is one of our best residents. His patients know that he listens to them and cares for them. Once he gets into the room, all the time they had to wait seems to be forgotten because they have his undivided attention. He takes the time to read the chart and goes beyond the chief complaint, looking for ways to improve their overall health and overcoming barriers to compliance. He actively searches out resources in a demographic that struggles for even basic necessities. This is the doctor you want your grandmother to have.

My meeting with the resident makes me ponder difficult questions. I wonder, have we created this problem ourselves? Have we scheduled too many patients to be manageable? How many is too many? Recently, on a social media group of healthcare providers I belong to, the discussion of how long we are allotted for patient visits came up. One provider, a pediatrician, indicated she had 10 minutes allotted for sick visits and this appalled most of the group. How do you even take an appropriate history or examine a patient in that period of time? This 10-minute visit might work for a straightforward ear infection in a well-known patient with no comorbidities, but that is rarely what walks through the door.

We are robbing our patients of the resource of our time and I truly believe their health is suffering for it.

For my resident going the extra mile for all of his patients, the system does not allow for the hand-on-the-doorknob confession of suicidal thoughts or the unanticipated positive pregnancy test. Patients are scheduled for slots designed for simple, single problems and when they diverge from this the schedule suffers and other patients wait. I sympathize with the patients that are sitting in the waiting room not understanding why their 10 o’clock appointment time has come and gone; but I also know that the most important patient is the one in the exam room and each patient will get that opportunity. In an ideal world there would be enough doctors such that all the patients could see their doctor when they had the need without long wait times, but this is not an ideal world that we live in.

I struggle on how to counsel my resident. I am often running behind myself, trying to explain why a specific medication is necessary or why the medical test on the commercial is not actually all it claims to be, trying to be the resource my patients need and deserve.

I do not want the resident to be less thorough. I do not want him to cut corners or skimp on the care he provides. I tell him we all struggle with unreasonable time expectations, all of us have had the patient with urgent health needs that throws off our morning and ultimately, we are the ones responsible for the quality of the care we provide our patients. But, I am not sure that provided any sort of solution to his problem.
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Ingredients for streamlining care management | Healthcare IT News

Ingredients for streamlining care management | Healthcare IT News | Healthcare and Technology news | Scoop.it

In an era where medicine is highly specialized and different specialties are involved in the care of a patient, intelligent use of information technology is essential to help providers, payers and patients achieve better care management outcomes while simultaneously improving cost and quality of care.

While some entities, such as the Department of Veterans Affairs, have implemented solutions where patients have the ability to view their personal health records online and offline, the majority of the healthcare industry continues to face multiple challenges while implementing care management processes. Care management for large, diverse populations is highly complex and subjective, largely because needs vary for each patient and encounters may span across multiple care settings and plans.

Although a large proportion of health information today is captured electronically, integrated data around patients and their underlying disorders is often not available to providers at the point of care. However, efforts to code clinical content with standard terminology has, to some extent, helped streamline information across applications. There is also a lack of alignment between payers and providers in regards to cost of care management services and shared risk arrangements, leading to sub-optimal care quality.

How organizations manage their healthcare data, and what they use this data for, therefore becomes extremely critical to the success of these programs. While technology plays a very important role in areas like decision support, care coordination and population health management, providers and payers are still faced with the challenge of managing both complex people and process challenges.

