New Way Bacterium Spreads in Hospital

A new study from the UK has shown that the transmission of hospital aquired infections that used to be confined to contact and surfaceode has now been found air borne

>>>>A study finds that clostridium difficile, which causes deadly intestinal infections in patients, is not only spread by contact with contaminated surfaces but can also travel through the air.
This is troubling and will create even more challenges for patients admitted to hospitals

http://nyti.ms/adIGNi

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Redesigning Medicine

Through provoking piece in the Washington Post today - Health Reform's Next Test by Jim Yong Kim and James N Weinstein at Dartmouth Hitchkcock. As they state

It is well known that U.S. health-care costs, as a share of our economy, are the highest in the world but that compared to other industrialized countries, our results are the worst. The Dartmouth Atlas has documented the enormous waste in our system and shown that spending more money and performing more medical procedures do not equal better outcomes for patients.

So true and so troubling as health reform marches forward under the new law. We do deserve good care and the blame storming that continues to affect all the efforts is counter productive and as they point out

We cannot blame government or insurers or physicians for the complex and multilayered problem. No single group or entity created the puzzle that is our health-care system; it is not reasonable to expect one group to solve it

Their use case shines a spot light on the challenges we face

Consider the moving pieces of a patient-health system encounter. A patient comes into the emergency room. Immediately, judgments are made about how sick she is and what treatments she needs. There is no universal medical record for that patient, so the provider has no idea about her medical history, medication use or preexisting conditions. Incomplete information is relayed through layers of nurses, physicians, specialists and the shifts of personnel who replace them. In the absence of real-time information, tests are ordered and treatment decisions made. Perhaps after an overnight stay, barring complications from drug interactions or perhaps an unrecognized underlying condition, she is discharged, with no further transfer of information to a provider and, more important, no follow-up to see whether the treatment was effective

But it is this summary point that amplifies the point:

The symptoms were treated; the patient was not.

This is exactly the point and their attempt to set up the "Center for Health Care Delivery Science" is one step int he process of many that needs to start with a realistic look at the challenges we face and the need for everyone to be part of the solution and not part of the problem.

Busy physicians want to leverage power of dictation

The use of speech as an integral tool to clinical documentation and the capture of clinical knowledge continues to expand. In this piece from Healthcare IT News (Busy physicians want to leverage power of dictation) Dr Levine an OBGYN resident reports his experiences and states

speech recognition software allows me to "interpret out loud" and document at the same time. For example, when reviewing an electronic fetal heart monitor tracing or reading an EKG, it is much easier to say what I see, as I read it, than see, type, read, see, type, etc.

It really is easier, less distracting to the process and while some will find the experience difficult in front of the patient there are some benefits to this method that include engaging & educating patients and the additional check of the content by someone who probably has the biggest vested interest in the accuracy of the record and the contribution this has to a successful outcome

Don’t miss this boat – as Dr Levine states “I'm sure it's only a matter of time until we all have workstations that have microphones, because speech recognition truly is the way of the future”. It may not fit in all instances and there are good reasons texting is popular, voice remains the fastest and most efficient means of communicating. Speech technology is integrating this into our healthcare world to make life easier and more efficient.

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Narrative Key to Physicians Acceptance of EHR Systems

Hidden in an article that reviewed nursing opinions on computerized records: (AFT: Nurses Express Mixed Opinions on Computerized Records) was a striking data point

While 73 percent said implementation of the systems went smoothly, many problems were identified, including 52 percent who said physicians are refusing to use the new systems. Yikes - that alone is a pretty revealing statistic that suggests that hidden behind implementations are a lot of reluctant users
The overall results suggest mixed view on the value of computerization (49% said "new computerized systems have had a positive effect on patient care") there are negative effects

While they see computerized systems improving some aspects of care, pluralities of nurses also say that these systems have had a negative effect on stress levels (49 percent) and morale (37 percent).

and more importantly:

50 percent of the nurses said the computerized systems have had a negative effect on the amount of time needed to chart patient information, while 38 percent said they have had a positive effect, and 12 percent said they have had no real effect.

So half the clinical staff believe these systems are adding to the time necessary to chart patient care. While the recommendations include a list of additional resources, training and involvement the glaring omission in my mind is the lack of consideration of the impact which implies an acceptance that it is reasonable to accept that the system will add more time to the burden of documentation? Better to reject this demand (which in one facility I heard about equated to a reduction in patient throughput volumes of 30-40%!) and identify solution's that don't add burdensome and time consuming tasks but instead save time. Now there's a radical thought.

Interestingly there was a conference held last week in Boston (Governors Health Information Technology Annual Meeting) that included presentations from David Blumenthal the National Coordinator for Health Information Technology, HHS, Kathleen Sebelius Secretary of Dept HHS and the Massachusetts Governor Deval Patrick  On the second day a Panel Session - "Getting Clarity - Developing Effective Health IT Policies and Standards" included a question to the audience:

“How many doctors are in the audience?” – a sea of hands went up.
“How many are using an EMR?” – about 2/3 of the hands remained up.
“How many of you love it?”’- 2 hands remained: Dr. Larry Garber, who is a medical director for informatics at Fallon Clinic, and Dr. Michael Lee, a practicing pediatrician at Atrius Health.

