Tuesday, November 26, 2013

Thanksgiving, Decency and End of Life - Be Thankful you had the conversation now #health

Patients deserve the same standard and car that doctors receive when they need treatment. But as I have said before (Doctors Die Differently and more recently Treatment Creep in Medicine - sucking Decency out of Patients) we remain challenged especially when it comes to dying.

This piece by Dan Gorenstein, How Doctors Die: Showing Others the Way touched on these issues in a moving a thoughtful way.

Dr. Elizabeth D. McKinley’s battled breast cancer for 17 years but this past spring discovered the cancer had spread to her liver, lungs and brain. Her choice was to undergo more treatment that would have potentially debilitating and mind altering effects on her or change course, accept death and work on getting the best out of what was left of her life...as she put it
..time with her husband, a radiologist, and their two college-age children, and another summer to soak her feet in the Atlantic Ocean...“a little more time being me and not being somebody else.” 
And some of her fight was with her own family - the non-medical members
clinging to the promise of medicine as limitless
And the medical members of her family (her husband is a radiologist)
looking at her disease as doctors, who know the limits of medicine
Its not a difference in the effects of disease and death but rather an advantage of knowledge and information that lead to truly informed decisions "doctors have control over their quality of life before they die and this sadly is control that eludes most other members of society" and it would appear especially try here in the USA. More than half of deaths take place in hospital and not at home surrounded by people we love which is the way most say they want to "go".

So if you do nothing else this Thanksgiving - take the time to talk about the subject with the people you love and create and advance directive or living will. In many respects no better way to be thankful than to set out what is important and let everyone know, now when you are fit and healthy.

Wishing you all a very happy family and friend fill Thanksgiving

Tuesday, November 19, 2013

Treatment Creep in Medicine - sucking Decency out of Patients

This recent post on the Atlantic: How CPR Became So Popular reminded me of a piece I wrote some time back - Doctors Die Differently. As I said then:
Its not that doctors don't want to die, its just that they knwo they know enough about modern medicine to know its limits, importantly they have talked about this with their families as they want to be sure that no heroic measures will be used during their last moments in this reality
And the chart demonstrating the big discrepancy between what doctors want in life saving measures vs the general public pretty much said it all

So this piece in the Atlantic took it a step further - tracing the history of CPR from the 1960 at Johns Hopkins where the surgeons had
...successfully resuscitated every one of the first 20 patients they treated, 14 of whom (70 percent) survived without brain damage or other ill effects

But their source patients were not typical (young and mostly healthy) and when you extrapolate that out to an elderly population survival can fall to as low as 0% a variation in the effectiveness when performed in the real world
But it was Hollywood adn the media that pushed these procedures into the general awareness suggesting
...that two-thirds of all (fictional) cardiac arrests portrayed on ER (and other doctor shows) involved young patients who had suffered rare events like drowning or lightning strikes, rather than old people with heart disease (who account for 90 percent of cardiac arrests in real-life settings.....most of these fictional TV patients did well, unlike the vast majority of CPR recipients in real life
Dr Peter Benton was well known as all in life saving heroics

In fairness Hollywood was dramatizing some real life events - and they applied their pixie dust to this as they have to many other things.

But the problem remains and health care professionals need to help their patients understand their disease and make good choices, bearing in mind that heroics and life saving may well be a significant driver as it was for Stephen Jay Gould who was diagnosed with a rare and deadly cancer with a median survival of eight months...but as he said in his essay "The Median Isn't the Message".
this median survival means that one-half of patients die within eight months but the other half live longer. Most important, because the mesothelioma survival curve has a very long “tail,” a few lucky patients will live a lot longer
In his case his experimental treatment may have contributed to his 20 year survival past the original diagnosis...leaving a legacy of hope.

