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Putting Patients into “Meaningful Use”

By DAVID HARLOW

The Health Research Institute at PricewaterhouseCoopers released a report today entitled Putting patients into “meaningful use.” It begins with the anecdote I’ve blogged about previously regarding a diagnosis by Facebook in lieu of a PHR, which some have highlighted as a great success for social media in health care.  I am much less sanguine on that front.

The PwC report, of course, has much more than that story in it; here are the key takeaways, backed up with some survey data and interviews:

  1. Engaging external constituents may postpone achievement of “meaningful use.”
  2. Patient awareness of and access to available health IT tools is low; social, expectation, and education hurdles also exist.
  3. Patient engagement in “meaningful use” is still low, despite consumer interest.
  4. “Meaningful use” has yet to explicitly call for measuring the level of patient engagement.
  5. Health systems will need to compete for consumers in the PHR market.Continue reading…

It’s Time to Tango: Impatient With Progress on Patient-Physician Partnerships

By JESSIE GRUMAN, PHD

The other day I came across this photo of a couple clasping each other in a dramatic tango on the cover of an old medical journal—a special issue from 1999 that was focused entirely on doctor-patient partnerships.  The tone and subjects of the articles, letters and editorials were identical to those written today on the topic: “it’s time for the paternalism of the relationship between doctors and patients to be transformed into a partnership;” “there are benefits to this change and dangers to maintaining the status quo;” “some doctors and patients resist the change and some embrace it: why?”

Two questions struck me as I impatiently scanned the articles from 12 years ago: First, why are these articles about doctor-patient partnerships still so relevant?  And second, why did the editor choose this cover image?

I’ve been mulling over these questions for a couple days and I think answer to the second question sheds light on the first.   Here are some thoughts about the relationship between patients and doctors (and nurse practitioners and other clinicians) evoked by that image of the two elegant people dancing together:

It takes two to tango.  Ever seen one guy doing the tango?  Nope.  Whatever he’s doing out there on the dance floor, that’s not tango.  Without both dancers, there is no tango. The reason my doctor and I come together is our shared purpose of curing my illness or easing my pain. We bring different skills, perspectives and needs to this interaction.  When in a partnership, I describe my symptoms and recount my history. I talk about my values and priorities. I say what I am able and willing to do for myself and what I am not.  My doctor has knowledge about my disease and experience treating it in people like me; she explains risks and trade-offs of different approaches and tailors her use of drugs, devices and procedures to meet my needs and my preferences. Both of us recognize that without the active commitment of the other we can’t reach our shared goal: to help me live as well as I can for as long as I can.Continue reading…

Tall Buildings

By KIMBERLY MANNING, MD

Dreading going in there. Know what you will say.  Your pain will be a ten out of ten. When I ask, “How are you?” you will say what you always say: “Terrible.” Your face will be a twisted snarl and you’ll cut your eyes so hard at me that I almost bleed.  I’ll ask you what can I do for you and your answer won’t be reasonable.  Or at least attainable.  That’s why I dread going in there.

Your family is tired. I have decided that they are tired because the only alternative explanation to them not coming to see you or see about you or call you or call about you is that they don’t care. I don’t like that explanation so instead I have decided that they are tired.

Tired of the exhausting marathons that you keep running in circles inside of your own mind. Tired of the short-lived glimmers of normalcy that you sometimes offer only to be smacked back into the reality of your never-quiet mind.  Tired of fighting you and fighting the bureaucracy of how to get you somewhere safe with virtually zero resources.  I know they are tired. Because it’s only been less than two weeks for me. And I’m tired, too.

And so each day I stand before your door on rounds. Secretly wanting to just keep on walking. Shadow boxing in my mind to get over my tired. And over my dread. And over my anger with my hands being tied snugly behind my back and, on some days, your hands being tied snugly down in restraints for your own safety. Your mind a cacophony of voices and poisonous thoughts that win over me and my little bag of internal medicine tricks. I don’t know what to do.

And so on this day, I just start with what my Mama always taught me.

“Good morning.”

“Hello.”

Something is different. Today, no scowl or lancinating eyes. Instead, you reach your hand out towards me. At first I look at it suspiciously, wondering if you intend to grab at me or shoo me away. I see the wrist ties near the rail of your bed from the corner of my eyes. But all you want to do is hold my hand. I am part surprised and part ashamed.

Hold my hand?

Me? I didn’t see that coming. Me? I was all business. There to just listen to your chest leaping with every thump of your dilated and failing heart, to interpret your engorged neck vein pattern, to look into your mouth, to inspect your swollen legs, and to review the orders. And in the midst of it all, to stand there taking your hand slaps and refusal to cooperate while sifting through my brain for a reasonable treatment plan marrying a terrible, end-stage medical problem to a slippery and elusive psychiatric illness.  With no money. And no family.