As pointed out in this piece in FierceHealthIT Saving healthcare with the clinical narrative what is striking about these two individuals is that they are both avid users of speech recognition. The principle is clear. Clinicians prefer to use their voice to capture clinical information. Failing to provide this feature and effectively blending the narrative into the EHR while facilitating the easy capture of discreet data is a surefire recipe to poor adoption and less than stellar acceptance by physicians of clinical systems.

Narrative and the easy capture of the narrative is both good for adoption but more importantly it's essential for high quality clinical care.

Where are your systems with this technology and do you include the narrative and if so is it easy to do so?

Speech recognition systems evolve and Radiologists find Technology Increasingly Useful

Imaging Economics ran a piece on Speech Recognition in use at Greensboro and Mount Sinai

http://www.imagingeconomics.com/issues/articles/2010-05_02.asp

Speech and voice recognition systems have come a long way, and while no technology translates everything perfectly, expanding capabilities have increased both usefulness and effectiveness.

As for its use in the EMR

Yet, the integration of speech recognition for EMR users is likely inevitable, in part because without it, the value of the technology will wane

And it’s moving into other areas rapidly

Meanwhile, other disciplines, such as family practice and emergency care, are just beginning to explore the technology. “As far as the rest of health care, I think we’re seeing the early adopters starting to grab hold of the technology,” said Willis. These new users, however, will not—have—to—start—slow.

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Reassessing Primary Care

In an article in the April 29 issue of the New England Journal of Medicine titled What's Keeping Us So Busy in Primary Care? A Snapshot from One Practice (pdf) Richard Baron analyzes his practices activities. What is surprising is the extent to which non-reimbursed activities are part of the general work.
The breakdown of services averaged per visit and physician and by patient is shown below

Telephone calls averaged 23.7 per physician per day with close to 80% being handled directly by physician. Even running at peak efficiency with no time requirement to get to the phone, waiting on hold you can expect this to conservatively consume 2-3 minutes of time per day which equates to over an hour on phone calls per day. There were slightly fewer e-mails but the time taken to respond is likely to be a little longer to read and then respond. Add in prescription refills, laboratory reports and imaging and consultation reports and the time consumed for this ancillary activity has to be approaching 2-3 hours. The overhead of the system places an undue burden on primary care physicians and it is no surprise that medical school graduates are avoiding the field given the low reimbursement and declining compensation. As the author states in the summary:

The core of primary care remains the longitudinal, trusted relationship with the patient, in which diagnostic skill, therapeutic understanding, and compassion come together for the benefit of the patient who seeks our help. Achieving that mission for patients with varying communication and computer skills is a daily challenge, even as our office faces a fragmented payment system and rapidly evolving technology. The work we describe arises from the needs of patients in a society that assigns many roles to physicians — from making diagnoses and providing treatment to ordering tests and filling out forms — and the practice must be organized to respond reliably. How and by whom the work is done is a continuing project of primary care redesign, dependent on both the skills of available non physician staff and the extent of information-technology support.

Recent reviews of compensation compared the broad categories imply that while this compensation is not as good as specialist it is still better than many others. Healthaffairs reviewed compensation and asked: Can We Close The Income And Wealth Gap Between Specialists And Primary Care Physicians (full text requires subscription) but the chart showing compensation comparisons over time is helpful:


Primary care practitioners (PCP) are better compensated than next closest - an MBA graduate but significantly less than specialists (and Cardiology is not the highest compensated specialty - AMGA Medical Group Compensation and Financial Survey pdf here). All this does not bode well for what is a the lynch pin in patient management and longitudinal relationships with patients. As noted in a recent posting in the Health care blog Why We Need Private Primary Care Doctors - aside from the basic need there is a clear economic justification that supports empowering and paying PCP's and attracting more physicians into this specialist area. And as Rob Lamberts points out points out

The solution from an overall cost standpoint is to give primary care physicians incentive to do what they should be doing in the first place: keep people healthy and away from hospitals. Any system that places too much value on procedures is going to fail at this, as the institutions and individuals who profit off of the procedures are going to fight for control of PCP’s. Independent PCP’s who profit from keeping people well are the best thing for a system.

Which reminds me of a point made some time back on Universal Healthcare - Pay While you are Healthy which cited age old system in China

Hark back to days gone by in Chinese villages where the villagers paid the medicine man when they were healthy. When they fell ill they stopped paying until they were better and able to work again

And as KevinMD originally said

Lifestyle matters. More doctors are entering the workforce seeking part-time jobs in order to maintain a family balance. By removing the administrative hassles from their plate, they can go back to focusing solely on practicing medicine and coming home at a reasonable hour

The way to do that is using technology that supports not hinders clinical work flow and clinical thinking. Incorporate new tools and communication methods into the process and acknowledge their value by including them in compensation structure.

Do you agree - do you have better ideas on how to make things better and what technology or processes can be applied or improved - let em know and leave your comments