Monday, November 18, 2013

The Patient Story is more Valuable than Check Boxes

In a great expose of the value of the narrative Dr Regina Harrell explores Why A Patient's Story Matters More Than A Computer Checklist in a journey documenting one elderly patient with knee pain and underlying Dementia

Sadly Dr Harrell spends more time on technology than on the important aspect of patient engagement and clinical care:

At day's end, I review my meaningful use. I spent more time checking boxes than talking to patients and their families
There aren't enough physicians to see all the homebound patients in my area, so I try to visit as many as I can safely care for. I could see twice as many patients if I could write their notes at the bedside while visiting with them. I would happily do this using paper or an EHR that took the same amount of time, but these are not options.
I spend more time talking to the information technology team than I do answering messages from patients.

The underlying problem of technology not fitting the need - in this case demanding a typed note to capture the details could at least be solved with some speech enablement

But I was more troubled by the impact on teaching of our future generations

As a teaching doctor, my feedback to the residents now consists mainly of explaining how to document their visits so that we will all get paid, instead of teaching them how to take care of elders in their homes.

This may fall under the category of Unintended Consequences - but it is a big one...If we are focusing on the documentation at the expense of teaching clinical care then the problems we have today will be amplified dramatically as these new doctors enter the workforce.

Finding the balance between the need for digitizing medical notes and electronic medical records with the time necessary to spent interacting with these systems is still problematic - there are a number of technologies available including Speech Recognition with embedded Clinical Langauge Understanding (CLU) that can help ease this transition form paper to digital. But technology is not always the answer and finding the right balance between the needs to the system and the needs of the patient and their doctor will remain central to successful use and roll out of HealthIT in Healthcare.

Friday, November 15, 2013

Monday, November 11, 2013

Artificial Intelligence - Good or Bad

I received a link form a friend to this article Robots, Soldiers, & Cyborgs: The Future Of Warfare - I think in part because I post on the value and opportunity of the intelligent agent
In fact I just talked about this recently around the concept of smart shelves instead of selling shelves. It was this comment in the article that stood out
Are we at the beginning of an inevitable process leading to the rise of “killer robots” predicted by science fiction, or can robots actually make war less destructive?
We know technology can be used for good and bad but even with the concern of the possible super soldier ala Terminator and the Rise of the Machines in Judgement Day...as seen in the opening scene from Terminator 2

Remember folks - this is Hollywood. No battery or power issues amongst the many other challenging technical problems. There is a school of thought that we will reach singularity and artificial intelligence will have progressed to the point of a greater-than-human intelligence that will "radically change human civilization, and perhaps even human nature itself.
Critics are also concerned that advanced artificial intelligence (AI) could develop in directions not anticipated by scientists. Because of this unpredictability, the US military has indicated that it will never remove humans from the decision loop completely. While unmanned weapons systems will become gradually more autonomous so that they can carry out very specific missions with less human direction, they may never entirely replace human soldiers on the battlefield.
While there is some potential for the bad I remain optimistic that the inherent good prevails - we develop smarter, faster and better technology to deliver an improved world and a new era of Super Intelligence that will chaperone in a new and exciting era
Meanwhile adding medical intelligence to the systems we interact with to simplify the interaction freeing people up to focus on tasks and the individual - not the technology offers interesting and exciting potential and I found this latest piece Startup Gets Computers to Read Faces, Seeks Purpose Beyond Ads on reading faces another step toward intelligence which like the smart supermarket shelves can be used for good or bad....
Imagine the doctors office or even the hospital waiting area that is using technology to triage patents intelligently based on their needs not the time of their arrival.

Life is good - my glass is always full

Thursday, November 7, 2013

Remembering those First Moments as a Junior #Doctor #hcsm

It's a long time ago but in many respects that first shift is still fresh in my memory and it all came flooding back when I read this great piece by Deepak Chopra: My First Job: My Dark Night As A Real Doctor

He recounts his first night on call having arrived in to work in a 400 bed community hospital in New Jersey in the 1970's and his first patient - "an expiration"

I cast my mind back to Friday 1st August 1986 and my first day - the Friday was significant as I discovered, marking the beginning of a weekend on call that commenced on Friday at 9am and finished at 5pm on Monday 4th August - yes that 80 hours! I don't think I quite understood what that meant but I sure did by the end.