Effective use of patient data

Patient data adds value across multiple areas such as decision support, planned interventions and medical reconciliation. Such examples include:

  • Using CPOE Based Order Sets: Effective clinical decision support tools contained within an order set can help enforce the use of quality measures or meaningful use criteria by providers. An example would be the use of a venous thromboembolism (VTE) risk assessment and subsequent prophylaxis for high risk patients embedded within an order set. Monitoring the prophylaxis regimen based on the VTE risk score can help reduce incidence of venous thrombosis.
  • Clinical Information Exchange: Effective care coordination requires healthcare data to flow seamlessly across all parts of the healthcare ecosystem, including providers, payers and consumers. By aligning incentives, all parties can reduce costs and improve quality of care. By leveraging health information exchanges across radiology, laboratory, perioperative, inpatient and outpatient applications, healthcare organizations have the ability to access patient data in a timely and secure fashion.
  • Medical Reconciliation: This feature is commonly available in electronic health records (EHRs) and can play a very important role in preventing adverse drug reactions. For example, the use of over-the-counter (OTC) medications like acetaminophen may not get recorded in an EHR, but can be retrieved from the pharmacy or the medication management application. This is extremely critical information for a physician, given the hepatotoxic profile of the drug.
  • Patient Registries: A patient registry fed with data from EHR applications can show the treatment prescribed to patients and identify care gaps, based on evidence-based guidelines. Care management programs can use this kind of analysis to highlight areas of improvement, thus positively impacting cost and quality of care.

Promoting patient engagement

Patient education plays a very important role in effective care management. Patients who are actively focused on learning more about their conditions are more likely to participate in initiatives that promote preventive steps and healthy behaviour. The use of patient portals, for instance, allow patients to have anytime, anywhere access to their medical records, and the ability to schedule appointments, request medication reconciliation, etc.

Processes such as discharge management and preventive care can also provide strong opportunities to increase patient participation. Such processes play a crucial role in keeping readmissions and acute care costs to a minimum. Automated alerts informing patients to make appointments or follow up on lab visits can help prevent potential acute and chronic conditions.

Patients today are increasingly using consumer devices and mobile apps to store and monitor their health parameters. Wearable devices have the ability to change the way health data is collected and managed, and care management processes will soon need to incorporate consumer technology to enhance patient engagement and self management.

Managing Stakeholder Expectations

To drive a sustainable care management program, it is important to demonstrate value to key stakeholders including providers, payers and patients. However, the definition of value differs from one entity to another. For instance, providers and payers often do not see eye to eye on issues such as risk sharing and care management goals. It is essential to build consensus on many of these issues and agree on clearly defined goals around care objectives, processes and costs.

Addressing issues around provider and payer expectations could lead to significant advantages for the healthcare industry as a whole. According to the Center for Disease Control and Prevention, the government spends nearly three-fourths of its total healthcare expenditure on chronic disease, an area where care management programs can make a large impact. A concerted effort from all major stakeholders to streamline care management objectives and processes would have a very large impact on healthcare cost and quality.

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Patients have changed. How do we manage them?

Patients have changed. How do we manage them? | Healthcare and Technology news | Scoop.it

In the past half century or so, medicine has changed the complexity of the human population as it has never been seen in the past. Think about it, there are people walking around today that fifty years ago, wouldn’t even be alive.   This evolution in medicine has not only brought about transformation in the human population, but it is also changing the approach of how clinicians need to treat these complex patients.


Traditional medicine has always focused on a single cause for a particular disease, without any consideration towards multiple risk factors and co-morbidities (a concomitant but unrelated pathologic or disease process). For this reason, clinical practice guidelines may not be able to address a particular patient’s needs if the patient has more than one medical issue that they are dealing with simultaneously.

My concern is that clinical outcome studies may not give a true representation of the type of patient many of us are seeing in our practices. This is because patients with multiple co-morbidities or multi-morbidities are on the rise, as diseases that were once considered death sentences are now seen as manageable. However, in many clinical trials, patients with other illnesses are usually excluded from these trials. Unfortunately, those of us in clinical practice do not have the luxury of excluding patients with multi-morbidities making these clinical trials/guidelines inadequate to manage patients.

Interestingly enough, the United States has been, for decades, in the forefront of dealing with multiple co-morbidities as opposed to the rest of the world, and is probably the leading cause of increased healthcare costs here in the United States, as opposed to other countries. However, the rest of the world is catching up to us at a rapid rate as medical technology and poor dietary habits become more available throughout the world.