See? I was shadow boxing to be able to do that. Not hold your hand. You catch me off guard. I stop my busy-ness and let you hold it. I wag my finger at myself and say, tsk-tsk. Your patient is sick, Dr. Manning.

But I knew that before I came. Yet still, I felt tired. I feel your trusting palm, resting in my own. I sit beside you on the mattress and envelope it with my other hand. The room falls quiet as our feet dangle off of the edge of the bed facing the Atlanta skyline. I remember in that moment how beautiful it is. Especially from this room.

“Doctor?”

“Yes?”

“You can see the buildings all the way across town from this window.”

“Yeah.”

“The Marriott Marquis. And behind that is Bank of America.”

I look.  “You’re right.”

“How did they make such tall buildings?”

I pause for a moment, pondering the answer to that question. I’m not exactly sure. “I think they do it with cranes and big equipment. And people who aren’t afraid of heights.” I smile and for the first time in two weeks, you smile, too.

“I’m afraid of heights.”

“You are?”

Your smile dissipates and your expression grows distant.

“I am afraid. What will become of me? I am so afraid.”

You look at me with eyes so sane that I forget all of the diagnoses that compete with believing them. Your fingers tighten around my own. I feel more ashamed for shadow-boxing and dreading seeing you.

“Doctor?”

“Yes?”

“I’m tired.”

“I know.”

I sit in silence, rubbing your veiny and weathered hand. I’m tired, too.  We both breath in synchrony, yours more laborious from fluid, mine affected by growing emotion. I stare out of the window at The Equifax Building, the shiny cylindrical Westin Hotel, and the skycraping Georgia Pacific building.  Suddenly my eyes sting and my face feels warm. Because you are trusting me to help. I want to leap from one of those tall buildings with a single bound to save you.  But I can’t. Sometimes even when I want to, I can’t.

I’m not sure how they build those buildings. I also don’t know how to save you. My wings are tied and clipped. So are yours.

On this day, I will start by simply holding your hand. And shadow boxing to keep myself from giving up on you.

Kimberly Manning, MD, is an assistant professor in the Department of Medicine at Grady Memorial Hospital in Atlanta. As both a clinician and educator, she teaches pre-clinical medical students and residents and serves as residency program director for the Transitional Year Residency Program. She blogs regularly at Reflections of a Grady Doctor.

Google Health: What Did We Learn About PHRs?

By SHAHID N. SHAH

As I mentioned by way of the Wall Street Journal back at the end of March, Google Health was supposed to get less support under the new CEO. We learned today that “less support” meant that it would be retired on January 1, 2012 and eventually shut down on January 1, 2013. Basically this means that the grand experiment didn’t work out, but it was valiant and worthy try.

The folks at Google raised the bar for PHRs and I for one was a fan; however,  if Google couldn’t make it work, does it mean that Personal Health Records (PHRs) in general aren’t worthwhile or won’t be successful? I don’t think so, but what we learned from the Google experiment is that there’s little or no demand from the general consumer to store their personal medical records — at least in numbers that would matter. Here’s what Google said in their retirement letter:

There has been adoption among certain groups of users like tech-savvy patients and their caregivers, and more recently fitness and wellness enthusiasts. But we haven’t found a way to translate that limited usage into widespread adoption in the daily health routines of millions of people.

PHRs managed and maintained by patients themselves has been sort of a holy grail for years — but no one has been able to figure out how to make enough money from them or keep the data accurate enough to make PHRs useful enough to clinicians. And, it’s not for a lack of trying; in fact, Microsoft’s got a nice offering (HealthVault) that’s still in good shape so far. But, it’s not clear how long even they can last without a sustainable business model. It’s not like Google didn’t have the money to continue the experiment — they just realized that there were not users in quantities high enough for them to be able to monetize it sometime in the future.

 

Continue reading…

Bucking the Established

By DR. WES

“Out with the old, in with the new!”

Who’s your doctor? Do you have one?

If you have one, you aren’t that interesting to them any longer because you’re “established.” This is not the fault of your doctor, but because of government rules for paying doctors: “new patient” visits pay better than “established patient” visits. “New patients” have a much better chance of needing new procedures, so they are even more special. Add to that the fact that more and more patients are going to need to become part of the “system” soon, and “new patients” quickly achieve the health care value trifecta.

Sorry. Those are the rules.