I was partnered with my medical school friend and colleague Niamh Anson part of my graduating class from the Royal Free Hospital School of Medicine. We were set to spend the next 6 months joined at the hip spending more time with each other than some married couples spend together. We would be each others support, backup, confidant and friend. I was lucky - she was the perfect balance to my brash youth and over confidence. She was a steady hand guiding through what were some very rough seas and although I did not know it at the time I was really lucky to be her partner offering me the chance to get to know her.

We worked for two consultants - Dr Woodgate and Dr Willoughby a cardiologist and a gastroenterologist and were joined by a dynamic registrar John Lee. Between us we took care of the cardiology patients, coronary care ward, coronary care monitoring unit and the gastroenterology patients day to day.  But come Friday afternoon took on medical responsibility for all medial patients, medical admissions through the Accident and Emergency Department (A&E aka as the ED) and the Intensive Care Unit. On top of that we (Niamh, John and I) were the code team - with the anesthetist (aka Gasman or Anesthesiologist) as the 4th member. I don't remember how many patients this covered but it was a lot.

Our first day was filled with taking on responsibility for the day to day activities finding out how to get things done, where things were kept and most importantly getting to know the nurses who were the key to surviving the ordeal since they knew everything, had worked there for far longer than you (and many others) and had more relevant experience that you needed to learn from. I was reminded of the "Doctor in the House" film with Sir Lancelot Spratt from years back:

To be a successful surgeon you need the eye of a hawk, heart of a lion and the hands of a lady

And while I don't remember all the nurses by name I remember all their kindness, support and actions that helped me survive the grueling assault course of medicine.

At 5pm we knew the patient load had changed as our "beepers" (aka pagers) started sounding like a cardiac monitor going off so frequently. There were missing orders for pain medication, tissued drips (a drip that was no longer working and needing to be re-done), admissions in the emergency department, patents with abnormal rhythms on the coronary care intensive unit, blood gases needing taken in ICU.....

Division of labor and unofficial coordination became the order of the day as Niamh and I split the work taking on admissions and ward coverage. I remember during that period working out my rate of pay based on the number of hours I did per week (typically 136 hours per week) and thinking that while I understood that I was inexperienced I felt worth a little more than the £1.36 per hour (roughly $2.20 per hour) given that I recall all the critical clinical decisions we made, the CPR we performed, the relatives we had to speak to give them the sad news that their spouse had died.

By Saturday afternoon we had been on call for 36 hours and there seemed no let up in activity. The nights were sometimes quieter but that was rarity. As a means of coping we split the night with either Niamh or I taking all the calls after midnight (except in the case of a code when it was all hands on deck necessary to cope with the high work load in these events). In one memorable night I remember 23 admissions coming through the emergency department - if I saw my bed it was never for more than a few minutes. The nurses were all familiar with the work load adn they knew when they paged us that even if we answered and said we were coming they would oftentimes have to page us a second and third time as we would answer but then fall immediately back to sleep. As for our performance and efficiency - I hesitate to imagine how poor we were at tasks and what our decision making would look like if it were assessed. The good news was that there were many experienced nurses involved who did not work the same hours so were not suffering the same chronic sleep deprivation and were checking up on our orders and activities, prompting and intervening as necessary to prevent errors

By Monday morning we were all frazzled - I'd lost count of the patients and problems we had dealt with, the patients who had died, the admissions and therapies started and the slew of clinical problems and disasters we had averted. We stopped taking call but our day did not finish then and for us Monday was a regular working day dealign with the normal work load of admissions, award rounds treatments and patient management. It was only at 5pm on Monday evening we finally stopped work and handed our patient cover over to the new on call team.