For instance, it is predicted that by 2030, over fifty percent of the obese patients in the world will be from China and India combined. Also, right now, the rapidest growth in obesity is not here in the U.S. but is occurring in Europe and Asia, mostly due to the rapid expansion of fast food markets in those areas.

The question now becomes: How do we manage this new type of patient?

The first thing is for clinicians to have a better understanding of how multi-morbidities can affect a patient simultaneously. This is going to require better history taking and a better understanding of how disease processes work. In addition, the clinician is going to have to be aware of poly-pharmacy and drug-drug interactions.  This can be accomplished by listening and establishing a dialog with the patient. Unfortunately, many clinic guidelines do not allow for this, but it must change if we are to be successful.

Second, it is my belief that there should be more emphasis on case studies where complex patients are described and how the clinician or clinicians successfully treated that patient. I believe this because in my thirty years of practice, no two patients have ever presented the same way or responded exactly the same way.

Thirdly, there needs to be a change in the medical education system with a better understanding of how all these multi-morbidities will impact a patient. This will not be easy to test considering that testing has always been driving towards a more traditional single-disease approach. Regardless, it must be done if we are to succeed.

As I have said before, the human race is evolving, and medical technology has been a major factor in this evolution. The old model of medical management is no longer able to help many patients, so it is now time for medicine to evolve to meet this new challenge.


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Realistic Patient Scheduling for Your Medical Practice

Realistic Patient Scheduling for Your Medical Practice | Healthcare and Technology news | Scoop.it

One of the primary frustrations in any medical practice is the apparent inability to schedule effectively. The most often cited culprits are late patients, inefficient front-office staff, uncooperative insurance companies, EHR inefficiencies, and inconsiderate physicians.

While each of these could be causal, they are often symptoms of a single root cause: failure to acknowledge and account for the lead times between the stages of each patient visit. Consider Mary Doe, a considerate patient who has the first appointment of the day at 8 a.m.

Registration

Mary will appear at the reception desk at 8 a.m., her appointment time. She may have arrived earlier. It does not matter because the door would have been locked.

Mary probably knows it will take time to do some paperwork, but she has assumed that the practice wants her there at her appointment time. She is unaware of the time it will take to get her information updated in the practice management system. Depending upon the office and whether Mary is a new or existing patient, all of this can take between 5 minutes and 50 minutes.

Mary will be frustrated because she actually expected to be in an exam room soon after 8 a.m., and the physician is frustrated because he did, too. And the frustration will intensify throughout the day because the office will inevitably fall farther and farther behind schedule, because all of the delays are additive.

A solution would be to schedule two appointments for Mary: one for the front desk and one for the physician. The length of the front-desk appointment would depend upon whether Mary is a new or existing patient. When making the appointment, the scheduler should explain to Mary that there will be some paperwork to be handled before she can be seen. (An alternative is to schedule a single appointment for Mary and advise her to arrive 15 minutes to 45 minutes earlier so she can be seen "on time.")

Ancillary services

Depending upon the type of practice, Mary may need to have a test, X-ray, or blood drawn before being seen. In that instance, she needs yet another appointment slot. Mary should be told the sequence of events at the time she makes the appointment and be given an estimate of the time she can expect the appointment, in total, to take.

In some specialties, the physician sees the patient before these other services are performed. If the patient is coming back to the physician after these services are complete, Mary needs another appointment slot on the schedule.

As many as four appointment entries for a single appointment probably sounds crazy, a foolish waste of limited resources. I understand. Before you reject it out of hand, think about what it buys the practice and, especially, the physician:

• Providers and staff can be scheduled more effectively. It may be easier for everyone to have the same work hours, but it is not required.

• Appointments on the physician's schedule reflect when the physician is needed.

• Patients are more satisfied, because their experience is in line with their expectations.

• The office has a reasonable chance of staying on, or close to, schedule.

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