The higher payments made by insurers and government agencies for new patients was meant to offset the longer amount of time and cognitive challenges of dealing with a new patient that enters the doctors office. There is no question that there is more work to do when a new patient enters a medical facility: entering demographic data on a computer, actually taking a set of vital signs, performing a careful history and physical. But thanks to the explosion of ancillary health care assistants, imaging studies, the availability of the internet, and a constant push to do more in less time, doctors work differently today than they once did. Much of the data gathering is accomplished before the patient enters the office, imaging studies and baseline testing often occurs before a patient is even seen (remember those tests “required” for “quality” care?). Furthermore, because limitations for the frequency of testing has been imposed by government regulators, health care systems leap at the opportunity to “direct” doctors to order tests the moment the test might be needed. As such, “new patients” become particularly valuable to health care systems compared to “established” ones.

Continue reading…

Medicine is Child’s Play: Where’s Waldo, Spot the Difference and Whack-a-Mole

By HANS DUVEFELT, MD

I started writing a post a few days ago about the challenge of quickly finding what you’re looking for in a medical record. As I came back to my draft this morning, it struck me how much this felt like some of the games my children played when they were young. This got me thinking…

Where’s Waldo: Finding what’s important in the medical record

I did a peer review once of an office note about an elderly man with a low grade fever. The past medical history was all there, several prior laboratory and imaging tests were imported and there was a long narrative section that blended active medical problems and ongoing specialist relationships. There was also a lengthy Review of Systems under its own heading.

In what would probably have printed out over ten pages long, the final diagnosis was “Urinary tract infection” and the man was prescribed antibiotics.

This final diagnosis seemed to come out of left field. I didn’t recall reading anything about urinary symptoms, urinalysis, an abdominal exam or pain on percussion over the back.

Continue reading…

HealthcareDIY: An Old Idea Made New

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By Jane Sarasohn-Kahn

My wisest and longest-time friend in health care, Jane Sarasohn-Kahn has a new project, new research and a new website called HealthcareDIY out today. I encourage all of you to look around her new site and consider the stories she is telling, as they matter to all of us.–Matthew Holt

We’re DIY’ing home renovations, photo development, music playlists, personal financial management, and travel reservations. Increasingly, we’re also DIY’ing health. Think: Maker Faire-Meets-Health.

My thinking about HealthcareDIY was first inspired by my mother Polly, who died 34 years ago this month. She was my first role model for an engaged patient. When she was diagnosed with Hodgkins lymphoma in 1971, there was no internet for her to tap into for a patient network, a clinical trial, or a directory of oncologists or centers of excellence that were Top Doctors for treating the condition.

Polly did, however, absorb the books of Adelle Davis and her Let’s Get Well series on nutrition and health. Polly’s good friend, a librarian with whom she worked, tapped into the Index Medicus on her behalf and retrieved abstracts of articles on blood cancers that he printed out from the microfiche. Polly partnered with her doctor, an internist with a keen interest in hematology, for her care. She also had a huge and diverse social network (offline, of course) that surrounded her with a whole lot of love. Her M.O. was informed by Dr. Bernie Siegel, who started Exceptional Cancer Patients in 1978 and evangelized about patient engagement, living fully with cancer, and dying in peace, which she did, in October 1979.

Among many legacies Polly left me was her can-do attitude when faced with a six-month-prognosis upon diagnosis with Hodgkin’s. Mom worked full-time until the last two years of her life, wore beautifully tailored clothes and put on lipstick every day, and project-managed her health through eight years of treatment: primarily, radiation and blood transfusions. Polly figured out how to take control where she could, and she did it with grace, humor and sheer human will.

She DIY’d her health given the resources she had at-hand between 1971 and 1979: books, cassette tapes, in-person support groups, medical journals in print, a specialist and internist, and lots of love.

In the three decades since Polly’s death, two seismic forces have structurally changed consumers in America: the Great Recession beginning in December 2007, and the near-universal use of the internet in health. Ogilvy’s report, Eyes Wide Open, Wallet Half Shut, found two countervailing forces re-shaping U.S. consumers: re-trenching and re-imagining. On the retrenching side of behavior, people began to do more binging: in media consumption, drinking, and eating.

On the re-imagining front, some people looked to re-invent themselves, reconnect with others, and re-train to re-tool careers. This group of people has sought to be more active and more deliberate, and accept more complexity in daily living. These people are more mindful, more frugal, and open to trading down. 9 in 10 use coupons, shop at discount stores, and buy more store brands and generics.

For this latter group, Ogilvy said, “Self Reliance is the new insurance policy,” with a group ethos believing that, “Americans need to be strong, get their house in order, and protect themselves,” per the report.

That’s where HealthcareDIY comes into play.Continue reading…