There was some solace in the genuine feeling that you were making the difference in people's lives but much like Deepak Choopra I struggled with what I was actually delivering - was this really healthcare

In the end, after six years of studying, medicine was turning out to have too little to do with healing and making people happy. It had to do instead with my work in the hospital, into their lives, pronouncing a few of them, the most unlucky ones, as expirations. I thought about myself a lot before I forced myself to sleep, but, on reflection, I didn't think about my patients much. We had all met and parted in a few moments. It would have been hard to look at them directly. 
What of the interaction as defined by Hippocrates

Even though a patient may be aware that his condition is perilous, he may yet recover because he has faith in the goodness of his physician...I will keep pure and holy both my life and my art.

I did not have a good feeling about the interactions - the fleeting exchanges with these people who were trusting me with their lives and the lives of their family. And as technology and innovation continued its march the reality of the practice of medicine changed

Practicing medicine as we do now makes a doctor's life as nerve-racking as a soldier's. It consists of an endless struggle to conquer disease, and to keep at this, a doctor must deny to himself that disease, and to keep at this, a doctor must deny to himself that disease ultimately wins. If you feel called to practice medicine, these are not the kinds of thoughts you permit yourself. But doctors do face up to them from time to time and wonder what the work is for

I had some great experiences - I had some awful ones and I continue to be part of what I consider an honorable profession and one I am privileged to be a contributing member . In fact on a recent flight there was a request for a doctor - a lady suffering an attack of pancreatitis but fortunately we were not far from our destination and my contribution was small and mostly not medical in nature helping to control and comfort for the short period of time till we arrived and then hand the patient on to the ground emergency medical staff. That transition proved to be sub-optimal and it was well over an hour before she was taken care of - I stayed of course, wanting to be sure that her care was transferred to the healthcare team on the ground. The following day I received a note from one of the flight attendants that made my day. She had searched for my name and found me and sent a note to the Nuance Web site thanking me for my assistance and complimenting me for my "display of genuine heart". My contribution was not so much medical although that had played a part in the diagnosis, assessment and review of treatment options and the course of action. But what had made the difference was compassion - the focus on the person (and in this case there were two people and I ended up helping her companion navigate London Heathrow airport late at night to get her out to the accommodation they had booked). I had never doubted what I would do and was upset for this lady and her companion who's holiday was not starting off well. This is why I did medicine - I wanted to be the contributor, the person caring for the patient. It is this fundamental aspect of medicine we seem to be loosing site of - I can certainly accept some blame - I have a keen eye towards technology and possibilities it offers - but at its hearts medicine is about people caring for people and providing the support that in many cases is the difference between a good or bad outcome (at least perceived by the patient anyway). In fact I tweeted something along these lines earlier this week:

People forget what you said and what you did but they remember how you made them feel

As Deepak Choopra quotes:
Rejoice at your inner powers, for they are the makers of wholeness and holiness in you,
Rejoice at seeing the light of day, for seeing makes truth and beauty possible. 
and he ends with

a physician must trust in Nature and be happy in himself

As a guding light that works for me - hope it works for you too

Monday, November 4, 2013

Must we Move to ICD10 - Short Answer is Yes

The short answer is yes - but I hear occasional stories and push back from clinicians and sometimes other healthcare staff - is it worth the spend and investment. Why not just wait for ICD-11 (Check out the beta draft of ICD-11 here). Why not just use SNOMED CT

For the individual doctor taking care of the patients they often see no direct benefit from ICD-10….or from SNOMED CT, LOINC, RxNorm, APR-DRG’s, ICD-9, APC’s, HCC’s, etc. But in the healthcare continuum that requires more than a single patient to be cared for and whole populations to be considered we need evidence and data to manage populations that has enough detail that has kept up with the explosion of medical knowledge. Yes capturing the codes may be difficult but the good news is there is technology to help clinicians to capture it at the point of care - anywhere and offers realtime feedback to the doctor with the unique and innovative Computer Assisted Physician Documentation (CAPD). ICD-10 is no longer to be feared but should be embraced as a bright new future that will start to code information in sufficient detail that is more representative of the complex nature of patients and their clinical condition. No longer grouped together in broad categories that do not adequately take account of the complex cases offering a much more nuanced view of the severity of illness.

So what is the difference between the two systems and what makes ICD-10 the right choice? Some of this relates to terminology and classification - nicely explained here by Dr Peter Johnson explaining the SNOMED CT system. As he says
Classification system,
A classification scheme could be thought of as a collection of buckets into which a care provider throws a particular concept or record. And since there can only be one bucket into which a concept fits, the process of labeling the buckets often leads to catch-all terms like: ‘Disease X, unspecified’ or ‘Y, not elsewhere classified’. As a result, accurately classifying records is rightly seen by most care providers as a separate process from record creation and is typically carried out by specially trained coders who know how to apply the process.

Terminology System
..a terminology allows the user to specify precisely what they want to record. Specifically, a terminology doesn’t have any ‘not elsewhere classified’ bucket terms, but is designed to have the terms that a user needs to record what actually happened.

Which brings me to the problem with SNOMED CT as a replacement for ICD-XX - clearly described by Carl Natale’s in his post: Why SNOMED cannot replace the ICD-10-CM/PCS code sets. As Carl rightly points out:
Physicians are going to have to learn how to communicate with EHRs — which will be based upon SNOMED — to comply with Meaningful Use. So the transition to SNOMED-CT already is in the works.
We do need more specific documentation but as a colleague of mine has pointed out this is not the onerous task that it first appears to be - much of the data is already information we capture as part of a normal clinical interaction and the additional data requirement may only be one clinical element.
For the construct of an ICD-10 code we have 7 characters made up as follows
  • Section,
  • Body System,
  • Root Operation,
  • Body Part,
  • Approach,
  • Device,
  • Qualifier
In a single specialty building up the code is part of the natural clinical content that we capture when documenting the patent encounter. The clinicians should not be expected to construct the code but does need to include all the details to allow the coding to be completed accurately. For example:

Open reduction internal fixation distal phalanx right index finger with K wire
contains everything necessary to code this as
0PST04Z - which is made up of:

  • 0 - Medical Surgical
  • P - Upper Bones
  • S - Reposition
  • T - Finger Phalanx R
  • 0 - Open
  • 4 - Internal Fixation Device
  • Z - No Qualifier
As Carl points out
Basically, ICD-10 codes aren't the problem. It's the specificity of documentation that will be required one way or another. SNOMED should make it easier to document to the required specificity. It is then up to the EHR system to convert that data to ICD information. Hopefully the physicians won't know what level of ICD is being used. They will just need to know what needs to be recorded.
So what does this look like in the clinical setting - this video offers a peek into the new world of documentation and how Healthcare technology, Clinical Language Understanding and integrated solutions will start to ease the documentation burden, allowing clinicians to focus on care and the patient and not documentation coding

Friday, November 1, 2013

A Paper Towel as a Medical Record - Really! #safety #HealthIT #EHR #hcsm

I ran across this posting on Mark Hindle's Twitter account:
The picture is shocking:

This is not just a hand written note as a simple reminder...this paper towel addresses the Pharmacy and says
"Please dispense Colecalciferol 20,000 units"
And it appears the pharmacy or maybe the nurses have dispenses this as evidenced by the "tick" over the top.

The Institute of Medicine published several studies including:

1999: To Err is Human
2001: Crossing the Quality Chasm

And the Journal of the Royal Society of Medicine Published a study in 2006; Poor handwriting remains a significant problem in medicine that stated:
Leape and Berwick called handwritten medical notes a ‘dinosaur long overdue for extinction

Yet here we are in 2013 and not only do we still have hand written notes but they are written on a paper towel......I'm left